Staying current with condition codes for UB-04 is essential for successful hospital billing. These two-digit alphanumeric codes—entered in Form Locators 18–28—help explain special circumstances that may impact claim processing. In 2025, new codes and updates require careful attention to detail. This guide explains what UB-04 condition codes are, reviews key updates, and provides best practices to help you avoid denials and ensure proper payment.
What Are UB-04 Condition Codes?
UB-04 condition codes are two-character codes that communicate specific conditions or situations affecting the claim. These codes inform payers about exceptions, such as hospice exclusions, inpatient-to-outpatient changes, disaster-related billing, or claim adjustments. Issued by the National Uniform Billing Committee (NUBC), condition codes are recognized by all payers, including Medicare and Medicaid.
2025 Updates: New Condition Codes and Rules
Several new condition codes have been introduced in recent years. Here’s what’s new for 2025:
- Code 90 – Expanded Access Approval: For services delivered under expanded access to investigational treatments (introduced in 2021).
- Code 91 – Emergency Use Authorization (EUA): Used for services under EUA, such as COVID-19 vaccines (effective since 2021).
- Code 92 – Intensive Outpatient Program (IOP): Required for IOP claims as of January 1, 2024. Applies to hospitals and mental health centers.
Other updates include the continued use of code DR (Disaster Related) for events like public health emergencies or natural disasters. While COVID-19 has ended, this code remains active for future crises.
Common UB-04 Condition Codes Explained
Below are frequently used condition codes and their billing significance:
- 07 – Treatment of Non-terminal Condition for Hospice: Used when the treatment is unrelated to the hospice diagnosis.
- 21 – Billing for Denial Notice: Signals that the claim is submitted to obtain a Medicare denial for secondary payer processing.
- D0–D9 and E0 – Adjustments and Corrections: D0 changes service dates, D1 changes charges, and so on. E0 is for correcting discharge status.
- 44 – Inpatient Changed to Outpatient: Indicates a change in patient status prior to discharge. Must be supported by proper documentation.
- 51 – Unrelated Outpatient Services: Declares that pre-admission outpatient services are not related to the inpatient stay and should not be bundled.
- DR – Disaster Related: Used during federally declared emergencies or disasters. Enables special processing rules.
Other notable codes include:
- 17 – Patient is Homeless
- 25 – Patient is a Non-U.S. Resident
- 78 – New Coverage Not Paid by HMO
- 79 – CORF Services Provided Off-Site
Refer to the NUBC Manual or your MAC’s website for a full list.
Best Practices for Using UB-04 Condition Codes in 2025
- Use codes only when applicable: Don’t add unnecessary codes—use them only in valid scenarios.
- Ensure documentation supports the code: Always back up the use of condition codes with medical records or notes.
- Stay informed: Subscribe to CMS and payer newsletters to keep track of updates and new code implementations.
- Check payer-specific rules: Some insurers require special condition codes (e.g., TRICARE’s code 48 for child residential treatment).
- Verify before submission: Double-check claims for accurate and complete condition code entries during QA review.
Frequently Asked Questions
Do all UB-04 claims require condition codes?
No. Condition codes are only required when specific circumstances apply. Many claims will not include any codes in Form Locators 18–28.
Where do I find the full list of condition codes?
The official list is available in the NUBC UB-04 Data Specifications Manual. Many MACs also post condition code references on their websites.
Why are condition codes important?
They help payers understand unique billing situations. Using the correct code avoids rejections, improves compliance, and supports accurate reimbursement.
Conclusion
Condition codes are a key component of hospital billing. In 2025, updates like codes 90–92 highlight the need to stay informed and compliant. Applying the correct codes improves claim accuracy, ensures faster payment, and reduces denials. As healthcare billing grows more complex, mastering UB-04 condition codes is vital for smooth revenue cycle management. Use this guide to stay updated and prepared for the latest billing demands.