UB04 Patient Discharge Status Code 64: Discharged/transferred to a nursing facility certified under Medicaid but not certified under Medicare

Overview

Patient Discharge Status Code 64 is used when a patient is discharged or transferred to a nursing facility that is certified under Medicaid but not certified under Medicare. ^[1] This code specifically identifies facilities that participate in the Medicaid program but do not meet Medicare certification requirements, distinguishing them from skilled nursing facilities (SNF) with Medicare certification (Code 03) or facilities providing custodial care (Code 04). ^[2]

The code reflects the destination facility type and certification status for care coordination and statistical purposes.

When to Use

Use Code 64 when discharging a patient to a nursing facility that meets the following criteria: (1) the facility is certified to participate in the Medicaid program, and (2) the facility is not certified to participate in the Medicare program. ^[1] This typically includes facilities that provide custodial or supportive nursing care but do not have Medicare certification for skilled nursing services.

Do not use this code for facilities that are Medicare certified (use Code 03 for SNF, Code 61 for swing beds, or Code 63 for LTCH). ^[1] Also avoid using it for facilities primarily providing custodial care without Medicaid certification (use Code 04). The code applies only when the nursing facility has active Medicaid certification.

This code requires verification of the receiving facility's certification status. The discharging provider should confirm that the facility is currently enrolled in Medicaid and does not hold Medicare certification. ^[2] For MassHealth members, this code is appropriate when transferring to a Nursing Facility (NF) that provides skilled nursing care but only under the Medicaid program.

Step-by-Step Claim Example

Scenario: A 78-year-old patient is admitted to a general acute hospital with a diagnosis of pneumonia and functional decline. After treatment, the patient cannot return home independently. The hospital social worker arranges transfer to "Sunrise Nursing Home," which is certified by Medicaid but not by Medicare.

Step 1: Verify Facility Certification – Confirm Sunrise Nursing Home's Medicare certification status through the CMS Provider of Services file. The facility is NOT Medicare certified but IS Medicaid certified. ^[1]

Step 2: Complete Form Locator 17 – Enter "64" in the Patient Discharge Status field. The code represents "Discharged/transferred to a nursing facility certified under Medicaid but not certified under Medicare." ^[1]

Step 3: Complete Other Required Fields – In Form Locator 12 (Patient Name), enter the patient's full legal name. ^[2] In Form Locator 23 (Medical Record Number), enter the hospital-assigned number.

Step 4: Complete Discharge Information – Enter the discharge date in Form Locator 6 (Statement Covers Period - Through Date). Ensure this matches the clinical discharge note.

Step 5: Submit the claim – Submit the completed UB-04 claim electronically or on paper if a waiver applies. ^[2] The reimbursement will be calculated based on DRG or per-diem rates, with appropriate notice that the patient was transferred to a non-Medicare certified facility.

Common Mistakes & Audit Red Flags

Using Code 64 for Medicare-certified facilities – This is a common error. If the nursing facility has Medicare certification (even if it also accepts Medicaid), use Code 03 (SNF) instead. ^[1]

Confusing Code 64 with Code 04 – Code 04 is for facilities providing custodial or supportive care without specific Medicaid certification. Code 64 requires active Medicaid certification. Verify the facility's certification status before selecting the code.

Failing to update discharge status for readmissions – If a patient discharged with Code 64 is readmitted within a planned acute care window, the claim should use Code 92 (discharge with planned readmission) if applicable for Medicare patients. ^[1]

Inconsistent documentation – The discharge summary and social worker notes must clearly state that the patient was transferred to a Medicaid-certified, non-Medicare-certified nursing facility. Missing documentation can trigger audits and denials.

Using Code 64 when the facility is not certified by any program – If the facility lacks both Medicare and Medicaid certification, use Code 04 (custodial care facility) instead. Code 64 specifically requires Medicaid certification. ^[1]

Audit Red Flag: Claim with Code 64 but no corresponding Medicaid coverage – If the patient's insurance is Medicare or commercial, using Code 64 may raise questions about why the facility is not Medicare certified. Ensure the patient's payer matches the facility's certification.

Related Codes/Fields

The following table shows discharge status codes directly related to Code 64 for accurate differentiation and transition planning:

Code	Description	Relationship to Code 64
03	Discharged/transferred to SNF with Medicare certification	Differentiates Medicare-certified SNF from Medicaid-only facility
04	Discharged/transferred to facility providing custodial care	Both provide supportive care, but Code 04 lacks Medicaid certification
61	Discharged/transferred to hospital-based Medicare approved swing bed	Swing beds are Medicare certified, not Medicaid-only
62	Discharged/transferred to IRF including rehab distinct part units	Rehabilitation-focused, not custodial nursing care
63	Discharged/transferred to Medicare certified LTCH	Long-term care hospital with Medicare certification
65	Discharged/transferred to psychiatric hospital or unit	Psychiatric care, not nursing facility care
70	Discharged/transferred to other health care institution not defined	Use only when no other code fits, not for Medicaid-only nursing
92	Discharged/transferred to nursing facility (Medicaid only) with planned readmission	Same destination as 64 but with planned acute readmission

^[1]

Form Locator 17 on the UB-04 claim form is the specific field where Code 64 is entered. ^[2] This field is mandatory for all inpatient claims and must match the clinical discharge documentation. For outpatient claims, this field may be left blank unless the patient is transferred from observation status.

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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