FLs 18-28 on the UB-04 are used for reporting condition codes—two-digit numeric or alphanumeric codes that identify special conditions or unique circumstances that affect the processing and payment of the claim. Condition codes are used to clarify a patient's eligibility and benefits. For example, they help the payer determine whether coverage exists under more than one type of insurance, whether primary or secondary insurance coverage is to be administered, whether medical necessity affects room assignment, whether an injury or illness is related to employment, and other details about a patient's circumstances so that the claim can be processed efficiently and accurately.
The UB-04 allows eleven condition codes to be listed at one time—one each in FLs 18-28. Condition codes can be grouped as follows: insurance codes, patient condition codes, room codes, TRICARE/product replacement/SNF information codes, and other special codes, including codes for renal dialysis settings, miscellaneous codes, and codes for special programs, QIO approval indicator services, and claim change reasons. Many condition codes are reserved for national or payer assignment or are currently payer-only codes.
When particular condition codes are used, various billing situations arise. For example, many of the insurance codes require MSP development—that is, verification of Medicare's responsibility for the claim; one TRICARE information code is used when a non-availability statement is on file; and certain codes connected to QIO approvals are automatically excluded from the billing timeliness and accuracy standard.
Many condition codes must also be coordinated with data in other fields on the UB-04. For example, the room codes require particular accommodation revenue codes in FL 42; the renal dialysis setting codes require a revenue code for dialysis services in FL 42; the QIO approval code for admission preauthorization requires a treatment authorization code in FL 63; all the claim change reason codes require the document control number assigned to the previously submitted claim to be listed in FL 64, and many also require an explanation of the change in the Remarks field (FL 80) or a particular occurrence code and date (FLs 31-34) to justify the change.
FL 29 (Accident State) is new to the UB-04 and is used to report the state in which an accident occurred for claims containing services related to an auto accident. FL 30 is an unlabeled field reserved for future assignment by the NUBC.
