Medical Billing

How is the Condition Code in Medical Billing defined?

How is the Condition Code in Medical Billing defined

If you’re in the medical billing field, you know that condition codes are an important part of coding and billing procedures. But what exactly are condition codes, and how do you use them correctly? In this blog post, we’ll explore everything you need to know about condition code, from what they are to how to use them correctly.

What is a Condition Code?

Condition coding is used to specific circumstances or occurrences connected to a medical bill that could influence processing. The Official UB-04 Data Specifications Manual 2007, published by the National Uniform Billing Committee (NUBC), defines condition codes.

Condition codes are used to inform payers of unique aspects of a patient’s care, such as whether the patient was an inpatient or an outpatient at the time of service, whether they were transferred from another facility, or whether the service was provided in an unusual setting.

What is a Condition Code

Understand the Conditions by NUBC

The Official UB-04 Data Specifications Manual is produced and updated by the National Uniform Billing Committee (NUBC). The manual offers comprehensive instructions on how to properly complete the UB-04 claim form for reimbursement.

The form locators from 18-28 are further divided into situations identified by sub-codes referring to and/or explaining the situation. The NUBC’s 2007 manual lists 99 situations with numeric codes ranging from 01-99. For instance, sub-code 01 refers to the Military Service-Related situation, which is defined as medical issues that arose while a person was serving in the military. The sub-code 09 refers to the patient being homeless, as the patient is homeless. The sub-code 80 refers to home dialysis provided in a skilled nursing facility or nursing facility. The final numeric sub-codes, ranging from 81 to 99, are held in reserve for NUBC’s use.

These codes can be used to identify particular services or programs for which a patient may qualify, such as TRICARE, abortions performed as a result of rape, or Do Not Resuscitate directives.

Condition codes can also help explain why a procedure was performed, such as in the case of the UMWA demonstration indicator. By understanding what these codes mean, medical billing professionals can more accurately code claims and ensure that patients receive the correct level of care and services.

How is Condition Code used?

Understanding how to properly use condition codes can help ensure that claims are processed correctly and payments are made promptly.

There are a few things to keep in mind when using condition codes:

  • Condition codes must be used in sequence.
  • Be sure to include all the relevant information when filling out the condition codes. Leaving out key details could result in delays or denied claims.

If you have any questions about how to properly use condition codes, don’t hesitate to reach out to your medical billing provider for guidance.

List of Condition Codes

List of Condition Codes

Condition codes are used in medical billing to indicate a change or correction to a claim. There are many different condition codes, each with its specific meaning.

Here is a list of some of the most common condition codes:

  • D0: This code is used when changing the from and through dates of a claim.
  • D1—This code is used when changing the diagnosis or procedure code on a claim.
  • D2: This code is used when changing the revenue codes, HCPCS codes, HIPPS codes, or RUG codes on a claim.
  • D3—This code is used when submitting subsequent or second interim claims by inpatient PPS hospitals.
  • D4—This code is used when adding or changing diagnosis and procedure codes (ICD-9/ICD-10). To delete codes, D9 would be appropriate.
  • D5—This code is used when canceling claims to correct the Medicare ID or provider number.
  • D6 – This code is used when canceling claims to repay a payment. The D6 condition code is only applicable on an xx8 type of bill.
  • D1 – If none of the above condition codes apply and there is a change to the covered charges, adding a modifier would make the charges covered on the adjustment claim.
  • E0: Use E0 when a correction to the patient status code needs to be made on the claim. Changes to patient status can include things like discharged/not discharged, deceased/not deceased, etc.


The special circumstances surrounding a patient’s treatment are noted using a condition code in case they have an impact on how the bill is handled. Condition codes are important because they help alert players to events or conditions that might otherwise go unnoticed. Understanding how to use condition codes can help ensure that medical bills are processed correctly and efficiently.