What does condition code 42 mean?

The condition code 42 is used to indicate the homecare/continuing care post-discharge. And it really further says that it is not related to the condition or the diagnosis of why the patient was admitted to the hospital.

What are condition codes on a claim?

Currently, Condition Codes are designed to allow the collection of information related to the patient, particular services, service venue and billing parameters which impact the processing of an Institutional claim.

What is a condition code 43?

Condition Code 43 may be used to indicate that Home Care was started more than three days after discharge from the Hospital and therefore payment will be based on the MS-DRG and not a per diem payment.

What is a Medicare condition code?

Basic of Medicare Condition Codes

Condition codes refer to specific form locators in the UB-04 form that demand to describe the conditions applicable to the billing period. It is important to note that condition codes are situational. These codes should be entered in an alphanumeric sequence.

What is a condition code 44?

Back. A Condition Code 44 is a billing code used when it is determined that a traditional Medicare patient does not meet medical necessity for an inpatient admission. An order to change the patient status from Inpatient to Observation (bill type 13x or 85x) MUST occur PRIOR TO DISCHARGE.

Understanding condition code 42



What does condition code 69 mean?

Condition code 69 (teaching hospitals only - code indicates a request for a supplemental payment for Indirect Medical Education/Graduate Medical Education/Nursing and Allied Health)

What does condition code 51 mean?

Condition code 51 (attestation of unrelated outpatient non-diagnostic services”) is not included on the outpatient claim. The line item date of service falls on the day of admission or any of the 3-days/1-day prior to an inpatient hospital admission.

What is condition code 40 mean?

Condition code 40. Appropriate patient status code. Charges submitted as covered. Admission date, statement “From” and “Through” dates are same.

What does condition code 41 mean?

All hospitals, including CAHs, report condition code 41 to indicate the claim is for partial hospitalization services.

What does condition code 45 mean?

Policy: For Part A claims processing, institutional providers shall report condition code 45 (Ambiguous Gender Category) on any outpatient claim related to transgender or hermaphrodite issues.

What does condition code 47 mean?

Enter condition code 47 for a patient transferred from another HHA. HHAs can also use cc 47 when the patient has been discharged from another HHA, but the discharge claim has not been submitted or processed at the time of the new admission.

What is condition code 21 used for?

Condition code 21 indicates services are noncovered, but you are requesting a denial notice in order to bill another insurance or payer source. These claims are sometimes called "no-pay bills" because they are submitted with only noncovered charges on them.

What is a 55 occurrence code?

The National Uniform Billing Committee (NUBC) approved a new occurrence code to report date of death with an effective/implementation date of October 1, 2012. Medicare systems shall accept and process new occurrence code 55 used to report date of death.

How many condition codes are there?

It is used to keep information regarding the results of arithmetic operations, so we can look at them later. There are four condition codes: N: was the result negative?

What is a condition code 20?

Claims are billed with condition code 20 at a beneficiary's request, where the provider has already advised the beneficiary that Medicare is not likely to cover the service(s) in question.

What does condition code 64 mean?

Enter condition code 64 to indicate that the claim is not a "clean" claim, and therefore, not subject to the mandated claims processing timeliness standard.

What is Medicare condition code 20?

Claims are billed with condition code 20 at a beneficiary's request, where the provider has already advised the beneficiary that Medicare is not likely to cover the service(s) in question.

What is Medicare condition code 54?

A new condition code 54 is effective on July 1, 2016 and is defined as “No skilled HH visits in billing period. Policy exception documented at the HHA.” Submission of this code will streamline claims processing for both the payer and provider.

What does condition code 08 mean?

If a patient or other party refuses to furnish information concerning other insurance coverage, you may submit a Part A claim as Medicare primary with condition code 08 (beneficiary would not furnish information concerning other insurance coverage). The CWF monitors these claims and alerts the BCRC.

What is a 50 occurrence code?

Occurrence Code 50: Assessment Date Definition: Code indicating an assessment date as defined by the assessment instrument applicable to this provider type (e.g. Minimum Data Set (MDS) for skilled nursing). (For IRFs, this is the date assessment data was transmitted to the CMS National Assessment Collection Database).

Can a patient be admitted and discharged on the same day?

When a patient has been admitted to inpatient hospital care for a minimum of 8 hours but less than 24 hours and discharged on the same calendar date, Observation or Inpatient Hospital Care Services (Including Admission and Discharge Services), from CPT code range 99234 – 99236, shall be reported.

When would you use condition code 61?

Outlier Related Definitions

Condition Code (CC) 61: Cost Outlier. Providers do not report this code. Indicates the bill is paid as an outlier.

What is condition code B4?

B4 - Admission Unrelated to Discharge - Admission unrelated to discharge on same day. • 42 - Continued 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.

What is condition code 30 and what is it used for?

Condition Code 30 means "Qualified Clinical Trial". It must appear on the hospital inpatient or outpatient claim when billing for items/services related to a Qualified Clinical Trial or qualified study regardless of whether all services on the claim are related to the clinical trial or not.

What is the Medicare 72 hour rule?

The 3-day payment window applies to services you provide on the date of admission and the 3 calendar days preceding the date of admission that will include the 72-hour time period that immediately precedes the time of admission but may be longer than 72 hours because it's a calendar day policy.