Claims · Reference

Condition / Occurrence / Value Codes

The UB-04 code sets in form locators 18–41 — condition, occurrence, occurrence-span, and value codes — across post-acute and institutional claims. Switch sets with the tabs or search within a set.

Code	Condition codes (FL 18–28)
01	Military service related
02	Condition is employment related
03	Patient covered by insurance not reflected here
04	Information-only bill
05	Lien has been filed
06	ESRD patient in first 30 months covered by an employer group plan
07	Treatment of a non-terminal condition for a hospice patient
08	Beneficiary would not provide other-insurance information
09	Neither patient nor spouse is employed
10	Patient/spouse employed but no employer group plan
11	Disabled beneficiary but no large group health plan
17	Patient is homeless
18	Maiden name retained
19	Child retains mother's name
20	Beneficiary requested billing
21	Billing for a denial notice
24	Home IV patient also receiving home health services
25	Patient is a non-US resident
26	VA-eligible patient chooses a non-VA facility
28	Patient/spouse employer plan is secondary to Medicare
29	Disabled beneficiary/family large group plan is secondary
30	Qualifying clinical trial
31	Patient is a full-time day student
32	Patient is a cooperative / work-study student
33	Patient is a full-time night student
34	Patient is a part-time student
36	General-care patient in a special unit
37	Ward accommodation at patient request
38	Semi-private room not available
39	Private room medically necessary
40	Same-day transfer
41	Partial hospitalization
42	Continuing care not related to the inpatient admission
43	Continuing care not provided within the prescribed post-discharge window
44	Inpatient admission changed to outpatient
45	Ambiguous gender category
46	Non-availability statement on file
48	Psychiatric residential treatment for children
49	Product replacement within the product lifecycle
50	Product replacement for a known recall
51	Attestation — unrelated outpatient non-diagnostic services
55	SNF bed not available
56	Medical appropriateness
57	SNF readmission
60	Day outlier
61	Cost outlier
66	Provider does not wish a cost-outlier payment
67	Beneficiary elects not to use lifetime reserve days
68	Beneficiary elects to use lifetime reserve days
69	IME / direct graduate medical education payment requested
70	Self-administered erythropoietin (EPO)
71	Full care in the dialysis unit
72	Self-care in the dialysis unit
73	Self-care dialysis training
74	Home dialysis
75	Home dialysis — 100% reimbursement
76	Back-up in-facility dialysis
77	Provider accepts/obligated to accept payment as payment in full
78	New coverage not implemented by the managed care plan
79	CORF services provided off-site
80	Home dialysis — nursing facility
81	Elective C-section / induction before 39 weeks — medically necessary
82	Elective C-section / induction before 39 weeks — non-medically necessary
A1	EPSDT / CHAP
A2	Physically handicapped children's program
A4	Family planning
A5	Disability
A6	Vaccines — Medicare 100% payment
A9	Second-opinion surgery
D0	Change to service dates
D1	Change in charges
D2	Change in revenue code / HCPCS / HIPPS
D3	Second or subsequent interim PPS bill
D4	Change in ICD-10-CM diagnosis and/or procedure code
D5	Cancel to correct provider ID / HICN
D6	Cancel only to repay a duplicate or OIG overpayment
D7	Change to make Medicare the secondary payer
D8	Change to make Medicare the primary payer
D9	Any other change
E0	Change in patient status
W2	Duplicate of an original bill

Code	Occurrence codes (FL 31–34)
01	Accident / medical coverage
02	No-fault insurance involved
03	Accident / tort liability
04	Accident / employment related
05	Other accident
06	Crime victim
09	Start of an infertility treatment cycle
10	Last menstrual period
11	Onset of symptoms or illness
12	Date of onset for a chronically dependent individual
16	Date of last therapy
17	Date occupational therapy plan established or last reviewed
18	Date of retirement — patient/beneficiary
19	Date of retirement — spouse
20	Date guarantee of payment began
21	Date UR notice received
22	Date active care ended
24	Date insurance denied
25	Date benefits terminated by the primary payer
26	Date SNF bed became available
27	Date of hospice certification or recertification
28	Date comprehensive outpatient rehab plan established or reviewed
29	Date outpatient physical therapy plan established or reviewed
30	Date outpatient speech-language pathology plan established or reviewed
31	Date beneficiary notified of intent to bill — accommodations
32	Date beneficiary notified of intent to bill — procedures/treatments
33	First day of the Medicare coordination period for an ESRD beneficiary with an employer plan
34	Date of election of an extended care facility
35	Date treatment started — physical therapy
36	Date of inpatient hospital discharge for a covered transplant
37	Date of inpatient hospital discharge for a non-covered transplant
38	Date treatment started — home IV therapy
39	Date discharged on a continuous course of IV therapy
40	Scheduled date of admission
41	Date of first pre-admission testing
42	Date of discharge
43	Scheduled date of canceled surgery
44	Date treatment started — occupational therapy
45	Date treatment started — speech-language pathology
46	Date treatment started — cardiac rehabilitation
47	Date cost-outlier status begins
A1	Birthdate — insured A
A2	Effective date — insured A policy
A3	Benefits exhausted — payer A
B1	Birthdate — insured B
B2	Effective date — insured B policy
B3	Benefits exhausted — payer B
C1	Birthdate — insured C
C3	Benefits exhausted — payer C

Code	Occurrence span codes (FL 35–36)
70	Qualifying stay dates (SNF prior hospital stay)
71	Prior stay dates
72	First / last visit dates
73	Benefit eligibility period
74	Non-covered level of care / leave of absence dates
75	SNF level-of-care dates
76	Patient liability dates
77	Provider liability period
78	SNF prior stay dates
79	Payer code dates
M0	QIO / UR approved stay dates

Code	Value codes (FL 39–41)
01	Most common semi-private room rate
02	Hospital has no semi-private rooms
04	Inpatient professional component charges (combined billing)
06	Medicare blood deductible
08	Medicare lifetime reserve amount — first year
09	Medicare coinsurance amount — first year
10	Lifetime reserve amount — second year
11	Coinsurance amount — second year
12	Working-aged beneficiary/spouse with an employer group plan
13	ESRD beneficiary in a Medicare coordination period with an employer plan
14	No-fault, including auto / other
15	Workers' compensation
16	Public Health Service or other federal agency
17	Operating outlier amount
18	Operating DRG amount
19	Operating federal specific portion
20	Operating hospital specific portion
21	Medicaid
23	Recurring monthly income
24	Medicaid rate code
30	Pre-admission testing
31	Patient liability amount
37	Pints of blood furnished
38	Blood deductible pints
39	Pints of blood replaced
41	Black lung
42	Veterans Affairs
43	Disabled beneficiary under 65 with a large group health plan
44	Amount the provider agreed to accept (less than charges)
45	Accident hour
46	Number of grace days
47	Any liability insurance
48	Hemoglobin reading
49	Hematocrit reading
50	Physical therapy visits
51	Occupational therapy visits
52	Speech-language pathology visits
53	Cardiac rehabilitation visits
54	Newborn birth weight in grams
56	Skilled nurse — home visit hours
57	Home health aide — home visit hours
58	Arterial blood gas
59	Oxygen saturation
61	CBSA — location where service was furnished (wage index)
62	Home health visits — paid from Part A
63	Home health visits — paid from Part B
67	Peritoneal dialysis
68	Erythropoietin (EPO) drug
80	Covered days
81	Non-covered days
82	Coinsurance days
83	Lifetime reserve days
A1	Deductible — payer A
A2	Coinsurance — payer A
A3	Estimated responsibility — payer A
B1	Deductible — payer B
B2	Coinsurance — payer B
B3	Estimated responsibility — payer B
C1	Deductible — payer C
C2	Coinsurance — payer C
FC	Patient-paid amount

Value code 61 (CBSA) carries the wage-index locality; occurrence 27 is the hospice certification date; occurrence-span 70 holds the SNF qualifying hospital stay; condition 07 flags treatment of a non-terminal condition for a hospice patient.

Code numbers follow the public-domain CMS Claims Processing Manual (Ch.25); descriptions are written for this reference. The complete, authoritative sets with official wording are the NUBC Official UB-04 Data Specifications Manual (AHA-copyrighted). Verify exact codes and wording against NUBC or your MAC before billing.

Source: CMS Medicare Claims Processing Manual, Chapter 25. Revenue codes → · Type of Bill →