Condition Codes for UB-04 Explained In Detail

If your team files facility claims and still gets avoidable denials, the issue is often missing or incorrect condition codes for UB-04. These small two-character indicators tell the payer what special circumstance applies to the claim. When they are wrong or absent, the claim loses context and stalls. In this article, you will learn what these codes mean, where they go on the form, how they affect adjudication, a practical view of a list of condition codes for UB 04 you will see most often, and a workflow you can apply today to reduce rework. 

Definition of Condition Codes

The National Uniform Billing Committee (NUBC) defines condition codes as short codes that flag special situations on a UB-04 claim, things that can change how the claim is processed. On the UB-04, these codes go in Form Locators (FL) 18–28. CMS confirms this placement in its Medicare Claims Processing Manual, Chapter 25.
The field attributes of condition codes described in NUBC’s manual are “11 fields, 1 line, two positions, alphanumeric, and all positions fully coded.”

Key attributes of condition codes

• Fields: 11 available slots on the UB-04 (FL 18–28)
• Format: two-character, alphanumeric
• Entry: include the applicable codes for proper claim submission
• Official source: NUBC Official UB-04 Data Specifications Manual

What Are Condition Codes for UB-04, and Why Do They Matter?

Condition codes are two-digit alphanumeric indicators reported on the UB-04 to describe a billing circumstance that changes how the payer reads the claim. Examples include treatment for a hospice patient when services are unrelated to the terminal diagnosis, information-only billing, non-work-related injuries, second surgical opinions, or asking for a denial so a secondary plan can process.

They matter because they affect three key outcomes.

• First, whether the claim is accepted during front-end processing.
• Second, which payer rules and pricing methods are applied?
• Third, who is financially responsible when coverage is limited or overlaps?

Where Do Condition Codes Appear On The UB-04, and  How Many Can You Report?

Report condition codes only in Form Locators 18 through 28. You can submit more than one when multiple circumstances apply. Payer and plan manuals also note that these fields accept multiple entries so long as each is relevant and supported by documentation.

If you use a code that implies a patient notice, such as an ABN, keep the signed paperwork with the encounter in case of post-payment review.

Who Defines and Maintains the  Official List

The National Uniform Billing Committee (NUBC) owns the official data set for the UB-04, including FL 18-28 Condition Codes, and licenses the specifications. CMS points providers to the NUBC data for the authoritative definitions. Always validate any crib sheet against the current NUBC manual.

Most commonly used UB-04 Condition Codes for 2026

Below is a practical view of common condition codes you will meet frequently in hospital, outpatient, and dental facility claims. Use payer manuals for exact applicability and state variations.

Code	Meaning	When You Typically Use It
20	Demand bill / Beneficiary requested billing	The patient wants Medicare to deny, so Medicaid/other payer can pay (common in SNF/home health)
21	Billing for denial notice	Hospital knows services are non-covered but needs an official denial for secondary payer
40	Same-day transfer	Patient transferred to another acute-care hospital the same day
41	Partial hospitalization (psych)	Psychiatric partial hospitalization program
42	Home health/SNF care not related to inpatient stay	Breaks the 3-day rule linkage
44	Inpatient admission changed to outpatient (W0/W1 on 837I)	Hospital billed inpatient but UR changed it to outpatient observation before discharge
47	Transfer to a Critical Access Hospital (CAH)	Used when transferring to a CAH
55	SNF bed not available	Patient discharged from hospital >30 days ago because no SNF bed was available
56	Delayed SNF admission – medical appropriateness	Patient too sick to go to SNF within 30 days
57	SNF readmission within 30 days	Patient returns to SNF within 30 days of prior covered SNF stay

Medicare Secondary Payer (MSP) – Very Common

Code	Meaning
2	Condition is employment-related (Workers’ Comp)
4	Auto accident / no-fault
6	ESRD – first 30–36 months with employer group health plan (Medicare is secondary)
8	Beneficiary refuses to tell you about other insurance
09–11	No EGHP/LGHP despite patient/spouse/disabled beneficiary working

Claim Adjustment / Correction Codes (for 7xx/8xx bills)

Code	Meaning
D0	Change in dates only
D1	Change in charges only
D2	Change in revenue/HCPCS/CPT codes
D4	Change in diagnosis or procedure codes
D7	Change Medicare from primary to secondary
D8	Change Medicare from secondary to primary
D9	Any other change / “catch-all”

Other Frequent Codes

Code	Meaning
7	Treatment of non-terminal illness for a hospice patient
30	Qualified clinical trial (non-research services)
G0	Multiple medical visits on the same day (distinct E/Ms)
77	The provider accepts the primary payer’s amount as payment in full (zero Medicare payment expected)

 

For a detailed list of condition codes for UB 04, check out this – UB04 Condition Codes List 2026

How Do Condition Codes Influence Payment?

Condition codes frame the claim. They help the payer connect the clinical service to the correct policy path.

• Acceptance: Front-end edits check whether required indicators are present when the situation applies. Missing or conflicting entries can cause an immediate return without medical review.
• Adjudication path: Hospice-related indicators, transfers, liability or no-fault exhaustion, and information-only billing all change routing and pricing logic. Medicare contractors document these nuances and how certain codes shift claims between primary and secondary responsibility. 
• Patient responsibility: ABN-related codes influence whether the patient becomes liable when coverage does not apply. Use them only with proper documentation and timing. Guidance from planners and contractors aligns with this requirement.

How To Build A Clean Workflow For Condition Codes

Adopt a short, repeatable checklist that reduces variation and keeps your indicators accurate.

• Intake: Capture accident, work relation, hospice or military status, and other liability signals at registration.
• Coverage: Verify primary and secondary benefits, effective dates, and any new coverage since service. Ask directly about a plan change.
• Clinical: Identify scenarios that need a patient notice, such as an ABN. Store the signed form with the encounter.
• Coding: Select the right condition codes for UB-04 in FL 18 through 28. If the scenario implies an event, add the correct occurrence code or occurrence span code with dates. 
• Quality check: Audit the claim before submission. Confirm that each code in FL 18-28 is supported by notes or documents and aligns with your revenue and value codes.
• Education: Update job aids quarterly. Replace internal copies after each official change notice. CMS directs providers to use the NUBC data set for the official specification.

 

Who Benefits Most From Mastering Condition Codes in  Dental and Outpatient Settings?

• Oral surgery centers that coordinate with medical benefits
• Hospital-based dental clinics using facility claims for anesthesia or operating room time
• Multi-specialty practices filing professional and facility claims for the same encounter
• Any office that needs a formal denial so a secondary plan can consider payment

Teams that keep a simple list of condition codes for UB 04, validate placement in FL 18-28, and train billers on documentation expectations see fewer returns and faster cash flow.

Final Thoughts

Mastering condition codes for UB 04 is not about memorizing every line in a manual. It is about recognizing the moments when a code is needed, putting it in the right field, and keeping proof that the circumstance applies. Keep a short internal list of condition codes for UB 04, train your team to document Advance Beneficiary Notice (ABNs) and special situations, and run a quick pre-submission audit so your common condition codes are accurate every time.

FAQs

What are the condition codes for UB-04?

They are two-character indicators in FL 18 through 28 that describe special circumstances affecting how a payer processes and prices an institutional claim.

Can I report more than one code?

Yes. Add all that apply and support each with documentation.

Do dental and oral surgery facilities use them?

Yes. If you file facility claims on the UB-04, use applicable indicators so the payer applies the correct rules.

Will the wrong or missing code cause denial?

It can. Edits and policy logic rely on accurate indicators placed in the correct fields.