UB04 Condition Codes Code 09: Neither Patient Nor Spouse is Employed

Overview

Condition Code 09 is a standardized UB-04 code indicating that "Neither the patient nor the spouse is employed" ^[1]. This code appears in Field 18-28 (Condition Codes) of the UB-04 claim form, typically in the first available position. The code is used to document employment status when processing claims where employment-based insurance coverage may be relevant.

On the UB-04 form, condition codes are entered in a two-character format across three boxes (Positions 1-3 for codes a and b, Positions 4-6 for codes c and d, and Positions 7-9 for codes e and f). Code 09 would be entered as "09" in the appropriate position ^[2]. This code is particularly important for coordination of benefits and third-party liability determinations, as it establishes that neither the patient nor the patient's spouse is currently employed, which may affect primary payer identification.

The code serves as a critical data element for Medicare, Medicaid, and other payers to determine if employer group health plan (EGHP) coverage should exist. When no employment exists, there is generally no employer-sponsored insurance available through employment. The code is distinct from Code 10 ("Patient and/or spouse is employed but no EGHP coverage exists") which indicates employment but without employer-sponsored coverage ^[1]. Proper use of this code helps prevent inappropriate denials and ensures correct claim processing.

When to Use

Code 09 should be used when both the patient and the patient's spouse are unemployed at the time of service. This applies in the following scenarios:

• The patient is not currently employed and the patient's spouse (if applicable) is also not employed
• The patient is unmarried and not employed
• The patient is retired and neither employed nor has an employed spouse
• The patient is receiving public assistance or disability benefits and neither the patient nor spouse works

This code is particularly relevant when billing Medicare as the primary payer, when submitting claims for Medicaid beneficiaries, or when completing coordination of benefits with other third-party payers. It helps establish that no employer group health plan (EGHP) coverage should exist through the patient's or spouse's employment ^[1].

Providers should not use this code when:

• The patient is employed but lacks EGHP coverage (use Code 10 instead)
• The patient refuses to provide insurance information (use Code 08)
• The patient is covered by insurance not reflected on the claim (use Code 03)

The code is also inappropriate for patients receiving workers' compensation benefits (use Code 02) or for patients with military service-related conditions (use Code 01) ^[1].

Step-by-Step Claim Example

Scenario: A 55-year-old female patient is admitted for a total knee replacement. She is retired, receives Social Security benefits, and is covered by Medicare Part A and B. Her husband is also retired and receives Social Security. Neither is employed.

UB-04 Claim Completion:

Step 1: Patient Information

• Field 58: Patient Name
• Field 11: Patient Date of Birth (09/15/1968)
• Field 10: Patient Status (Retired)

Step 2: Condition Codes (Field 18-28)

• Position a: Enter "09" (Neither patient nor spouse is employed)
• Note: This is placed first in the condition code field sequence

Step 3: Payer Information (Field 50-66)

• Payer A (Field 50-56): Medicare (Priority 1)
• Verify Medicare primary because patient is over 65 and no EGHP exists

Step 4: Additional Codes as Needed

• Admission/Disposition Codes: Per standard UB-04 requirements
• Diagnosis Codes: M17.9 (Osteoarthritis of knee, unspecified)

Step 5: Billing Notes

• No employer group health plan information is required
• Code 09 supports Medicare as primary payer
• No need for Code 10 (employed but no EGHP) since neither works

Step 6: Claim Submission

• Submit electronically (per MassHealth requirements unless waiver obtained) ^[2]
• Enter code 09 in the first available condition code position

Expected Outcome: The claim processes with Medicare as primary payer. The presence of Code 09 confirms that no employer-sponsored insurance should be expected, preventing improper coordination of benefit denials.

Common Mistakes & Audit Red Flags

Mistake 1: Using Code 09 when patient IS employed but lacks coverage

• Error: Submitting Code 09 when the patient works but without employer-sponsored health coverage
• Correct action: Use Code 10 ("Patient and/or spouse is employed but no EGHP coverage exists")
• Audit risk: May trigger medical review for inappropriate billing pattern

Mistake 2: Failing to use Code 09 when both are unemployed

• Error: Leaving condition code blank or using incorrect code when neither works
• Correct action: Always use Code 09 when applicable
• Audit risk: Delays in claim processing, potential overpayment reviews

Mistake 3: Confusing Code 09 with Code 08

• Error: Using Code 09 when patient simply won't provide information about employment
• Correct action: Use Code 08 ("Beneficiary would not provide information concerning other insurance coverage")
• Audit risk: May result in claim rejection for insufficient documentation

Audit Red Flags for Payers:

• Code 09 used with claims showing workers' compensation or employer information
• Code 09 used when patient age suggests likely employment (e.g., ages 18-64)
• Code 09 inconsistently applied across multiple admissions for same patient
• Code 09 appearing alongside codes indicating employment (e.g., Code 10)

Documentation Recommendations:

• Keep admission records showing patient and spouse employment status
• Document retirement status or unemployment in medical record
• If patient is disabled, note disability status as supporting documentation
• For Medicare beneficiaries, maintain records showing Medicare entitlement basis

Related Codes/Fields

The following table shows codes commonly used with or related to Condition Code 09 in UB-04 claims processing:

Code/Field	Description	Relationship to Code 09
Code 08	Beneficiary would not provide information concerning other insurance coverage	Alternative when patient refuses verification
Code 10	Patient and/or spouse is employed but no EGHP coverage exists	Direct alternative when employment exists
Code 02	Medical condition due to employment environment (workers' comp)	Use when injury is work-related
Code 01	Military service related	Use when condition is service-related
Code 11	Disabled beneficiary but no LGHP	Use for disabled beneficiaries without large group health plan
Field 50	Payer Identification	Contains primary payer information once coverage is established
Field 56	Provider Signature	Required for paper claims; ensure accuracy
Field 58	Patient Name	Must match Medicare/Medicaid enrollment
Field 10	Patient Status	Employment/retirement status field
Code 06	ESRD patient in first 30 months covered by EGHP	Excludes many ESRD patients from using Code 09

This condition code works in coordination with other codes to establish the correct payer hierarchy for claims processing ^[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