Staying current with UB-04 condition codes, occurrence codes, and occurrence span codes is crucial for accurate hospital billing and ensuring proper reimbursement. These essential two-digit alphanumeric codes communicate specific circumstances that significantly impact claim processing and payment. This comprehensive 2025 guide provides field-by-field guidance, explaining what each type of code is, their purpose, key updates, and best practices. Master these codes to avoid denials, ensure accurate reimbursement, and maintain compliance in hospital billing.
What Are UB-04 Condition Codes?
UB-04 condition codes are two-character alphanumeric codes (e.g., D0, 44, DR) that communicate specific conditions or situations affecting a claim. These codes, entered in Form Locators 18–28 on the UB-04 form, inform payers about exceptions, such as hospice exclusions, inpatient-to-outpatient changes, disaster-related billing, or claim adjustments. Issued and updated by the National Uniform Billing Committee (NUBC), these condition codes are universally recognized by all payers, including Medicare, Medicaid, and private insurers.
2025 Updates: Important NUBC Code Changes and Rules
Staying informed about the latest NUBC UB-04 code updates is critical for billing compliance. Several new condition codes have been introduced in recent years, impacting 2025 billing. For the most current and comprehensive information, always refer to the official NUBC Manual or official CMS guidelines.
- Code 90 – Expanded Access Approval: Used for services delivered under expanded access to investigational treatments. This code was introduced in 2021.
- Code 91 – Emergency Use Authorization (EUA): Applies to services provided under an Emergency Use Authorization, such as specific COVID-19 vaccines and treatments. Effective since 2021.
- Code 92 – Intensive Outpatient Program (IOP): Mandated for IOP claims as of January 1, 2024. This code is crucial for billing by hospitals and mental health centers offering intensive outpatient psychiatric services.
Other updates include the continued use of code DR (Disaster Related) for events like federally declared public health emergencies or natural disasters. While the COVID-19 Public Health Emergency has ended, this code remains active for future crises, allowing for special processing rules for services related to declared disasters.
Common NUBC UB-04 Condition Codes Explained
Understanding the most frequently used NUBC condition codes and their specific applications is vital for accurate billing. Below is an expanded explanation of key codes, including examples and their significance for various payers, including Medicare:
Condition Code D0-D9 Explained: Adjustments and Corrections
The D0-D9 series of codes (entered in Form Locators 18-28) is used to indicate adjustments or corrections to previously submitted claims. Each code specifies a particular type of change:
- D0 – Change in Patient Status: Corrects or changes service dates.
- D1 – Change in Charges: Adjusts the monetary charges on a claim.
- D2 – Change in Revenue Code: Modifies the revenue code used for a service.
- D3 – Change in HCPCS/CPT Code: Updates the procedure code.
- D4 – Change in Diagnosis Code: Corrects the diagnosis reported.
- D5 – Change in Physician/Provider: Adjusts the billing or attending physician information.
- D6 – Change in Payer Information: Corrects details related to the insurance carrier.
- D7 – Change in Prior Authorization: Updates authorization details.
- D8 – Change in Payer Assigned Control Number: Corrects a payer’s internal claim number.
- D9 – Other Change/Correction: Used for adjustments not covered by D0-D8.
For example, if an inpatient stay was initially billed but later changed to observation services, a D-code (and Condition Code 44) would be used to reflect this adjustment.
Condition Code 44: Inpatient Changed to Outpatient
Condition Code 44 (Form Locators 18-28) indicates that an inpatient admission was changed to an outpatient status by the hospital’s utilization review committee prior to discharge. This is particularly important for Medicare claims, as it allows hospitals to bill for medically necessary Part B services if the inpatient admission does not meet Part A criteria. Proper documentation from the physician and utilization review committee is essential.
Condition Code 51 Meaning: Unrelated Outpatient Services
Condition Code 51 (Form Locators 18-28) declares that pre-admission outpatient services are not related to the subsequent inpatient stay and therefore should not be bundled under the inpatient DRG. This is commonly used when a patient receives outpatient services (e.g., diagnostic tests) shortly before an inpatient admission, but those services are for a different diagnosis or reason than the inpatient stay. Using this code can prevent payment reductions for what would otherwise be considered bundled services.
Condition Code 40 on UB04: Lower Level of Care
Condition Code 40 (Form Locators 18-28) signifies that a patient was transferred to a lower level of care within the same facility or to a different facility, such as from an acute care hospital to a skilled nursing facility (SNF). This code often triggers specific payment adjustments, especially for Medicare patients, as it informs the payer about the truncated stay in the initial setting.
Other Important UB-04 Condition Codes:
- 04 – Hospice Stay – Discharged/No Hospice Election: Used when a patient admitted for a non-hospice diagnosis is also enrolled in hospice but is discharged without electing the hospice benefit for the services provided. This is relevant for Medicare claims to prevent hospice benefit bundling.
- 07 – Treatment of Non-terminal Condition for Hospice: Used when a hospice patient receives treatment for a condition entirely unrelated to their terminal hospice diagnosis. This allows the non-hospice treatment to be billed separately.
- 09 – Second Opinion Required: Indicates that a second opinion was required for the procedure or service, often a prerequisite for coverage by some payers.
- 17 – Patient is Homeless: Provides demographic information that may impact care coordination or special program eligibility.
- 21 – Billing for Denial Notice: Signals that the claim is submitted to obtain an official Medicare denial, necessary for processing by a secondary payer (e.g., Medicaid or a commercial insurer).
- 25 – Patient is a Non-U.S. Resident: Used for international patients who may have different billing requirements or payer responsibilities.
- C5 – Delayed Billing: Indicates that the billing for this service or claim is being delayed for a specific, valid reason.
- DR – Disaster Related: Used during federally declared emergencies or disasters, enabling special processing rules and potential waivers.
- G0 – Observation Stay: Denotes that the patient was in observation status. This helps payers distinguish between inpatient and observation services, which have different reimbursement methodologies.
- 78 – New Coverage Not Paid by HMO: Indicates that the patient has new coverage, but the HMO is not paying for the services due to specific circumstances.
- 79 – CORF Services Provided Off-Site: Used for Comprehensive Outpatient Rehabilitation Facility (CORF) services rendered at an approved off-site location.
For a complete and updated listing, always refer to the official NUBC UB-04 Data Specifications Manual.
Understanding UB-04 Occurrence Codes and Occurrence Span Codes
Beyond condition codes, UB-04 occurrence codes and occurrence span codes are equally critical for providing comprehensive information on a hospital claim. While condition codes describe circumstances, occurrence codes identify specific events and their dates, and occurrence span codes indicate a period of time.
What Are UB-04 Occurrence Codes?
UB-04 occurrence codes are two-digit alphanumeric codes that report specific events that happened during a patient’s stay or that relate to the billing period. Each code is accompanied by a specific date when the event occurred. These codes are entered in Form Locators 31-34 (along with their associated dates) and are crucial for providing payers with a clear timeline and context for the services rendered. They help determine liability, coverage, and proper payment for claims, especially for Medicare.
Occurrence Code 11 Meaning: Admission Date
Occurrence Code 11 is used to report the patient’s admission date to the facility for the specific episode of care being billed. This is one of the most common and essential occurrence codes, critical for establishing the start of the billing period.
Occurrence Code 72 Medicare: First Day of Inability to Work
Occurrence Code 72 is often used for Medicare patients or in workers’ compensation cases to indicate the “first day of inability to work” due to illness or injury. This code, along with its date, is vital for determining lost wages or disability periods and can impact benefit coordination.
Common UB-04 Occurrence Codes:
Here are other frequently used occurrence codes:
- 01 – Accident/Illness Date: Date of accident or onset of illness.
- 02 – Accident Date (No-fault auto): Specific to auto accident claims.
- 04 – Date of Admission: Often used interchangeably with code 11.
- 11 – Admission Date: The official date the patient was admitted for the current stay.
- 17 – Date of Discharge: Date the patient was formally discharged from the facility.
- 20 – Date of Last Therapy: Used for outpatient therapy services.
- 24 – Date of Last Menstrual Period: Relevant for obstetrical services.
- 29 – Date First Furnished: Date when a specific piece of durable medical equipment (DME) was first provided.
- A2 – Date of Psychiatric Observation: Indicates the start of a psychiatric observation period.
- 57 – Date of Injury (External Cause): Specifically for injuries with an external cause, often used with Form Locator 72.
- 61 – Date of Initial Treatment: The date when the first treatment for the current condition began.
- 70 – Through Date for Covered Services: Often used in conjunction with occurrence span codes.
- 72 – First Day of Inability to Work: As mentioned above, particularly important for Medicare and workers’ compensation.
What Are UB-04 Occurrence Span Codes?
UB-04 occurrence span codes are two-digit alphanumeric codes that identify a specific period of time (a “span”) during a patient’s stay or treatment. Unlike occurrence codes, which mark a single event date, span codes indicate a beginning and end date for a particular situation. These codes are entered in Form Locators 35-36, along with their ‘From’ and ‘Through’ dates, and are essential for billing extended services or periods of specific care.
Occurrence Span Code 70 on UB04: Covered Days
Occurrence Span Code 70 (and its associated ‘From’ and ‘Through’ dates) is typically used to denote the period of covered days under a specific benefit. For Medicare, this might signify the period for which inpatient services are covered under a benefit period, helping to track benefit exhaustion.
Other Key Occurrence Span Codes:
- 71 – Prior Stay Dates: Indicates the “from” and “through” dates of a previous inpatient stay that might impact the current claim.
- 72 – First/Last Day of Coinsurance: For Medicare, this signifies the period during which the patient was responsible for inpatient or SNF coinsurance.
- 74 – Non-covered Days (Utilization Review): Specifies a period where services were deemed non-covered due to utilization review decisions.
- 76 – Patient Liability: Denotes a period during which the patient had a specific financial liability.
UB-04 Form Locators: Field-by-Field Guidance for Codes and Dates
Accurately placing codes and dates on the UB-04 claim form is paramount for proper processing. Here’s specific guidance on where to enter various critical pieces of information:
- Form Locators 18-28: Condition Codes
These eleven two-digit fields are reserved for UB-04 condition codes. Enter codes sequentially, starting with FL 18, and only use them when applicable to the specific circumstances of the claim. - Form Locators 31-34: Occurrence Codes and Dates
Each of these four sections requires both an occurrence code (e.g., Code 11 for Admission Date) and its corresponding date. For example, the injury date on a UB-04 would be entered in one of these fields (often with Code 57), followed by the exact date of injury. - Form Locators 35-36: Occurrence Span Codes and Dates
These two sections are for occurrence span codes, each requiring a ‘From’ date and a ‘Through’ date to define the duration of a specific event or period, such as covered days or patient liability. - Form Locator 29: Accident State
While not a code, this field is critical for accident-related claims. In FL 29 in UB04, you would enter the two-letter abbreviation for the state where an accident occurred. This informs payers about potential third-party liability (e.g., workers’ compensation or auto insurance). - Form Locator 72: External Cause of Injury
For claims involving injuries, what is box 72 on UB04? This field is used to report the external cause of injury (E-code) and is essential for specific payers like Medicare or workers’ compensation to understand the circumstances surrounding an injury. This is often used in conjunction with occurrence codes like 57 for the injury date.
Best Practices for Using UB-04 Condition, Occurrence, & Occurrence Span Codes in 2025
- Apply codes judiciously: Only use condition, occurrence, or occurrence span codes when specific circumstances warrant them. Avoid adding unnecessary codes that could lead to confusion or denials.
- Ensure documentation supports codes: Every code used on a UB-04 claim must be thoroughly supported by the patient’s medical records or other relevant documentation. This is crucial for audit readiness and preventing claim rejections.
- Stay informed with official sources: Subscribe to newsletters and updates from official bodies like the NUBC and CMS (Centers for Medicare & Medicaid Services) to keep abreast of new codes, revised definitions, and updated billing rules. For the most current official guidance, consult the CMS Medicare Claims Processing Manual or the NUBC Manual directly.
- Check payer-specific guidelines: While NUBC codes are standardized, some insurers or programs (e.g., TRICARE, specific Medicaid programs) may have unique requirements or interpretations for certain codes. Always verify with individual payer manuals or websites.
- Conduct thorough QA review: Before submitting claims, double-check all condition, occurrence, and occurrence span code entries for accuracy, completeness, and appropriate dates during your quality assurance review process. This proactive step can significantly reduce resubmissions and accelerate reimbursement.
- Understand Medicare-specific implications: Pay close attention to how various codes impact Medicare claims, as many have direct implications for patient liability, benefit period tracking, and covered services. For example, Condition Code 04 Medicare has specific usage for hospice patients.
Frequently Asked Questions About UB-04 Codes
What is a condition code in medical billing?
A condition code in medical billing is a two-character alphanumeric code used on a UB-04 claim form to describe specific circumstances or conditions that may affect claim processing, such as patient status changes or disaster-related services.
What is the purpose of occurrence codes and occurrence span codes?
The purpose of occurrence codes is to report specific events and their dates (e.g., admission date, injury date) relevant to a patient’s care. Occurrence span codes, on the other hand, identify a period of time (from/through dates) during which a particular situation existed, such as covered days or a period of patient liability. Both provide crucial context for payers.
Do all UB-04 claims require condition, occurrence, or occurrence span codes?
No. These codes are only required when specific circumstances or events apply to the claim. Many claims will not include any codes in Form Locators 18–28 (condition), 31-34 (occurrence), or 35-36 (occurrence span).
Where can I find the official list of UB-04 codes?
The official and most comprehensive list for all UB-04 codes (condition, occurrence, and occurrence span) is available in the NUBC UB-04 Data Specifications Manual. Many Medicare Administrative Contractors (MACs) and other payers also post references and guidelines on their respective websites.
Why are UB-04 codes important for hospital billing?
These codes are vital because they provide payers with necessary information to understand unique billing situations, evaluate coverage, and determine accurate reimbursement. Using the correct codes helps hospitals avoid claim rejections, improves compliance, and supports efficient revenue cycle management.
Conclusion
Mastering UB-04 condition, occurrence, and occurrence span codes is fundamental for accurate and compliant hospital billing in 2025. With continuous updates and the increasing complexity of healthcare regulations, staying informed about NUBC code changes and payer-specific guidelines is more important than ever. By diligently applying the correct codes in their designated Form Locators, healthcare providers can significantly improve claim accuracy, ensure faster payment, and reduce costly denials. This guide serves as a valuable resource to help you navigate the latest billing demands and optimize your revenue cycle management.