CMS Pub. 100-05, ch. 5, § 70.3.1.1

The reviewer shall review the following items, which are not specific to a particular bill

type.

A. Condition Codes: FLs 24 thru 30

The following condition codes must be completed where applicable:

• 08 - Beneficiary would not provide information concerning other

insurance coverage;

• 09 - Neither patient nor spouse employed;

• 10 - Patient and/or spouse is employed, but no GHP;

• 11- Disabled beneficiary but no Large Group Health Plan (LGHP);

• 28 - Patient and/or spouse's GHP is secondary to Medicare; or

• 29- Disabled beneficiary and/or family member’s LGHP is secondary to

Medicare.

B. Occurrence Codes and Dates: FLs 32 thru 36

The following occurrence codes must be completed where applicable:

• 18 - Date of retirement (patient/beneficiary);

• 19 - Date of retirement (spouse);

• 24 - Date insurance denied; or,

• 25 - Date benefits terminated by primary payer (date on which

coverage, including Workers' Compensation benefits or no-fault coverage,

is no longer available to patient)

In relation to the reporting of occurrence codes 18 and 19, referenced above, hospitals are

now instructed that when precise retirement dates cannot be obtained during the intake

process, they should follow this policy:

When a beneficiary cannot recall his or her retirement date but knows it occurred prior to

his or her Medicare entitlement dates, as shown on his or her Medicare card, report his or

her Medicare A entitlement date as the date of retirement. If the beneficiary is a

dependent under his or her spouse's group health insurance and the spouse retired prior to

the beneficiary's Medicare Part A entitlement date, report the beneficiary's Medicare

entitlement date as his or her retirement date.

If the beneficiary worked beyond his or her Medicare A entitlement date, had coverage

under a group health plan during that time, and cannot recall his or her precise date of

retirement but it has been at least five years since the beneficiary retired, enter the

retirement date as five years retrospective to the date of admission. (That is, if the date of

admission is January 4, 2022, the provider reports the retirement date as January 4, 2017.

As applicable, the same procedure holds for a spouse who had retired at least five years

prior to the date of the beneficiary's hospital admission.

If a beneficiary's (or spouse's, as applicable) retirement date occurred less than five years

ago, the provider must obtain the retirement date from appropriate informational sources,

e.g., former employer or supplemental insurer.

C. Value Codes and Amounts: FLs 39 thru 41

Value codes and amounts should be completed to show the type of the other coverage

and the amount paid by the other payer for Medicare covered services. Where the

hospital is requesting conditional payment, zeros should be entered beside the appropriate

value code in this item.

D. Payer Identification: FL 50A

Payer identification should be completed to show the identity of the other payer primary

to Medicare. All additional entries across line A (FLs 51-55) supply information needed

by the payer named in FL 50A.

E. Payer Identification: FLs 50B, C

Payer identification should be completed to show when Medicare is the secondary

or tertiary payer.

F. Insured's Name: FL 58A

The insured's name should be completed to show the name of the individual in

whose name the insurance is carried. This information is of particular importance

when Medicare is not the primary payer.

G. Patient's Name: FL 58B

In FL 58B, the hospital should have entered the patient's name as shown on the HI

card or other Medicare notice or as annotated in the hospital's system.

H. Patient's Relationship to the Insured: FL 59

This item indicates whether the individual may have coverage based on the

current employment status of a spouse or other family member.

I. Certification/SSN/Medicare beneficiary identifier: FLs 60A, B, C

On the same lettered line (A, B, or C) that corresponds to the line on which Medicare

payer information is shown in FLs 50-54, the hospital should have entered the patient's

Medicare beneficiary identifier. If the hospital is reporting any other insurance coverage

higher in priority than Medicare (e.g., employer coverage for the patient or the spouse

or during the first 30 months of ESRD entitlement), the involved claim number for that

coverage should be shown on the appropriate line.