Healthcare Fraud Shield’s Latest Article: Facility Claims – Exploring Condition Codes!

14 Mar

This article is a continuation of the exploration into facility claims and their myriad of fields. As mentioned in our prior article, facility data can present many obstacles and contains a variety of fields that are often overlooked in analysis. Today’s article will focus on Condition Codes which are located on the UB-04 under Form Locators 18–28. Condition codes may describe conditions or circumstances surrounding the reason the patient is in a facility, information that could impact payment, personal information about the patient and much more.

What are condition codes?

They are two digit codes that may contain letters and/or numbers that are found on facility claims. The code entered on the claim may provide additional information that may or may not impact payment or processing of the claim. Some values are specifically related to insurance issues, special conditions, renal dialysis, accommodations and more. For example, codes with the values 01 through 19 are all insurance related. Codes 20 through 34 are special conditions such as condition code 30 which indicates that the patient is enrolled in a Qualifying Clinical Trial. Codes 35 through 54 relate to accommodations. An example is code 40 which indicates the patient was a Same Day Transfer: “The patient was transferred to another participating Medicare provider before midnight on the day of admission”. [1] Some organizations categorize the codes slightly differently so be sure to check your internal policies regarding the definition and impact of each code.

What are some examples of condition codes?

• 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.
• D8- Change to make Medicare the primary payer (report on adjustment when original claim was processed as an MSP claim or as a conditional claim).
• 22- Patient on multiple drug regimen
• 44- Inpatient admission changed to outpatient

Why is it important to review condition codes?

All fields on claims provide information impacting either claim processing, claim payments, member eligibility, member quality of care and more. Reviewing the sample of codes mentioned above, it is important for payers to understand if a patient or beneficiary is covered by another payer such as Medicare or perhaps Workman’s compensation. Reviewing the data provided in condition codes can assist in substantiating whether a claim should be reimbursed or not.

Using a tool such as PostShieldTM can help simplify some of the analysis surrounding Facility Claims.  For more information or if  you have any questions or comments, please contact us at SIU@hcfraudshield.com.

REFERENCES
[1] Condition Codes

 

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