Condition / Occurrence Codes


If you have questions about which condition or occurrence codes to use, please call the payer to ask. Barnestorm does not have this information.

D7 and/or D9 goes on the Medicaid payer extra billing info when the patient also has Medicare, but is not homebound; and Medicare is either d/c or was never used for that admission.

Condition code D7 can be used to override Medicare Part A, and condition code D9 can be used to override Medicare Part B when the services provided are noncovered or the services do not meet Medicare criteria.

If the patient has Medicare Part A and Medicare Part B, include both condition codes in the extra billing info tab, under Medicaid payer.

For CMS 1500 form > Box 10 Is Patient's Condition Related to Employment, Auto Accident, Other Accident:
Condition code 02 will make box 10a (employment) answer as yes; occurrence codes 01 or 02 will make box 10b (auto accident) answer as yes; occurrence code 03 or 05 will make 10c (other accident) answer as yes; occurrence code 04 will make 10a (employment)  yes and 10c (other accident).

No condition code is needed to bill supplies.
HI*BG:D7~   this is the line in the claim with the condition code. In this case, it's D7.

Here is a site with condition codes:

https://www.cgsmedicare.com/parta/pubs/news/2013/0213/cope21194.html#B

Condition / Occurrence Codes for a patient (which show on a UB form, for example) are found and changes as follows:

  1. Select the patient.
  2. Click on Referral.
  3. Click the Payers tab.
  4. Click the Extra Billing Info button.
  5. If the code is only for a specific time period then click the Add  New "From Date" to select your dates.  Otherwise, continue to next step.
  6. Enter the condition or occurrence code (and dates if needed).
  7. Click the Save button. 
  8. The panel in the upper right shows any dates for which there are extra billing listings for the patient. To update an existing code select the entry.
  9. Change the condition codes as needed.
  10. Click the Save button.
  11. Click the Exit button in the upper right.
      Read the highlighted box at the top of screen for extra direction.

For the new occurrence codes related to PDGM, you do not have to manually enter these codes.  These codes will be entered by the system, based on the information below:

Occurrence Code 61 and Occurrence Code 62
  • Make sure the staff is using the Patient Facility History and correctly classifying the facility.  This information will be used to create the Occurrence Code 61 (Acute Care Hospital stay) or 62 (SNF, IRF, LTCH, IPF facility stay) - even though these will ultimately be determined by the Medicare claims processing system itself, once the claims from the other facilities have been processed.  The main effect will be the $amount assigned to the episode when the RAP is created, so that revenue projections will be as real as possible.
Occurrence Code 50
  • Occurrence Code 50 will be added with the M0090 date of the OASIS.