UB04 Condition Codes Code 06: ESRD Patient in First 30 Months of Entitlement Covered by Employer Group Health Plan

Overview

Condition Code 06 is a UB‑04 code used to indicate that the patient is an End‑Stage Renal Disease (ESRD) beneficiary who is within the first 30 months of Medicare entitlement and is covered by an employer group health plan (EGHP). ^[1] The code is part of the standard condition code set maintained by Medicare administrative contractors and is entered in the condition code fields (18–28) of the UB‑04 claim form. ^[2] The purpose of this code is to alert the payer that Medicare is the secondary payer during the 30‑month coordination period, during which the employer group health plan is primary. ^[1] The code is defined exactly as “ESRD patient in the first 30 months of entitlement covered by employer group health insurance.” ^[1]

When to Use

The code is also distinct from Condition Code 28 (“Patient’s and/or spouse’s EGHP is secondary to Medicare”) and Condition Code 29 (“Disabled beneficiary and/or family members LGHP is secondary to Medicare”), which apply to different MSP scenarios. ^[1]

Step-by-Step Claim Example

A 55‑year‑old patient with ESRD is admitted to an acute inpatient hospital for dialysis‑related complications. The patient became entitled to Medicare on January 15, 2025, and is still within the first 30 months of that entitlement. The patient also has coverage through a large employer group health plan (EGHP) provided by their spouse’s employer. ^[1] The hospital prepares a UB‑04 claim for the inpatient stay. In the condition code fields (18–28), the biller enters “06” to indicate that the patient is an ESRD patient in the first 30 months of entitlement covered by an EGHP. ^[1] The claim is submitted to Medicare as the secondary payer. The primary EGHP is billed first, and after it pays, the remaining balance is submitted to Medicare with Condition Code 06. ^[1] The provider also includes the EGHP’s payment information in the appropriate fields. ^[2] Medicare processes the claim as secondary, applying the MSP rules for ESRD patients. ^[1]

Common Mistakes & Audit Red Flags

One common mistake is using Condition Code 06 for ESRD patients who are beyond the first 30 months of Medicare entitlement. ^[1] After the 30‑month coordination period ends, Medicare becomes the primary payer, and Code 06 should no longer be applied. ^[1] Another error is omitting the code entirely when the patient does have EGHP coverage during the 30‑month window, which can lead to Medicare incorrectly paying as primary and triggering an overpayment recovery. ^[1] Providers also sometimes confuse Code 06 with Code 28 (EGHP secondary to Medicare) or Code 59 (non‑primary ESRD facility). ^[1] Audit red flags include inconsistent use of the code across multiple claims for the same patient, or using Code 06 when the patient’s entitlement date is unknown. ^[1] To avoid these issues, providers should maintain accurate records of Medicare entitlement dates and EGHP coverage, and cross‑check the condition code against the patient’s MSP status. ^[1]

Related Codes/Fields

The following table lists related condition codes from the Noridian set that are often used in conjunction with or in place of Code 06 for ESRD and MSP scenarios. ^[1]

Code	Meaning	Relevance to Code 06
28	Patient’s and/or spouse’s EGHP is secondary to Medicare	Used when EGHP is secondary (opposite of Code 06)
29	Disabled beneficiary and/or family members LGHP is secondary to Medicare	For disabled beneficiaries with large group health plans
59	Non‑primary ESRD facility	Identifies a facility that is not the patient’s primary ESRD facility
70	Self‑administered EPO (home dialysis)	Related to ESRD treatment modality
71	Full care in unit (dialysis)	Indicates dialysis setting
72	Self‑Care in unit (dialysis)	Indicates dialysis setting
73	Self‑Care training (dialysis)	Indicates dialysis training
74	Billing is for a patient who received dialysis services at home	Home dialysis billing
75	Billing for home dialysis with machine purchased under 100% payment program	Home dialysis equipment
76	Back‑up dialysis in‑facility	Backup dialysis services

These codes are entered in the condition code fields (18–28) of the UB‑04 form. ^[2] Proper selection ensures correct MSP processing and payment. ^[1]

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References

[1] Noridian Condition Codes — https://med.noridianmedicare.com/web/jea/topics/claim-submission/condition-codes

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