Variable: CLM_RLT_COND_CD

Claim Related Condition Code

Description

The code that indicates a condition relating to an institutional claim that may affect payer processing.

Comment

n/a

Values

This variable is coded, and will contain one of the following values.

Values for

Value	Description
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. 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 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 other employer sponsored/provided health insurance covering patient.
11	The disabled beneficiary and/or family member has no group coverage from a LGHP or other employer sponsored/provided health insurance covering patient.
12	Payer code - Reserved for internal use only by third party payers. CMS will assign as needed. Providers will not report them.
13	Payer code - Reserved for internal use only by third party payers. CMS will assign as needed. Providers will not report them.
14	Payer code - Reserved for internal use only by third party payers. CMS will assign as needed. Providers will not report them.
15	Clean claim. Delayed in CMS's processing system.
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 homeless.
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	Beneficiary requested billing - Provider realizes the services on this bill are at a non-covered 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 non-covered 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	Home caregiver 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
27	Patient referred to a sole community hospital for a diagnostic laboratory test -(sole community hospital only).
28	Patient and/or spouse's EGHP is secondary to Medicare - Qualifying EGHP for employers who have fewer than 20 employees.
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 at 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 accommodations 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 services. For OP services, this includes a variety of psychiatric 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 Post-discharge 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	Non-availability statement on file for TRICARE claim for nonemergency IP care for TRICARE bene residing within the catchment area (usually a 40 mile radius) of a uniform services hospital.
47	Reserved for TRICARE.
48	Psychiatric Residential Treatment Centers for Children and Adolescents (RTCs). Claims submitted by TRICARE.
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	Terminated Managed Care Organization Enrollee - patient is a terminated enrollee in a Managed Care Plan whose three-day inpatient hospital stay was waived.
59	Non-primary ESRD Facility - ESRD beneficiary received non-scheduled or emergency dialysis services at a facility other than his/her primary ESRD dialysis facility. (eff.10/2004)
60	Operating cost day outlier - PRICER indicates this bill is length of stay outlier (PPS)
61	Operating cost outlier - PRICER indicates this bill is a cost outlier (PPS)
62	PIP bill - This bill is a periodic interim payment bill.
63	Payer Only Code - Reserved for internal payer use only. CMS assigns as needed. Providers do not report this code. Indicates services rendered to a prisoner or patient in State or local custody meeting requirements of 42 CFR 411.4(b)
64	Other than clean claim - The claim is not a 'clean claim'
65	Non-PPS bill - The bill is not a prospective payment system bill.
66	Hospital Does Not Wish Cost Outlier Payment - Bill may meet the criteria for cost outlier, but the hospital did not claim the cost outlier (PPS)
67	Beneficiary elects not to use Lifetime Reserve (LTR) days
68	Beneficiary elects to use LTR days
69	IME/DGME/N&A Payment Only - providers request for request for a supplemental payment for IME/DGME/N&AH (Indirect Medical Education/Graduate Medical Education/Nursing and Allied Health).
70	Self-administered Epoetin (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 dialysis patient using a dialysis machine that was purchased under the 100% program.
76	Back-up in facility dialysis - 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 the primary payer as payment in full - no Medicare payment is due.
78	New coverage not implemented by HMO, 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)
A1	EPSDT/CHAP - Early and periodic screening diagnosis and treatment special program indicator code.
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.
A3	Special federal funding - Designed for uniform use by state uniform billing committees. Special program indicator code
A4	Family planning - Designed for uniform use by state uniform billing committees. Special program indicator code
A5	Disability - Designed for uniform use by state uniform billing committees.
A6	PPV/Medicare - Identifies that pneumococcal pneumonia 100% payment vaccine (PPV) services should be reimbursed under a special Medicare program provision.
A7	Induced abortion to avoid danger to woman's life.
A8	Induced abortion - Victim of rape/incest. Special program indicator code
A9	Second opinion surgery - Services requested to support second opinion on surgery. Part B deductible and coinsurance do not apply.
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 - Claim has been reviewed by the QIO and has been fully approved including any outlier.
C2	QIO approval indicator services. 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 - some portion (days or services). From/Through dates of the approved portion of the stay are shown as code “M0” in FL 36. The hospital excludes grace days and any period at a non-covered level of care (code “77” in FL 36 or code “46” in FL 39-41).
C4	Admission denied - The patient’s need for inpatient services was reviewed and the QIO found that none of the stay was medically necessary.
C5	Post-payment review applicable - Any medical review will be completed after the claim is paid. This bill may be a day outlier, cost outlier, part of the sample review, reviewed for other reasons, or may not be reviewed.
C6	Preadmission/Pre-procedure authorization - The QIO authorized this admission/procedure but has not reviewed the services provided.
C7	Extended authorization - The QIO has authorized these services for an extended length of time but has not reviewed the services provided.
C8	Reserved for national assignment. QIO approval indicator services
C9	Reserved for national assignment. QIO approval indicator services
D0	Changes to service dates.
D1	Changes in charges.
D2	Changes in revenue codes/HCPCS/HIPPS Rate Code - Report this claim change reason code on a replacement claim (Bill Type Frequency Code 7) to reflect a change in Revenue Codes (FL42)/HCPCS/HIPPS Rate Codes (FL44)
D3	Second or subsequent interim PPS bill.
D4	Change in ICD-9-CM diagnosis and/or procedure code
D5	Cancel only to correct a beneficiary claim account number (HICN) or provider identification number.
D6	Cancel only to repay a duplicate payment or OIG overpayment (includes cancellation of an outpatient bill containing services required to be included on the inpatient bill).
D7	Change to make Medicare the secondary payer.
D8	Change to make Medicare the primary payer.
D9	Any other change.
DR	Disaster Relief (eff. 10/2005) - Code used to facilitate claims processing and track services/items provided to victims of disasters.
E0	Change in patient status.
EY	National Emphysema Treatment Trial (NETT) or Lung Volume Reduction Surgery (LVRS) clinical study
G0	Distinct Medical Visit - Report this code when multiple medical visits occurred on the same day in the same revenue center. The visits were distinct and constituted independent visits.
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.
M0	All-inclusive rate for outpatient services. Used by a Critical Access Hospital electing to be paid an all-inclusive rate for outpatient services.
M1	Roster billed influenza virus vaccine or pneumococcal pneumonia vaccine (PPV).
M2	HHA Payment Significantly Exceeds Total Charges - Used when payment to an HHA is significantly in excess of covered billed charges.
MA	GI Bleed.
MB	Pneumonia.
MC	Pericarditis.
MD	Myelodysplastic Syndrome.
ME	Hereditary Hemolytic and Sickle Cell Anemia.
MF	Monoclonal Gammopathy.
W0	United Mine Workers of America (UMWA) SNF demonstration indicator
XX	Transgender/Hermaphrodite Beneficiaries (eff. 1/2/07)

Other Info

Some additional information on this variable:

• Short Name: RLT_COND
• Long Name: CLM_RLT_COND_CD
• Type: CHAR
• Length: 2
• Source: NCH
• Value Format: