UB04 Patient Discharge Status Code 04: Discharged/transferred to an intermediate care facility (ICF)

Overview

Code 04 on the UB-04 claim form (Field 17 – Patient Discharge Status) is defined as “Discharged/transferred to a facility that provides custodial or supportive care.” This category covers patients who are moved to a setting where the primary purpose is long‑term maintenance, personal care, or supervision rather than active medical treatment. Examples include intermediate care facilities for intellectual disabilities (ICF/IID), residential care homes, assisted living facilities, or other custodial‑care institutions. It is distinct from a skilled nursing facility (SNF) stay (Code 03), a Medicare‑certified long‑term care hospital (Code 63), or a nursing facility certified only under Medicaid (Code 64). The source for this definition is the Noridian Medicare patient status code list, which explicitly assigns “04” to “Discharged/transferred to a facility that provides custodial or supportive care.” ^[1]

When a patient is discharged to such a facility, the provider must ensure the destination meets the “custodial or supportive” definition and that no higher‑acuity designation applies. The code is used for Medicare, Medicaid, and commercial claims alike, though payers may require additional documentation (e.g., a transfer form or level‑of‑care assessment). The MassHealth UB‑04 billing guide notes that all UB‑04 claims must be completed accurately using the current code sets, but it does not provide a separate list of discharge status codes; providers should refer to the National Uniform Billing Committee (NUBC) or payer‑specific guidance. ^[2]

When to Use

Code 04 should be applied when a patient is transferred to a facility that provides custodial or supportive care, meaning the primary services are assistance with activities of daily living (ADLs), supervision, or non‑skilled care. This includes:

• Intermediate care facilities for individuals with intellectual disabilities (ICF/IID).
• Assisted living facilities where the resident does not require daily skilled nursing.
• Residential care homes or group homes that provide room, board, and personal care.
• Any other custodial‑care facility that is not a skilled nursing facility, inpatient rehabilitation, or acute‑care hospital.

Important nuance: If the transfer is to a nursing facility that is certified under Medicaid but not under Medicare, use Code 64 instead. If the facility is a Medicare‑certified SNF, use Code 03. If the patient is discharged to home with home health, use Code 06. Code 04 should never be used when the patient is discharged to a short‑term general hospital (Code 02) or expires (Code 20).

The source Noridian list shows that Code 04 is the base code; a related code 84 exists for the same destination when there is a planned acute care hospital inpatient readmission (effective 10/1/13). ^[1]

When to use Code 84 instead of 04: If at the time of discharge to custodial/supportive care, the medical record documents a planned readmission to an acute care hospital for a scheduled procedure or treatment (e.g., a staged surgery or planned chemotherapy) that will occur within a specific timeframe. Using the base code without the planned readmission indicator in such cases may trigger audit scrutiny.

Step‑by‑Step Claim Example

Below is a realistic scenario demonstrating how to complete UB-04 Field 17 (Patient Discharge Status) with Code 04.

Scenario:

• Patient: John Doe, Medicare Part A beneficiary.
• Admitted to General Hospital on 01/10/2025 for pneumonia.
• After stabilization, he is transferred to an assisted living facility that provides custodial care (no skilled nursing needed).
• No planned acute care hospital readmission is scheduled.

UB-04 Fields (partial):

Field	Description	Entry
1	Provider Name, Address, Telephone	General Hospital, 123 Main St., Anytown, USA
2	Pay-to Name & Address	Same as above
3a	Patient Control Number	12345
3b	Medical Record Number	MRN-98765
4	Type of Bill	111 (Hospital Inpatient)
6	Statement Covers Period (From/Through)	01/10/2025 – 01/15/2025
8a	Patient Identifier	123-45-6789
9a	Patient Name	Doe, John
10	Patient Birthdate	01/01/1945
11	Patient Sex	M
12	Admission Date	01/10/2025
13	Admission Hour	14 (2:00 PM)
14	Admission Type	1 (Emergency)
15	Source of Admission	4 (Transfer from another health care facility)
17	Patient Discharge Status	04
18	Condition Codes	(blank)
19-24	Discharge Dates & Hours	01/15/2025, 11 (11:00 AM)
31-34	Occurrence Codes	(if applicable)
42-49	Revenue Codes and Charges	0120 (Room & Board – Semi‑Private) etc.

The claim is submitted with Code 04 in Field 17, indicating transfer to a custodial/supportive care facility. The billing staff would also attach a transfer form or discharge summary confirming the facility’s level of care. The MassHealth guide reminds providers that all claims must be accurate and complete; for paper claims (if a waiver is granted), the UB-04 must be filled legibly. ^[2]

Common Mistakes & Audit Red Flags

1. Mixing custodial care with skilled nursing. Using Code 04 when the destination facility is a Medicare‑certified SNF (should be Code 03) or a Medicaid‑only nursing facility (should be Code 64) is a frequent error. Auditors will cross‑reference the receiving facility’s provider number and certification type.
2. Omitting the planned readmission indicator (Code 84). If the discharge is to custodial care but a future acute care admission is already scheduled, the base code 04 is incorrect. Use Code 84 to avoid denials.
3. Using Code 04 for patients who expire or leave against medical advice. Code 20 (Expired) or Code 07 (Left AMA) must be used when appropriate.
4. Failing to document the type of facility. The medical record must clearly state the name and type of the custodial/supportive facility. If the facility is an ICF/IID, the documentation should reflect that.
5. Inconsistent revenue codes. If the discharge status is custodial care, revenue codes should match the level of care (e.g., no skilled nursing revenue codes like 012X for medical/surgical should appear for a custodial patient).
6. Wildcard or unclear use of Code 04 when patient goes to a private residence. Discharge to home (even with home health) is Code 01 or 06, never 04.

Audit red flags: Medicare Administrative Contractors (like Noridian) use automated edits to check that the discharge status code aligns with the patient’s length of stay, diagnosis, and any prior claims from the receiving facility. A high frequency of Code 04 claims with no corresponding admission to a custodial facility may trigger review. ^[1]

Related Codes/Fields

The following table lists key patient discharge status codes from Field 17 that are related to Code 04, along with their meanings and source references. All definitions are from the Noridian patient status code list unless otherwise noted.

Code	Meaning	Notes
01	Discharged to home or self‑care (routine discharge)	[1]
02	Discharged/transferred to a short‑term general hospital for inpatient care
03	Discharged/transferred to skilled nursing facility (SNF) with Medicare certification
04	Discharged/transferred to a facility that provides custodial or supportive care
05	Discharged/transferred to a designated cancer center or children’s hospital
06	Discharged/transferred to home under care of organized home health service organization
07	Left against medical advice or discontinued care
09	Admitted as an inpatient to this hospital
20	Expired
61	Discharged/transferred to a hospital‑based Medicare approved swing bed
62	Discharged/transferred to an inpatient rehabilitation facility (IRF)
63	Discharged/transferred to a Medicare certified long‑term care hospital (LTCH)
64	Discharged/transferred to a nursing facility certified under Medicaid but not under Medicare	[1]
65	Discharged/transferred to a psychiatric hospital or psychiatric distinct part unit
66	Discharged/transferred to a critical access hospital (CAH)
84	Custodial/supportive care with planned acute care hospital inpatient readmission	Effective 10/1/13; code 04 variant
85-94	Various planned readmission variants for other destinations	See full list in source

Related UB-04 Fields (Field 17 context):

• Fields 12-17 contain admission and discharge details.
• Field 17 (Patient Discharge Status) is the location for these codes.
• Fields 19-24 capture occurrence codes and dates that may corroborate the transfer (e.g., Occurrence Code 42 for date of transfer to a custodial facility).

Always consult the latest NUBC guidelines and payer bulletins to ensure correct code usage. ^[2] provides general form instructions but does not list specific discharge status codes; reliance on Medicare‑based sources like Noridian is recommended.

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References

[1] Noridian Patient Status — https://med.noridianmedicare.com/web/jea/topics/claim-submission/patient-discharge-status-codes

[2] MassHealth UB-04 Guide — https://www.mass.gov/doc/ub-04-billing-guide-0/download