CLM_RLT_COND_TB Claim Related Condition Table 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. Eff 9/93, 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 18 months of entitlement covered by employer group health insurance - indicates Medicare may be secondary insurer. Eff 3/1/96, 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 (eff 9/93) other employer sponsored/provided health insurance covering patient. 11 = The disabled beneficiary and/or family member has no group coverage from a LGHP or (eff 9/93) other employer sponsored/provided health insurance covering patient. 12 = Payer code - Reserved for internal use only by third party payers. HCFA will assign as needed. Providers will not report them. 13 = Payer code - Reserved for internal use only by third party payers. HCFA will assign as needed. Providers will not report them. 14 = Payer code - Reserved for internal use only by third party payers. HCFA will assign as needed. Providers will not report them. 15 = Clean claim (eff 10/92) 16 = SNF transition exemption - An exemption from the 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 over 100 years old - Code indicates that the patient was over 100 years old at the date of admission. 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 = Bene 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 noncovered 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 = Homecaregiver 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 (eff 3/92) 27 = Patient referred to a sole community hospital for a diagnostic laborator test - (sole community hospital only) (eff 9/93) 28 = Patient and/or spouse's EGHP is secondary to Medicare - Qualifying EGHP for employers who have fewer than 20 employees (eff 9/93) 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. 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 is 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 accomodations 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 - Eff 3/92, indicates claim is for partial hospitalization services. For OP services, this includes a variety of psych 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. 10/01) 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 post-discharge window (eff. 10/01) 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. 4/1/04) 45 = Reserved for national assignment. 46 = Nonavailability statement on file for CHAMPUS claim for nonemergency IP care for CHAMPUS bene residing within the catchment area (usually a 40 mile radius) of a uniform services hospital. 47 = Reserved for CHAMPUS. 48 = Reserved for national assignment. 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 = Reserved for national assignment. 52 = Reserved for national assignment. 53 = Reserved for national assignment. 54 = Reserved for national assignment. 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 = Payment of SNF claims for beneficiaries disenrolling from terminating M+C plans plans who have not met the 3-day hospital stay requirement (eff. 10/1/00) 59 = Reserved for national assignment. 60 = Operating cost day outlier - PRICER indicates this bill is length of stay outlier (PPS) 61 = Operating cost cost outlier - PRICER indicates this bill is a cost outlier (PPS) 62 = PIP bill - This bill is a periodic interim payment bill. 63 = PRO denial received before batch clearance report - The HCSSACL receipt date is used on PRO adjustment if the PRO's notification is before orig bill's acceptance report (Payer only code eff 9/93) 64 = Other than clean claim - The claim is not a 'clean claim' 65 = Non-PPS code - The bill is not a prospective payment system bill. 66 = Outlier not claimed - Bill may meet the criteria for cost outlier, but the hospital did not claim the cost outlier (PPS) 67 = Beneficiary elects not to use LTR days 68 = Beneficiary elects to use LTR days 69 = Operating IME Payment Only - providers request for IME payment for each discharge of MCO enrollee, beginning 1/1/98, from teaching hospitals (facilities with approved medical residency training program); not stored in NCH. Exception: problem in startup year may have resulted in this special IME payment request being erroneously stored in NCH. If present, disregard claim as condition code '69' is not valid NCH claim. 70 = Self-administered 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 100% reimbursement - (not to be used for services after 4/15/90) The billing is for home dialsis patient using a dialysis machine that was purchased under the 100% program. 76 = Back-up facility - 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 a primary payer as payment in full - Medicare pays nothing. 78 = New coverage not implemented by HMO - eff 3/92, 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. 4/4/05) 81 - 99 = Reserved for state assignment. A0 = Special Zip Code Reporting - five digit zip code of the location from which the beneficiary is initially placed on board the ambulance (eff. 9/01) A0 = CHAMPUS external partnership program special program indicator code (eff 10/93) (obsolete) A1 = EPSDT/CHAP - Early and periodic screening diagnosis and treatment special program indicator code (eff 10/93) 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. (eff 10/93) A3 = Special federal funding - Designed for uniform use by state uniform billing committees. Special program indicator code (eff 10/93) A4 = Family planning - Designed for uniform use by state uniform billing committees. Special program indicator code (eff 10/93) A5 = Disability - Designed for uniform use by state uniform billing committees. Special program indicator code (eff 10/93) A6 = PPV/Medicare - Identifies that pneumococcal pneumonia 100% payment vaccine (PPV) services should be reimbursed under a special Medicare program provision. Special program indicator code (eff 10/93) A7 = Induced abortion to avoid danger to woman's life. Special program indicator code (eff 10/93) A8 = Induced abortion - Victim of rape/incest. Special program indicator code (eff 10/93) A9 = Second opinion surgery - Service requested to support second opinion on surgery. Part B deductible and coinsurance do not apply. Special program indicator code (eff 10/93) AA = Abortion Performed due to Rape (eff. 10/1/02) AB = Abortion Performed due to Incest (eff. 10/1/02) AC = Abortion Performed due to Serious Fetal Genetic Defect, Deformity or Abnormality (eff. 10/1/02) AD = Abortion Performed due to a Life Endangering Physical Condition Caused by, arising from or exacerbated by the Pregnancy itself (eff. 10/1/02) AE = Abortion Performed due to physical health of mother that is not life endangering (eff. 10/1/02) AF = Abortion Performed due to emotional/psychological health of mother (eff. 10/1/02) AG = Abortion performed due to social economic reasons (eff. 10/1/02) AH = Elective Abortion (eff. 10/1/02) AI = Sterilization (eff. 10/1/02) AJ = Payer Responsible for copayment (4/1/03) AK = Air Ambulance Required - For ambulance claims. Time needed to transport poses a threat. (eff. 10/16/03) AL = Specialized Treatment/bed Unavailable - For ambulance claims. Specialized treatment bed unavailable. Transported to alternate facility. (eff. 10/16/03) AM = Non-emergency Medically Necessary Stretcher Transport Required - For ambulance claims. Non-emergency medically necessary stretcher transport required. (eff. 10/16/03) AN = Preadmission Screening Not Required - person meets the criteria for an exemption from preadmission screening. (eff. 1/1/04) B0 = Medicare Coordinated Care Demonstration Program - patient is a participant in a Medicare Coordinated Care Demonstration (eff. 10/01) B1 = Beneficiary ineligible for demonstration program (eff. 1/02). 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. 10/16/03) 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 - The services provided for this billing period have been reviewed by the QIO/UR or intermediary and are fully approved including any day or cost outlier. (eff 10/93) NOTE: Beginning July 2005, this code is relevant to type of bills other than inpatient (18X, 21X, 22X, 32X, 33X, 34X, 75X, 81X, 82X). C2 = Automatic approval as billed based on focused review. (No longer used for Medicare) QIO approval indicator services (eff 10/93) 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 - The services provided for this billing period have been reviewed by the QIO/UR or intermediary and some portion has been denied (days or services). (eff 10/93) NOTE: Beginning July 2005, this code is relevant to type of bills other than inpatient (18X, 21X, 22X, 32X, 33X, 34X, 75X, 81X, 82X). C4 = Admission/services denied - Indicates that all of the services were denied by the QIO/UR. QIO approval indicator services (eff 10/93) NOTE: Beginning July 2005, this code is relevant to types of bill other than inpatient (18X, 21X, 22X, 32X, 33X, 34X, 75X, 81X, 82X). C5 = Postpayment review applicable - QIO/UR review to take place after payment. QIO approval indicator services (eff 10/93) NOTE: Beginning July 2005, this code is relevant to types of bill other than inpatient (18X, 21X, 22X, 32X, 33X, 34X, 75X, 81X, 82X). C6 = Admission preauthorization - The QIO/UR authorized this admission/service but has not reviewed the services provided. QIO approval indicator services (eff 10/93) NOTE: Beginning July 2005, this code is relevant to types of bill other than inpatient (18X, 21X, 22X, 32X, 33X, 34X, 75X, 81X, 82X). C7 = Extended authorization - the QIO has authorized these services for an extended length of time but has not reviewed the services provided. QIO approval indicator services (eff 10/93) NOTE: Beginning July 2005, this code is relevant to types of bill other than inpatient (18X, 21X, 22X, 32X, 33X, 34X, 75X, 81X, 82X). C8 = Reserved for national assignment. QIO approval indicator services (eff 10/93) C9 = Reserved for national assignment. QIO approval indicator services (eff 10/93) D0 = Changes to service dates. Change condition (eff 10/93) D1 = Changes in charges. Change condition (eff 10/93) D2 = Changes in revenue codes/HCPCS/HIPPS Rate Code Change condition (eff 10/93) D3 = Second or subsequent interim PPS bill. Change condition (eff 10/93) D4 = Change in ICD-9-CM diagnosis and/or procedure code Change condition (eff 10/93) D5 = Cancel only to correct a beneficiary claim account number or provider identification number. change condition (eff 10/93) D6 = Cancel only to repay a duplicate payment or OIG overpayment (includes cancellation of an OP bill containing services required to be included on the IP bill). Change condition eff 10/93. D7 = Change to make Medicare the secondary payer. Change condition (eff 10/93) D8 = Change to make Medicare the primary payer. Change condition (eff 10/93) D9 = Any other change. Change condition (eff 10/93) DR = Disaster Relief (eff. 10/2005) - Code used to facilitate claims processing and track services and items provided to victims of Hurricane Katrina and any future disasters. E0 = Change in patient status. Change condition (eff 10/93) EY = National Emphysema Treatment Trial (NETT) or Lung Volume Reduction Surgery (LVRS) clinical study (eff. 11/97) G0 = Multiple medical visits occur on the same day in the same revenue center but visits are distinct and constitute independent visits (allows for payment under outpatient PPS -- eff. 7/3/00). 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. (eff. 9/01) M0 = All inclusive rate for outpatient services. (payer only code) M1 = Roster billed influenza virus vaccine. (payer only code) Eff 10/96, also includes pneumoccocal pneumonia vaccine (PPV) M2 = HH override code - home health total reimbursement exceeds the $150,000 cap or the number of total visits exceeds the 150 limitation. (eff 4/3/95) (payer only code) W0 = United Mine Workers of America (UMWA) SNF demonstration indicator (eff 1/97); but no claims transmitted until 2/98) XX = Transgender/Hermaphrodite Beneficiaries (eff. 1/2/07)