General
Condition Codes
Condition Codes
The following lists of Condition Codes are valid for use on the 1500 Health Care Claim Form and in the 837 Professional transaction.
Expanded Access and Emergency Use Authorization
| 90 | Service provided as part of an Expanded Access (EA) approval |
| 91 | Service provided as part of an Emergency Use Authorization (EUA) |
COVID-19 Claims
| DR | Disaster related |
Abortion
| AA | Abortion Performed due to Rape |
| AB | Abortion Performed due to Incest |
| AC | Abortion Performed due to Serious Fetal Genetic Defect, Deformity, or Abnormality |
| AD | Abortion Performed due to a Life Endangering Physical Condition Caused by, Arising from or Exacerbated by the Pregnancy Itself |
| AE | Abortion Performed due to Physical Health of Mother that is not Life Endangering |
| AF | Abortion Performed due to Emotional/psychological Health of the Mother |
| AG | Abortion Performed due to Social or Economic Reasons |
| AH | Elective Abortion |
| AI | Sterilization |
Worker's Compensation
The above Condition Codes have been approved by the National Uniform Billing Committee (NUBC) for use by the NUCC and are posted on the NUCC website with the permission of the NUBC.
Background Information
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. Some examples of this information are, employment status, qualified clinical trial, same day transfer, home care giver available, cost outlier and pregnancy indicator. These codes are integral to the institutional claim, both the paper UB and the electronic 837I.
The National Uniform Billing Committee (NUBC) ballots and maintains these Condition Codes as part of the NUBC Universal Billing (UB) Code Set, which is an external code set.. Requests for new codes or modification of codes may be submitted through the NUBC web site at nubc.org.
As the health care industry prepared for HIPAA implementation, it became apparent that conditional information, not available in the claim formats, was needed to effectively process claims in an electronic format. In 2002, several requests were entered into the DSMO process for changes to the 837 Professional transaction. The NUCC in reviewing the DSMO requests agreed that the functionality provided by the Condition Codes could potentially be an asset to the 1500 Health Care Claim Form and approved the constrained use of Condition Codes. In agreement with the NUBC, requirements for the creation of a subset of the Condition Codes for use in the professional claim were developed and license granted by NUBC for publication of the subset of codes by NUCC. Because of legal ramifications and rules for federal financial participation (FFP) with state Medicaid programs, the NUCC approved the Condition Codes for abortion and sterilization as part of the NUCC data set and the X12 Claims workgroup voted to add these codes to the claim level starting with version 004050 of the 837 Professional Health Care Claim. The Condition Codes may be reported in field 10D of the 1500 Claim Form. However, entities reporting these codes should refer to the most current instructions for any federal, state, or individual payment specific instructions that may be applicable to the 1500 Claim Form.
Definitions
Definitions
The following definitions apply to terms used in the Professional Claim.
PROVIDER TERMS
Referring Provider
The Referring Provider is the individual who directed the patient for care to the provider rendering the services being reported.
Examples include, but are not limited to, primary care provider referring to a specialist; orthodontist referring to an oral and maxillofacial surgeon; physician referring to a physical therapist; provider referring to a home health agency.
Ordering Provider
The Ordering Provider is the individual who requested the services or items being reported on this service line.
Examples include, but are not limited to, provider ordering diagnostic tests and medical equipment or supplies.
Rendering Provider
5010A1 837P
The Rendering Provider is the person or company (laboratory or other facility) who rendered the care. In the case where a substitute provider (locum tenens) was used, enter that provider's information here.
Future Versions of 837P
The Rendering Provider is the individual who provided the care. In the case where a substitute provider (locum tenens) was used, that individual is considered the Rendering Provider.
The Rendering Provider does not include individuals performing services in support roles, such as lab technicians or radiology technicians.
Supervising Provider
The Supervising Provider is the individual who provided oversight of the Rendering Provider and the care being reported.
An example includes, but is not limited to, supervision of a resident physician.
Purchased Service Provider
A Purchased Service Provider is an individual or entity that performs a service on a contractual or reassignment basis for a separate provider who is billing for the service.
Examples of services include, but are not limited to: (a) processing a laboratory specimen; (b) grinding eyeglass lenses to the specifications of the Rendering Provider; or (c) performing diagnostic testing services (excluding clinical laboratory testing) subject to Medicare’s anti-markup rule. In the case where a substitute provider (a locum tenens physician) is used, that individual is not considered a Purchased Service Provider.
INDIVIDUAL TERMS
Patient
An individual who has received, is receiving, or intends to receive health care services. (Health care services as defined by federal and state regulations.)
Dependent
An individual who has insurance coverage under the policy of another individual.
Subscriber
An individual or entity that is the holder of an insurance policy (including health, property and casualty, auto, workers’ compensation, or other liability) for the purposes of health care services.
Insured
An individual or entity that has insurance coverage.