01 THRU 16 = Insurance related
17 THRU 30 = Special condition
31 THRU 35 = Student status codes
which are required
when a patient is a
dependent child over
18 years old
36 THRU 45 = Accommodation
46 THRU 54 = CHAMPUS information
55 THRU 59 = Skilled nursing facility
60 THRU 70 = Prospective payment
71 THRU 99 = Renal dialysis setting
A0 THRU B9 = Special program codes
C0 THRU C9 = QIO approval services
D0 THRU W0 = Change conditions
===========================================
01 = Military service related — Medical condition incurred during military service.
02 = Employment related — Patient alleged that the medical condition causing this episode
of care was due to environment/events resulting from employment.
03 = Patient covered by insurance
not reflected here — Indicates
that patient or patient
representative has stated that
coverage may exist beyond
that reflected on this bill.
04 = Health Maintenance
Organization (HMO) enrollee
— Medicare beneficiary is
enrolled in an HMO. Hospital
must also expect to receive
payment from HMO.
05 = Lien has been filed — Provider
has filed legal claim for
recovery of funds potentially
due a patient as a result of
legal action initiated by or on
behalf of the patient.
06 = ESRD patient in 1st 30 months
of entitlement covered by
employer group health
insurance.
07 = Treatment of nonterminal
condition for hospice patient
— The patient is a hospice
enrollee, but the provider is
not treating a terminal
condition and is requesting
Medicare reimbursement.
08 = Beneficiary would not provide
information concerning other
insurance coverage.
09 = Neither patient nor spouse is
employed — Code indicates
that in response to
development questions, the
patient and spouse have
denied employment.
10 = Patient and/or spouse is
employed but no EGHP
coverage exists or other
employer sponsored/provided
health insurance covering
patient.
11 = The disabled beneficiary
and/or family member has no
group coverage from a LGHP
or other employer
sponsored/provided health
insurance covering patient.
12 = Payer code — Reserved for
internal use only by third party
payers. CMS will assign as
needed. Providers will not
report them.
13 = Payer code — Reserved for
internal use only by third party
payers. CMS will assign as
needed. Providers will not
report them.
14 = Payer code — Reserved for
internal use only by third party
payers. CMS will assign as
needed. Providers will not
report them.
15 = Payer code - Clean claim. 
Delayed in CMS's processing system.
16 = Payer code - SNF transition exemption —
An exemption from post-hospital requirement 
applies for this SNF stay or the
qualifying stay dates are more
than 30 days prior to the
admission date.
17 = Patient is homeless.
18 = Maiden name retained — A
dependent spouse entitled to
benefits who does not use her
husband's last name.
19 = Child retains mother's name —
A patient who is a dependent
child entitled to CHAMPVA
benefits that does not have
father's last name.
20 = Beneficiary requested billing —
Provider realizes the services
on this bill are at a noncovered level of care or
otherwise excluded from
coverage, but the bene has
requested formal
determination
21 = Billing for denial notice — The
SNF or HHA realizes services
are at a non-covered level of
care or excluded, but requests
a Medicare denial in order to
bill Medicaid or other insurer
22 = Patient on multiple drug
regimen — A patient who is
receiving multiple intravenous
drugs while on home IV
therapy
23 = Home caregiver available —
The patient has a caregiver
available to assist him or her
during self-administration of
an intravenous drug
24 = Home IV patient also receiving
HHA services — the patient is
under care of HHA while
receiving home IV drug
therapy services
25 = Reserved for national
assignment
26 = VA eligible patient chooses to
receive services in Medicare
certified facility rather than a
VA facility
27 = Patient referred to a sole
community hospital for a
diagnostic laboratory test -
(sole community hospital
only).
28 = Patient and/or spouse's EGHP
is secondary to Medicare —
Qualifying EGHP for employers
who have fewer than 20
employees.
29 = Disabled beneficiary and/or
family member's LGHP is
secondary to Medicare —
Qualifying LGHP for employer
having fewer than 100 full and
part-time employees
30 = Qualifying Clinical Trials —
Non-research services
provided to all patients,
including managed care
enrollees, enrolled in a
Qualified Clinical Trial.
31 = Patient is student (full time
day) — Patient declares that
he or she is enrolled as a full
time day student.
32 = Patient is student
(cooperative/work study
program)
33 = Patient is student (full time
night) — Patient declares that
he or she is enrolled as a full
time night student.
34 = Patient is student (part time)
— Patient declares that he or
she is enrolled as a part time
student.
35 = PACE eligible patient disenrolls
during and inpatient admission. (eff. 1/2024)
36 = General care patient in a
special unit — Patient is
temporarily placed in special
care unit bed because no
general care beds were
available.
37 = Ward accommodation at
patient's request — Patient is
assigned to ward
accommodations at patient's
request.
38 = Semi-private room not
available — Indicates that
either private or ward
accommodations were
assigned because semi-private
accommodations were not
available.
39 = Private room medically
necessary — Patient needed a
private room for medical
reasons.
40 = Same day transfer — Patient
transferred to another facility
before midnight of the day of
admission.
41 = Partial hospitalization services.
For OP services, this includes a
variety of psychiatric
programs.
42 = Continuing Care Not Related to
Inpatient Admission —
continuing care not related to
the condition or diagnosis for
which the beneficiary received
inpatient hospital services. (eff. 10/2001)
43 = Continuing Care Not Provided
Within Prescribed Postdischarge Window —
continuing care was related to
the inpatient admission but
the prescribed care was not
provided within the postdischarge window. (eff. 10/2001)
44 = Inpatient Admission Changed
to Outpatient — For use on
outpatient claims only, when
the physician ordered
inpatient services, but upon
internal review performed
before the claim was initially
submitted, the hospital
determined the services did
not meet its inpatient criteria. (eff 4/2004)
45 = Gender incongruence (eff. 7/2023)
46 = Non-availability statement on
file for TRICARE claim for
nonemergency IP care for
TRICARE bene residing within
the catchment area (usually a
40 mile radius) of a uniform
services hospital.
47 = Reserved for TRICARE.
48 = Psychiatric Residential
Treatment Centers for
Children and Adolescents
(RTCs). Claims submitted by
TRICARE.
49 = Product Replacement within
Product Lifecycle —
replacement of a product
earlier than the anticipated
lifecycle due to an indication
that the product is not
functioning properly. (eff. 4/2006)
50 = Product Replacement for
Known Recall of a Product —
Manufacturer or FDA has
identified the product for
recall and therefore
replacement.(eff 4/2006)
51 = Attestation of unrelated
outpatient nondiagnostic services.
(eff 4/2011)
52 = Reserved for national
assignment.
53 = Initial placement of a medical
device provided as part of a clinical trial or 
a free sample. (eff. 7/2015)
54 = No skilled HH visits in billing period
(eff. 7/2016).
55 = SNF bed not available — The
patient's SNF admission was
delayed more than 30 days
after hospital discharge
because a SNF bed was not
available.
56 = Medical appropriateness —
Patient's SNF admission was
delayed more than 30 days
after hospital discharge
because physical condition
made it inappropriate to begin
active care within that period
57 = SNF readmission — Patient
previously received Medicare
covered SNF care within 30
days of the current SNF
admission.
58 = Terminated Managed Care
Organization Enrollee —
patient is a terminated
enrollee in a Managed Care
Plan whose three-day
inpatient hospital stay was
waived.
59 = Non-primary ESRD Facility —
ESRD beneficiary received nonscheduled or emergency
dialysis services at a facility
other than his/her primary
ESRD dialysis facility. (eff 10/2004)
60 = Operating cost day outlier —
PRICER indicates this bill is
length of stay outlier (PPS)
61 = Operating cost outlier —
PRICER indicates this bill is a
cost outlier (PPS)
62 = Payer code - PIP bill — 
This bill is a periodic
interim payment bill.
63 = Payer Code — Reserved
for internal payer use only.
CMS assigns as needed.
Providers do not report this
code. Indicates services
rendered to a prisoner or
patient in State or local
custody meeting requirements
of 42 CFR 411.4(b)
64 = Payer code -
Other than clean claim — The
claim is not a 'clean claim'
65 = Payer code -
Non-PPS bill — The bill is not a
prospective payment system
bill.
66 = Hospital Does Not Wish Cost
Outlier Payment — Bill may
meet the criteria for cost
outlier, but the hospital did
not claim the cost outlier (PPS)
67 = Beneficiary elects not to use
Lifetime Reserve (LTR) days
68 = Beneficiary elects to use LTR
days
69 = IME/DGME/N&A Payment
Only — providers request for
request for a supplemental
payment for
IME/DGME/N&AH (Indirect
Medical Education/Graduate
Medical Education/Nursing
and Allied Health).
70 = Self-administered Epoetin
(EPO) — Billing is for a home
dialysis patient who self-administers EPO.
71 = Full care in unit — Billing is for
a patient who received staff
assisted dialysis services in a
hospital or renal dialysis
facility.
72 = Self-care in unit — Billing is for
a patient who managed his
own dialysis services without
staff assistance in a hospital or
renal dialysis facility.
73 = Self-care training — Billing is
for special dialysis services
where the patient and helper
(if necessary) were learning to
perform dialysis.
74 = Home — Billing is for a patient
who received dialysis services
at home.
75 = Home dialysis patient using a
dialysis machine that was
purchased under the 100%
program.
76 = Back-up in facility dialysis —
Billing is for a patient who
received dialysis services in a
back-up facility.
77 = Provider accepts or is
obligated/required due to
contractual agreement or law
to accept payment by the
primary payer as payment in
full — no Medicare payment is
due.
78 = New coverage not
implemented by HMO,
indicates newly covered
service under Medicare for
which HMO does not pay.
79 = CORF services provided off site
— Code indicates that physical
therapy, occupational therapy,
or speech pathology services
were provided off site.
80 = Home Dialysis — Nursing  Facility — Home dialysis furnished in a SNF or nursing facility (eff. 4/2005)
81 = C-sections/inductions < 39 weeks —
medical necessity (eff. 10/1/13)
82 = C-sections/inductions < 39 weeks —
elective (eff. 10/2013)
83 = C-sections/inductions 39 weeks or
greater (eff. 10/2013)
84 = Dialysis for acute kidney injury (AKI)
(eff. 1/2017)
85 = Delayed Recertification of Hospice Terminal Illness (eff. 1/2017)
86 = Additional hemodialysis treatments
with medical justification (eff. date
TBD)
87 = ESRD self-care retraining (eff.
7/2017)
88 = Allogeneic stem cell transplant
related donor charges (eff. 7/2020)
89 = Opioid Treatment Program (OTP) — indicates claim is for opioid treatment services (eff. 1/2021)
90 = Service provided as part of an Expanded Access Approval (EA) to the IPPS Price.
Code is for Inpatient and Outpatient claims that have re-ported EA) services (eff. 7/2021)
91 = Service provided as part of an Emergency Use Authorization (EUA) to the IPPS Pricer. Code is for Inpatient
and Outpatient claims that have reported Emergency EUA services (eff. 7/2021)
92 = Intensive outpatient program
(IOP) (eff. 1/2024)
93–97 = Reserved for state
assignment
98 = Payer code — data associated
with DRG 468 has been validated
(eff. 7/2023)
A0 = TRICARE External Partnership Program. This code identifies
TRICARE claims submitted under the External Partnership Program.
(note that previously this was a Special Zip Code Reporting — five-digit zip code of the location
from which the beneficiary is initially placed on board the ambulance; eff. 9/2001)
A1 = EPSDT/CHAP — early and periodic screening diagnosis and treatment special program indicator code
A2 = Physically handicapped children's program — services provided receive special funding through
Title 8 of the Social Security Act or the CHAMPUS program for the handicapped
A3 = Special federal funding — designed for uniform use by state uniform billing committees.
Special program indicator code
A4 = Family planning — designed for uniform use by state uniform billing committees. Special program indicator code
A5 = Disability — designed for uniform use by state uniform billing committees
A6 = PPV/Medicare — identifies that pneumococcal pneumonia 100% payment vaccine (PPV) services
should be reimbursed under a special Medicare program provision
A7 = Induced abortion to avoid danger to woman's life
A8 = Induced abortion — victim of rape/incest. Special program indicator code
A9 = Second opinion surgery — services requested to support second opinion on
surgery. Part B deductible and coinsurance do not apply
AA = Abortion performed due to rape (eff. 10/1/2002)
AB = Abortion performed due to incest (eff. 10/1/2002)
AC = Abortion performed due to serious fetal
genetic defect, deformity, or abnormality (eff. 10/1/2002)
AD = Abortion performed due to a life endangering physical condition caused by,
arising from, or exacerbated by the pregnancy itself (eff. 10/1/2002)
AE = Abortion performed due to physical health of mother that is not life endangering (eff. 10/1/2002)
AF = Abortion performed due to emotional/psychological health of mother (eff. 10/1/2002)
AG = Abortion performed due to social economic reasons (eff. 10/1/2002)
AH = Elective abortion (eff. 10/1/2002)
AI = Sterilization (eff. 10/1/2002)
AJ = Payer responsible for copayment (4/1/2003)
AK = Air ambulance required — for ambulance claims. Time needed to transport poses a threat. (eff. 10/16/2003)
AL = Specialized treatment/bed unavailable — for ambulance claims. Specialized
treatment bed unavailable. Transported to alternate facility. (eff. 10/16/2003)
AM = Non-emergency medically necessary stretcher transport
required — for ambulance claims. Non-emergency medically
necessary stretcher transport required. (eff. 10/16/2003)
AN = Preadmission screening not required — person meets the
criteria for an exemption from preadmission screening. (eff. 1/1/2004)
B0 = Medicare Coordinated Care Demonstration Program —
patient is a participant in a Medicare Coordinated Care Demonstration (eff. 10/2001)
B1 = Beneficiary ineligible for demonstration program (eff. 1/2002)
B2 = Critical Access Hospital Ambulance Attestation — attestation by CAH that it meets
the criteria for exemption from the Ambulance Fee Schedule
B3 = Pregnancy indicator — indicates the patient is pregnant. Required
when mandated by law. (eff. 10/16/2003)
B4 = Admission unrelated to discharge — admission unrelated to
discharge on same day. This code is for discharges starting on January 1, 2004
B5 = Special program indicator Reserved for national assignment
B6 = Special program indicator Reserved for national assignment
B7 = Special program indicator Reserved for national assignment
B8 = Special program indicator Reserved for national assignment
B9 = Special program indicator Reserved for national assignment
C0 = Reserved for national assignment
C1 = Approved as billed — claim has been reviewed by the QIO and has been fully approved including any outlier
C2 = QIO approval indicator services. NOTE: Beginning July 2005, this code is relevant
to type of bills other than inpatient (18X, 21X, 22X, 32X, 33X, 34X, 75X, 81X, 82X)
C3 = Partial approval — some portion (days or services). From/Through dates of the
approved portion of the stay are shown as code “M0” in FL 36. The hospital
excludes grace days and any period at a non-covered level of care (code “77” in FL 36 or code “46” in FL 39–41)
C4 = Admission denied — the patient’s need for inpatient services was reviewed and the
QIO found that none of the stay was medically necessary
C5 = Post-payment review applicable — any medical review will be completed after the claim is paid. This bill may be a day outlier, cost outlier, part of the sample review, reviewed for other reasons, or may not be reviewed
C6 = Preadmission/Pre-procedure authorization — the QIO authorized this
admission/procedure but has not reviewed the services provided
C7 = Extended authorization — the QIO has authorized these services for an extended
length of time but has not reviewed the services provided
C8 = Reserved for national assignment. QIO approval indicator services
C9 = Reserved for national assignment. QIO approval indicator services
D0 = Changes to service dates
D1 = Changes in charges
D2 = Changes in revenue codes/HCPCS/HIPPS rate code — report this claim change reason
code on a replacement claim (Bill Type Frequency Code 7) to reflect
a change in Revenue Codes (FL42)/HCPCS/HIPPS Rate Codes (FL44)
D3 = Second or subsequent interim PPS bill
D4 = Change in ICD-9-CM diagnosis and/or procedure code
D5 = Cancel only to correct a beneficiary claim account number (HICN) or provider identification number
D6 = Cancel only to repay a duplicate payment or OIG overpayment (includes cancellation of an
outpatient bill containing services required to be included on the inpatient bill)
D7 = Change to make Medicare the secondary payer
D8 = Change to make Medicare the primary payer
D9 = Any other change
DR = Disaster relief (eff. 10/2005) — code used to facilitate claims
processing and track services/items provided to victims of disasters
E0 = Change in patient status
EY = National Emphysema Treatment Trial (NETT) or Lung Volume Reduction Surgery (LVRS) clinical study
G0 = Distinct medical visit — report this code when multiple medical visits occurred on the same day
in the same revenue center. The visits were distinct and constituted independent visits
H0 = Delayed filing, statement of intent submitted — statement of intent was submitted within the
qualifying period to specifically identify the existence of another third-party liability situation
H3 = Reoccurrence of GI bleed comorbid
category (eff. 1/2011)
H4 = Reoccurrence of pneumonia category
(eff. 1/2011)
M0 = All-inclusive rate for outpatient services. Used by 
a critical access hospital electing to be paid an allinclusive rate for outpatient services. Obsolete
M1 = Roster billed influenza virus vaccine or pneumococcal pneumonia vaccine (PPV). Obsolete
M2 = HHA Payment Significantly Exceeds Total Charges — used when payment to an
HHA is significantly more than covered billed charges. Obsolete
M3 = Payer code — SNF three-day
stay bypass for NG/Pioneer ACO
waiver (eff. 7/2023)
M4 = Payer code — presence of
infected wound or wound with
morbid obesity (eff. 7/2023)
M5 = Payer code — not currently
used by Medicare (eff. 7/2023)
M6 = Pennsylvania (PA) Rural Health Model (PARHM) (payer only code)
M7 = Payer only — shared system
Medicare deductible bypass
(eff. 7/2023)
M8 = Payer only — shared system
Medicare coinsurance bypass
(eff. 7/2023)
M9 = Payer only — shared system
Medicare deductible/coinsurance
bypass (eff. 7/2023)
MA =GI Bleed (bill type
072x), Managed Care enrollee (bill
type 012x, 013x, and 076x)
MB = Pneumonia (bill type 072x)
MC = Pericarditis (bill type 072x)
MD =Myelodysplastic Syndrome (bill type 072x)
ME = Hereditary hemolytic and sickle cell anemia (bill type 072x)
MF =Monoclonal gammopathy (bill type 072x)
MG = Payer code — Grandfathered Tribal Federally Qualified Health Centers
MH = Acute hospital care at home (payer only code) (eff. 7/2021)
MI = Payer only — MAC Medicare coinsurance bypass (eff. 7/2023)
MJ = Payer only — MAC Medicare
deductible/coinsurance bypass (eff.
7/2023)
MO = Payer code — MAC override appeal
timeliness
MP = Payer code — PHP claim contains
initial admit week
MQ = Payer code — PHP claim contains
final discharge week
MS = Payer only — Medicare SNF three-day
edit bypass (eff. 7/2023)
MV = Payer code — 20 hours for partial PHP
subsequent week not met
MW = Payer code — 20 hours for partial
PHP initial week net met
MX = Payer code — wrong surgery on
patient (inpatient)
MY = Payer code — surgery wrong
body part (inpatient), outlier cap
bypass (CMHC)
MZ = Payer code — surgery wrong
patient (inpatient), IOCE error
code bypass (outpatient)
R1 = Request for reopening reason
code — mathematical or
computational mistakes (eff.
1/2016)
R2 = Request for reopening reason
code — inaccurate data entry (eff.
1/2016)
R3 = Request for reopening reason
code — misapplication of a fee
schedule (eff. 1/2016)
R4 = Request for reopening reason
code — computer errors (eff.
1/2016)
R5 = Request for reopening reason
code — incorrectly identified
duplicate claim (eff. 1/2016)
R6 = Request for reopening reason
code — other clerical errors or
minor errors and omissions not
specified in R1–R5 above (eff.
1/2016)
R7 = Request for reopening reason code
— corrections other than clerical
errors (eff. 1/2016)
R8 = Request for reopening reason code
— new and material evidence (eff.
1/2016)
R9 = Request for reopening reason code
— faulty evidence (eff. 1/2016)
UU = Payer code — not currently used
by Medicare
W0 = United Mine Workers of America (UMWA) SNF demonstration indicator
XX = Transgender/Hermaphrodite beneficiaries (eff. 1/2/2007)
ZA = Inpatient. Positive test result is not included in the patient's medical record. eff. 7/2021 (payer only code)
ZB = Inpatient. Service provided as part of an expanded access approval. eff. 7/2021 (payer only code)
ZC = Inpatient. Clinical trial of a different product. (payer only code)
ZD–ZZ = Reserved. Not currently in use by Medicare
Z0 = PACE straddle claim