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February 12, 2013

Medicare Secondary Payer (MSP): Condition, Occurrence, Value, and Patient Relationship, and Remarks Field Codes

This article includes tables of some of the most common Condition, Occurrence, Value, Patient Relationship, and Remarks Field Codes associated with MSP claims. Please note: these code lists are not all-inclusive. Complete code sets are available through the National Uniform Billing Committee (NUBC) website, www.nubc.org.

To navigate directly to a particular type of code, click on the type of code from the following list:

Condition Codes (ccs) (UB-04 FLs 18-28)

Code Description
02 Condition is employment related
06 End-stage renal disease (ESRD) beneficiary in first 30 months of eligibility/entitlement covered by an employer group health plan (EGHP)
08 Beneficiary refused to provide information concerning other insurance coverage
09 Neither the beneficiary nor spouse is employed
10 Beneficiary and/or spouse is employed but no EGHP
11 Disabled beneficiary and/or family member is employed but no large group health plan (LGHP)
28 Beneficiary's and/or spouse's EGHP is secondary to Medicare. Beneficiary and/or spouse are employed and there is an EGHP that covers beneficiary but either:
  1. EGHP is a single employer plan and employer has fewer than 20 full- and/or part-time employees
  2. EGHP is a multi- or multiple-employer plan that elects to pay secondary to Medicare for employees and spouses aged 65 and older for those participating employers who have fewer than 20 employees
29 Disabled beneficiary and/or family member's LGHP is secondary to Medicare. Beneficiary and/or family member(s) are employed and there is a LGHP that covers beneficiary but either:
  1. LGHP is a single employer plan and employer has fewer than 100 full- and/or part-time employees
  2. LGHP is a multi-or multiple employer plan and all employers participating in plan have fewer than 100 full- and/or part-time employees
63 Services rendered to beneficiary in state or local custody (prisoner) meets requirements of 42 CFR 411.4(b) for payment
77 Provider accepts or is obligated/required, due to a contractual arrangement/law, to accept payment by primary payer as payment in full (and that amount has been received and no Medicare payment is due). MSP claim is being filed because claim is an inpatient claim or claim is an outpatient claim and the beneficiary has not yet met his/her annual Medicare Part B deductible.
D7 Change to make Medicare the secondary payer (report on adjustment when original claim was processed as a Medicare primary claim, conditional claim or was rejected for MSP).
D8 Change to make Medicare the primary payer (report on adjustment when original claim was processed as an MSP claim or as a conditional claim).
D9 Any other change (report on adjustment claim when original claim was rejected for MSP but Medicare is primary or when original claim was processed as an MSP or conditional claim and a change needs to be made to the claim such as a change in the MSP VC amount).

Occurrence Codes (OCs) and Dates (UB-04 FLs 31 34)

Code Description
01 Accident/Medical Payment Coverage Date of accident/injury for which there is medical payment coverage. Reported with VC 14 or VC 47. If filing for a Conditional Payment, report with Occurrence Code 24.
02 No-Fault Insurance (including automobile and other accidents) Date of accident/injury for which the state has applicable No-Fault laws. Reported with VC 14 or 47. If filing for a Conditional Payment, report with Occurrence Code 24.
03 Accident/Tort Liability - Date of an accident/injury resulting from a third party's action that may involve a civil court action in an attempt to require payment by third party, other than No-Fault. Reported with VC 47.
04 Accident/Employment-Related - Date of an accident/injury related to beneficiary's employment. Reported with VC 15 or VC 41. If filing for a Conditional Payment, report with Occurrence Code 24.
05 Accident/No Medical Payment, No-Fault or Liability Coverage Date of accident/injury for which there is no Medical Payment or other third-party liability coverage
06 Crime victim - Date on which a medical condition resulted from alleged criminal action committed by one or more parties
18 Date of retirement (beneficiary)
19 Date of retirement (spouse)
24* Date Insurance denied - Date of receipt of a denial of coverage by a higher priority payer. This could be date of primary payer's Explanation of Benefit (EOB) statement, letter or other documentation. Date is required on all Conditional Payment claims.
25 Date Coverage No Longer Available Date on which coverage, including Workers' Compensation benefits or No-Fault coverage, is no longer available to beneficiary
33 First day of MSP ESRD coordination period for ESRD beneficiaries covered by an EGHP

* Maintain documentation on file that supports the request for conditional payment from Medicare, such as the primary payer's EOB statement, denial/rejection letter, etc.

Value Codes (VCs) and Amounts (UB-04 FLs 39-41) When entering amounts for VCs (except for VC 44), the following applies:

Code Description
12 Working aged beneficiary/spouse with an EGHP (beneficiary over 65). Beneficiary must have Medicare Part A entitlement (enrolled in Part A) for this provision to apply. Primary Payer Code = A.
13 ESRD beneficiary with EGHP in MSP/ESRD 30-month coordination period. Primary Payer Code = B.
14 No-Fault including automobile/other. Examples: Personal injury protection (PIP) and medical payment coverage. Requires OC 01 or 02 with date of accident/injury. Primary Payer Code = D. If filing for a Conditional Payment, report with Occurrence Code 24.
15 Workers Compensation (WC). Requires CC 02 and OC 04 with date of accident/injury. Primary Payer Code = E. If filing for a Conditional Payment, report with Occurrence Code 24.
16 Public health services (PHS) or other federal agency. Conditional billing does not apply. Primary Payer Code = F.
41 Federal Black Lung (BL) Program. Primary Payer Code = H.
42 Veterans Administration (VA). Conditional billing does not apply. Primary Payer Code = I.
43 Disabled beneficiary under age 65 with an LGHP. Beneficiary must have Medicare Part A entitlement (enrolled in Part A) for this provision to apply. Primary Payer Code = G.
44 Amount provider was obligated/required to accept from a primary payer as payment in full due to contract/law when that amount is less than charges but higher than amount actually received. An MSP payment may be due. Note: When applicable, this VC is reported in addition to MSP VC.
47 Any Liability Insurance. Requires OC 03 with date of accident/injury. Primary Payer Code = L. If filing for a Conditional Payment, report with Occurrence Code 24.

Primary Payer Codes Primary Payer codes are not reported by the provider via electronic submission of a MSP claim. Primary Payer codes are applied to the claim upon transfer to the Fiscal Intermediary Standard System (FISS) based on the corresponding electronic data reported. Primary Payer Codes of A to L (except C) must match MSP VC reported on claim. For example, MSP VC 12 = Primary Payer Code A, etc.

FISS only:

Code Description MSP VC
A Working Aged with EGHP 12
B ESRD with GHP in 30-month coordination period 13
C Conditional Payment Any
D No-Fault including Automobile/other insurance 14
E Workers' Compensation (WC) 15
F Public Health Service (PHS) or other federal agency 16
G Disabled with LGHP 43
H Federal Black Lung (BL) Program 41
I Veteran's Administration (VA) 42
L Liability 47
Z Medicare None

Patient Relationship Codes (UB-04 FL 59A, B, C)

Code Description
01 Spouse
18 Self
19 Child
20 Employee
21 Unknown
39 Organ Donor
40 Cadaver Donor
53 Life Partner
G8 Other Relationship

Remarks The Remarks field (UB-04 FL 80) contains the following two-digit explanation code used for conditional claims. MSP and conditional claims require primary payer's address present in Remarks.

Code Description Acceptable with VC(s)
BE Benefits are exhausted. Always requires date benefits were exhausted in MM/DD/YY format. Bill conditionally when no payment received from primary payer and claim's DOS is prior to exhaustion date. *No-Fault states should use PE; not BE. Note: Automobile No-Fault states should not use this code on automobile accident claims. See code PE below. 12, 13, 14, 15, 41, 43
CD Charges applied to co-payment, coinsurance or deductible. 12, 13,14, 43
DA 120 days have passed since the primary payer was billed. Always requires date primary payer was billed in MM/DD/YY format. Report OC 24 with date insurance denied. *For VC 47, provider must have withdrawn claim with liability. 14, 15, 41, 47*
DP Delay in payment from liability insurer. Report OC 24 with date insurance denied. See OC 24 above. 47
FG Beneficiary did not follow guidelines of their primary health plan. Only used for out of network, untimely filing or no prior authorization. Always requires statement as to which of these guidelines was not followed. 12, 13, 15, 43
LD Response received from liability insurer stating they are not responsible for Claim. 47
NB Not a covered benefit. Report OC 24 with date insurance denied. See OC 24 above. 12, 13, 14, 15, 41, 43
PC Pre-existing condition. Report OC 24 with date insurance denied. See OC 24 above. 12, 13, 43
PE *No-Fault (also known as PIP) has been exhausted toward medical expenses. Always requires date benefits were exhausted in MM/DD/YY format. Provider must have copy of PIP on file. Bill conditionally when no payment received from primary payer and claim's DOS is prior to exhaustion date. 14
PP Beneficiary paid by liability insurer. Used only for conditional claims involving liability insurance payments to the beneficiary where the provider is not expecting any payment from the beneficiary. Report OC 24 with date insurance denied. See OC 24 above. Note: May not be used for medical payment insurance payments to the beneficiary (VC 14). Providers are required to pursue those dollars. 47

* Automobile No-Fault states include Florida, Hawaii, Kansas, Kentucky, Massachusetts, Michigan, Minnesota, North Dakota, New Jersey, New York, Pennsylvania, and Utah. Puerto Rico, a U.S. commonwealth, is also No-Fault.

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