Condition Codes

The following is a list of Condition Codes for worker's compensation claims that are valid for use on the 1500 Health Care Claim Form.

W2  Duplicate of original bill

W3   Level 1 appeal

W4   Level 2 appeal

W5   Level 3 appeal

Currently, Condition Codes are designed to allow the collection of information related to the patient, particular services, service venue and billing parameters which impact the processing of an Institutional claim.  Some examples of this information are, employment status, qualified clinical trial, same day transfer, home care giver available, cost outlier and pregnancy indicator.  These codes are integral to the institutional claim, both the paper UB and the electronic 837I.

The National Uniform Billing Committee (NUBC) ballots and maintains these Condition Codes as part of the NUBC Universal Billing (UB) Code Set, which is an external code set..  Requests for new codes or modification of codes may be submitted through the NUBC web site at http://www.nubc.org/change.htm.

As the health care industry prepared for HIPAA implementation, it became apparent that conditional information, not available in the claim formats, was needed to effectively process claims in an electronic format.  In 2002, several requests were entered into the DSMO process for changes to the 837 Professional transaction.  The NUCC in reviewing the DSMO requests agreed that the functionality provided by the Condition Codes could potentially be an asset to the 1500 Health Care Claim Form and approved the constrained use of Condition Codes.  In agreement with the NUBC, requirements for the creation of a subset of the Condition Codes for use in the professional claim were developed and license granted by NUBC for publication of the subset of codes by NUCC.  Because of legal ramifications and rules for federal financial participation (FFP) with state Medicaid programs, the NUCC approved the Condition Codes for abortion and sterilization as part of the NUCC data set and the X12 Claims workgroup voted to add these codes to the claim level starting with version 004050 of the 837 Professional Health Care Claim.  The Condition Codes may be reported in field 10D of the 1500 Claim Form.  However, entities reporting these codes should refer to the most current instructions for any federal, state, or individual payment specific instructions that may be applicable to the 1500 Claim Form.