02

Condition is Employment Related

Patient alleges that the medical condition causing this episode of care is due to environment/events resulting from the patient’s employment.

03

Patient Covered by Insurance Not Reflected Here

Indicates that patient/patient representative has stated that coverage may exist beyond that reflected on this bill.

04

Information Only Bill

Indicates bill is submitted for informational purposes only. Examples would include a bill submitted as a utilization report, or a bill for a beneficiary who is enrolled in a risk-based managed care plan and the hospital expects to receive payment from the plan.

05

Lien Has Been Filed

The provider has filed legal claim for recovery of funds potentially due to a patient as a result of legal action initiated by or on behalf of a patient.

06

ESRD Patient in the First 30 Months of Entitlement Covered By Employer Group Health Insurance

Medicare may be a secondary insurer if the patient is also covered by employer group health insurance during the patient’s first 30 months of end stage renal disease entitlement.

07

Treatment of Non-terminal Condition for Hospice Patient

The patient has elected hospice care, but the provider is not treating the patient for the terminal condition and is, therefore, requesting regular Medicare payment.

08

Beneficiary Would Not Provide Information Concerning Other Insurance Coverage

The beneficiary would not provide information concerning other insurance coverage. The FI develops to determine proper payment.

09

Neither Patient Nor Spouse is Employed

In response to development questions, the patient and spouse have denied employment.

10

Patient and/or Spouse is Employed but no EGHP Coverage Exists

In response to development questions, the patient and/or spouse indicated that one or both are employed but have no group health insurance under an EGHP or other employer sponsored or provided health insurance that covers the patient.

11

Disabled Beneficiary But no Large Group Health Plan (LGHP)

In response to development questions, the disabled beneficiary and/or family member indicated that one or more are employed, but have no group coverage from an LGHP.

12-14

Payer Codes

Codes reserved for internal use only by third party payers. CMS assigns as needed for FI use. Providers do not report.

15

Clean Claim Delayed in CMS’s Processing System (Medicare Payer Only Code)

The claim is a clean claim in which payment was delayed due to a CMS processing delay. Interest is applicable, but the claim is not subject to CPE/CPT standards.

16

SNF Transition Exemption (Medicare Payer Only Code)

An exemption from the post-hospital requirement applies for this SNF stay or the qualifying stay dates are more than 30 days prior to the admission date.

17

Patient is Homeless

The patient is homeless.

18

Maiden Name Retained

A dependent spouse entitled to benefits who does not use her husband’s last name.

19

Child Retains Mother’s Name

A patient who is a dependent child entitled to benefits that does not have his/her father’s last name.

20

Beneficiary Requested Billing

Provider realizes services are non-covered level of care or excluded, but beneficiary requests determination by payer. (Currently limited to home health and inpatient SNF claims.)

21

Billing for Denial Notice

The provider realizes services are at a noncovered level or excluded, but it is requesting a denial notice from Medicare in order to bill Medicaid or other insurers.

26

VA Eligible Patient Chooses to Receive Services In a Medicare Certified Facility

Patient is VA eligible and chooses to receive services in a Medicare certified facility instead of a VA facility.

27

Patient Referred to a Sole Community Hospital for a Diagnostic Laboratory Test

(Sole Community Hospitals only). The patient was referred for a diagnostic laboratory test. The provider uses this code to indicate laboratory service is paid at 62 percent fee schedule rather than 60 percent fee schedule.

28

Patient and/or Spouse’s EGHP is Secondary to Medicare

In response to development questions, the patient and/or spouse indicated that one or both are employed and that there is group health insurance from an EGHP or other employer-sponsored or provided health insurance that covers the patient but that either: (1) the EGHP is a single employer plan and the employer has fewer than 20 full and part time employees; or (2) the EGHP is a multi or multiple employer plan that elects to pay secondary to Medicare for employees and spouses aged 65 and older for those participating employers who have fewer than 20 employees.

29

Disabled Beneficiary and/or Family Member’s LGHP is Secondary to Medicare

In response to development questions, the patient and/or family member(s) indicated that one or more are employed and there is group health insurance from an LGHP or other employer-sponsored or provided health insurance that covers the patient but that either: (1) the LGHP is a single employer plan and the employer has fewer than 100 full and part time employees; or (2) the LGHP is a multi or multiple employer plan and that all employers participating in the plan have fewer than 100 full and part-time employees.

30

Qualifying Clinical Trials

Non-research services provided to all patients, including managed care enrollees, enrolled in a Qualified Clinical Trial.

31

Patient is a Student (Full-Time - Day)

Patient declares that they are enrolled as a full-time day student.

32

Patient is a Student (Cooperative/Work Study Program)

Patient declares that they are enrolled in a cooperative/work study program.

33

Patient is a Student (Full-Time - Night)

Patient declares that they are enrolled as a full-time night student.

34

Patient is a Student (Part-Time)

Patient declares that they are enrolled as a part-time student.

Accommodations

35

Reserved for National Assignment

Reserved for National Assignment.

36

General Care Patient in a Special Unit

(Not used by hospitals under PPS.) The hospital temporarily placed the patient in a special care unit because no general care beds were available.

Accommodation charges for this period are at the prevalent semi-private rate.

37

Ward Accommodation at Patient’s Request

(Not used by hospitals under PPS.) The patient was assigned to ward accommodations at their own request.

38

Semi-private Room Not Available

(Not used by hospitals under PPS.) Either private or ward accommodations were assigned because semi-private accommodations were not available.

NOTE: If revenue charge codes indicate a ward accommodation was assigned and neither code 37 nor code 38 applies, and the provider is not paid under PPS, the provider’s payment is at the ward rate. Otherwise, Medicare pays semi-private costs.

39

Private Room Medically Necessary

(Not used by hospitals under PPS.) The patient needed a private room for medical reasons.

40

Same Day Transfer

The patient was transferred to another participating Medicare provider before midnight on the day of admission.

41

Partial Hospitalization

The claim is for partial hospitalization services. For outpatient services, this includes a variety of psychiatric programs (such as drug and alcohol).

42

Continuing Care Not Related to Inpatient Admission

Continuing care plan is not related to the condition or diagnosis for which the individual received inpatient hospital services.

43

Continuing Care Not Provided Within Prescribed Post Discharge Window

Continuing care plan was related to the inpatient admission but the prescribed care was not provided within the post discharge window.

44

Inpatient Admission Changed to Outpatient

For use on outpatient claims only, when the physician ordered inpatient services, but upon internal utilization review performed before the claim was originally submitted, the hospital determined that the services did not meet its inpatient criteria. (NOTE: For Medicare, the change in patient status from inpatient to outpatient is made prior to discharge or release while the patient is still a patient of the hospital).

45

Reserved for national assignment

46

Non-Availability Statement on File

A non availability statement must be issued for each TRICARE claim for non emergency inpatient care when the TRICARE beneficiary resides within the catchment area (usually a 40-mile radius) of a Uniformed Services Hospital.

47

Reserved for TRICARE

48

Psychiatric Residential Treatment Centers for Children and Adolescents (RTCs)

Code to identify claims submitted by a “TRICARE – authorized” psychiatric Residential Treatment Center (RTC) for Children and Adolescents.

49

Product replacement within product lifecycle

Replacement of a product earlier than the anticipated lifecycle due to an indication that the product is not functioning properly.

50

Product replacement for known recall of a product

Manufacturer or FDA has identified the product for recall and therefore replacement.

51-54

Reserved for national assignment

55

SNF Bed Not Available

The patient’s SNF admission was delayed more than 30 days after hospital discharge because a SNF bed was not available.

56

Medical Appropriateness

The patient’s SNF admission was delayed more than 30 days after hospital discharge because the patient’s condition made it inappropriate to begin active care within that period.

57

SNF Readmission

The patient previously received Medicare covered SNF care within 30 days of the current SNF admission.

58

Terminated Managed Care Organization Enrollee

Code indicates that patient is a terminated enrollee in a Managed Care Plan whose three-day inpatient hospital stay was waived.

59

Non-primary ESRD Facility

Code indicates that ESRD beneficiary received non-scheduled or emergency dialysis services at a facility other than his/her primary ESRD dialysis facility. Effective 10/01/04

60

Operating Cost Day Outlier

Day Outlier obsolete after FY 1997. (Not reported by providers, not used for a capital day outlier.) PRICER indicates this bill is a length-of-stay outlier. The FI indicates the cost outlier portion paid value code 17.

61

Operating Cost Outlier

(Not reported by providers, not used for capital cost outlier.) PRICER indicates this bill is a cost outlier. The FI indicates the operating cost outlier portion paid in value code 17.

62

PIP Bill

(Not reported by providers.) Bill was paid under PIP. The FI records this from its system.

63

Payer Only Code

Reserved for internal payer use only. CMS assigns as needed. Providers do not report this code. Indicates services rendered to a prisoner or a patient in State or local custody meets the requirements of 42 CFR 411.4(b) for payment

64

Other Than Clean Claim

(Not reported by providers.) The claim is not 'clean'. The FI records this from its system.

65

Non-PPS Bill

(Not reported by providers.) Bill is not a PPS bill. The FI records this from its system for non-PPS hospital bills.

66

Hospital Does Not Wish Cost Outlier Payment

The hospital is not requesting additional payment for this stay as a cost outlier. (Only hospitals paid under PPS use this code.)

67

Beneficiary Elects Not to Use Lifetime Reserve (LTR) Days

The beneficiary elects not to use LTR days.

68

Beneficiary Elects to Use Lifetime Reserve (LTR) Days

The beneficiary elects to use LTR days when charges are less than LTR coinsurance amounts.

69

IME/DGME/N&A Payment Only

Code indicates a request for a supplemental payment for IME/DGME/N&AH (Indirect Medical Education/Graduate Medical Education/Nursing and Allied Health.

70

Self-Administered Anemia Management Drug

Code indicates the billing is for a home dialysis patient who self administers an anemia management drug such as erythropoetin alpha (EPO) or darbepoetin alpha.

71

Full Care in Unit

The billing is for a patient who received staff-assisted dialysis services in a hospital or renal dialysis facility.

72

Self-Care in Unit

The billing is for a patient who managed their own dialysis services without staff assistance in a hospital or renal dialysis facility.

73

Self-Care Training

The bill is for special dialysis services where a patient and their helper (if necessary) were learning to perform dialysis.

74

Home

The bill is for a patient who received dialysis services at home

75

Home 100-percent

Not used for Medicare.

76

Back-up In-Facility Dialysis

The bill is for a home dialysis patient who received back-up dialysis in a facility.

77

Provider Accepts or is Obligated/Required Due to a Contractual Arrangement or Law to Accept Payment by the Primary Payer as Payment in Full

The provider has accepted or is obligated/required to accept payment as payment in full due to a contractual arrangement or law. Therefore, no Medicare payment is due.

78

New Coverage Not Implemented by Managed Care Plan

The bill is for a newly covered service under Medicare for which a managed care plan does not pay. (For outpatient bills, condition code 04 should be omitted.)

79

CORF Services Provided Off-Site

Physical therapy, occupational therapy, or speech pathology services were provided off-site.

80

Home Dialysis-Nursing Facility

Home dialysis furnished in a SNF or Nursing Facility.

81-99

Reserved for National assignment.

Special Program Indicator Codes Required

The only special program indicators that apply to Medicare are:

A0

TRICARE External Partnership Program

Not used for Medicare.

A3

Special Federal Funding

This code is for uniform use by State uniform billing committees.

A5

Disability

This code is for uniform use by State uniform billing committees.

A6

PPV/Medicare Pneumococcal Pneumonia/Influenza 100% Payment

Medicare pays under a special Medicare program provision for pneumococcal pneumonia/influenza vaccine (PPV) services.

A7-A8

Reserved for national assignment

A9

Second Opinion Surgery

Services requested to support second opinion on surgery. Part B deductible and coinsurance do not apply.

AA

Abortion Performed due to Rape

Self-explanatory – Effective 10/1/02

AB

Abortion Performed due to Incest

Self-explanatory – Effective 10/1/02

AC

Abortion Performed due to Serious Fetal Genetic Defect, Deformity, or Abnormality

Self-explanatory – Effective 10/1/02

AD

Abortion Performed due to a Life Endangering Physical Condition Caused by, Arising From or Exacerbated by the Pregnancy Itself

Self-explanatory – Effective 10/1/02

AE

Abortion Performed due to Physical Health of Mother that is not Life Endangering

Self-explanatory – Effective 10/1/02

AF

Abortion Performed due to Emotional/psychological Health of the Mother

Self-explanatory – Effective 10/1/02

AG

Abortion Performed due to Social Economic Reasons

Self-explanatory – Effective 10/1/02

AH

Elective Abortion

Self-explanatory – Effective 10/1/02

AI

Sterilization

Self-explanatory – Effective 10/1/02

AJ

Payer Responsible for Copayment

Self-explanatory – Effective 4/1/03

AK

Air Ambulance Required

For ambulance claims. Air ambulance required – time needed to transport poses a threat – Effective 10/16/03

AL

Specialized Treatment/bed Unavailable

For ambulance claims. Specialized treatment/bed unavailable. Transported to alternate facility. – Effective 10/16/03

AM

Non-emergency Medically Necessary Stretcher Transport Required

For ambulance claims. Non-emergency medically necessary stretcher transport required. Effective 10/16/03

AN

Preadmission Screening Not Required

Person meets the criteria for an exemption from preadmission screening. Effective 1/1/04

AO-AZ

Reserved for national assignment

B0

Medicare Coordinated Care Demonstration Program

Patient is participant in a Medicare Coordinated Care Demonstration.

B1

Beneficiary is Ineligible for Demonstration Program

Full definition pending

B2

Critical Access Hospital Ambulance Attestation

Attestation by Critical Access Hospital that it meets the criteria for exemption from the Ambulance Fee Schedule

B3

Pregnancy Indicator

Indicates patient is pregnant. Required when mandated by law. The determination of pregnancy should be completed in compliance with applicable Law. – Effective 10/16/03

B4

Admission Unrelated to Discharge

Admission unrelated to discharge on same day. This code is for discharges starting on January 1, 2004. Effective January 1, 2005

B5-BZ

Reserved for national assignment

QIO Approval Indicator Codes

C1

Approved as Billed

Claim has been reviewed by the QIO and has been fully approved including any outlier.

C4

Admission Denied

The patient’s need for inpatient services was reviewed and the QIO found that none of the stay was medically necessary.

C5

Post-payment Review Applicable

Any medical review is completed after the claim is paid.

C6

Preadmission/Pre-procedure

The QIO authorized this admission/procedure but has not reviewed the services provided.

C7

Extended Authorization

The QIO has authorized these services for an extended length of time but has not reviewed the services provided.

C8-CZ

Reserved for national assignment

Claim Change Reasons

D0

Changes to Service Dates

Self-explanatory

D1

Changes to Charges

Self-explanatory

D2

Changes to Revenue Codes/HCPCS/HIPPS Rate Code

Report this claim change reason code on a replacement claim (Bill Type Frequency Code 7) to reflect a change in Revenue Codes (FL42)/HCPCS/HIPPS Rate Codes (FL44)

D3

Second or Subsequent Interim PPS Bill

Self-explanatory

D4

Changes In ICD-9-CM Diagnosis and/or Procedure Code

Use for inpatient acute care hospital, long-term care hospital, inpatient rehabilitation facility and inpatient Skilled Nursing Facility (SNF).

D5

Cancel to Correct HICN or Provider ID

Cancel only to delete an incorrect HICN or Provider Identification Number.

D6

Cancel Only to Repay a Duplicate or OIG Overpayment

Cancel only to repay a duplicate payment or OIG overpayment (Includes cancellation of an outpatient bill containing services required to be included on an inpatient bill.)

D7

Change to Make Medicare the Secondary Payer

Self-explanatory

D8

Change to Make Medicare the Primary Payer

Self-explanatory

D9

Any Other Change

Self-explanatory

DA – DQ

Reserved for national assignment

DR

Disaster related

Used to identify claims that are or may be impacted by specific payer/health plan policies related to a national or regional disaster.

DS – DZ

Reserved for national assignment

E0

Change in Patient Status

Self-explanatory

E1 – FZ

Reserved for national assignment

G0

Distinct Medical Visit

Report this code when multiple medical visits occurred on the same day in the same revenue center. The visits were distinct and constituted independent visits. An example of such a situation would be a beneficiary going to the emergency room twice on the same day, in the morning for a broken arm and later for chest pain. Proper reporting of Condition Code G0 allows for payment under OPPS in this situation. The OCE contains an edit that rejects multiple medical visits on the same day with the same revenue code without the presence of Condition Code G0.

G1 – GZ

Reserved for national assignment

H0

Delayed Filing, Statement Of Intent Submitted

Code indicates that Statement of Intent was submitted within the qualifying period to specifically identify the existence of another third party liability situation.

H1-LZ

Reserved for national assignment

M0

All Inclusive Rate for Outpatient Services (Payer Only Code)

Used by a Critical Access Hospital electing to be paid an all-inclusive rate for outpatient.

M1-MZ

Reserved for national assignment

N0-OZ

Reserved for national assignment

P0-PZ

Reserved for national assignment. FOR PUBLIC HEALTH DATA REPORTING ONLY

Q0-VZ

Reserved for national assignment.

W0

United Mine Workers of

America (UMWA)

Demonstration Indicator

United Mine Workers of America (UMWA)

Demonstration Indicator ONLY

W1-ZZ

Reserved for national assignment.