This chapter provides the information needed for filling in FLs 18-28 of the UB-04. This group of fields is used to describe special conditions about a claim that may affect its processing and payment. The chapter also covers FL 29, Accident State, and unlabeled FL 30 (See Figure 9.1).

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Some claims are straightforward, and payers easily understand what benefits are due. Other claims are more complex and may contain information that seems contradictory, incomplete, or illogical to a payer. Unless the payer understands the special circumstances surrounding the request for payment, the claim is either held up or denied. The codes reported in FLs 18-28 are used to explain such conditions so that claims can be processed efficiently and accurately.

For example, suppose the patient is a woman who kept her maiden name after she married. Although she has benefits under her husband's insurance plan, the insurance company will not recognize her as eligible for the benefits because she does not use the same last name as her husband. Reporting the appropriate condition code, in this case code 18 (Maiden name retained), in FL 18 explains the situation.

Many members of the hospital's team share responsibility for identifying and assigning condition codes with the patient account specialist. Coordination with the members of other departments, including utilization review, admissions, coding, and health information management staff members, is essential for gathering correct data for billing.

FL 29 (Accident State) in this section of the UB-04 is used to report the state in which an accident occurred when the claim involves an auto accident. The last field in this section, FL 30, is an unlabeled field.

Learning Objectives