UB04 Condition Codes Code 10: Patient and/or Spouse is Employed but No EGHP Coverage Exists

Overview

Condition Code 10 on the UB-04 claim form indicates that the patient and/or spouse is employed but no Employer Group Health Plan (EGHP) coverage exists. ^[1] The code is part of a standardized set of condition codes used to convey special circumstances about a patient’s insurance coverage or billing situation. ^[2] This code is specifically for cases where employment is confirmed, but the employer does not offer a group health plan, or the patient/spouse is not enrolled in such a plan. The UB-04 claim form is required by payers such as MassHealth for acute inpatient and outpatient hospital services. ^[2] Correct use of Condition Code 10 helps payers determine primary and secondary payer liability, especially when Medicare or other third-party payers are involved.

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When to Use

Use Condition Code 10 when the patient or the patient’s spouse is employed, but no Employer Group Health Plan (EGHP) coverage exists for the patient. ^[1] This situation commonly occurs when the employer does not offer health insurance, the employee is not eligible, or the employee has waived coverage. The code distinguishes these cases from others such as Condition Code 09 (neither patient nor spouse is employed) and Condition Code 28 (patient’s/spouse’s EGHP is secondary to Medicare). ^[1] Providers should verify the patient’s employment status and the existence of any EGHP through eligibility checks or patient interviews before assigning this code. The code may be used for any claim type (inpatient, outpatient) that requires a condition code to explain the absence of EGHP coverage.

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Step-by-Step Claim Example

A 45-year-old patient is admitted to a general acute care hospital for an overnight stay. The patient is employed full-time at a small business that does not offer health insurance. The patient’s spouse is also employed but has no health coverage through their employer. The hospital’s billing staff verifies the employment status and confirms that no EGHP is available. They document Condition Code 10 in the condition code fields (Fields 18–28) of the UB-04 claim form. ^[1] The inpatient claim is then submitted to Medicare as the primary payer. Because no EGHP exists, Medicare is the primary insurer. The billing staff also notes that Code 09 would be incorrect since the patient and spouse are employed. The claim is processed without a denial for missing EGHP information. This example illustrates how Code 10 clarifies the insurance status and avoids unnecessary coordination-of-benefit queries.

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Common Mistakes & Audit Red Flags

1. Using Code 09 instead of Code 10 – Code 09 (neither patient nor spouse is employed) is often erroneously used when the patient is actually employed but lacks EGHP. This triggers incorrect payer sequencing. ^[1]
2. Failing to verify employment status – Some providers assume no EGHP means unemployment, leading to a wrong code. Always confirm employment directly with the patient.
3. Confusing Code 10 with Code 28 – Code 28 (patient’s/spouse’s EGHP is secondary to Medicare) applies when EGHP does exist but is secondary. Using Code 28 when no EGHP exists is a red flag. ^[1]
4. Omitting the condition code entirely – When EGHP is absent, failing to report a condition code may cause the payer to suspend the claim for additional verification.
5. Inconsistent documentation – If medical records or patient registration notes indicate employment but the claim uses Code 10 without supporting notes, auditors may flag it as unsupported.

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Related Codes/Fields

The table below lists condition codes from the Noridian list that are closely related to Code 10, along with their meanings. All codes are entered in the condition code fields (Fields 18–28) on the UB-04 claim form.

Code	Meaning	Source
09	Neither the patient nor the spouse is employed	[1]
10	Patient and/or spouse is employed but no EGHP coverage exists	[1]
28	Patient’s and/or spouse’s EGHP is secondary to Medicare	[1]
29	Disabled beneficiary and/or family members’ LGHP is secondary to Medicare	[1]
11	Disabled beneficiary but no LGHP	[1]

These codes help payers correctly determine primary/secondary payer order and avoid duplicate coverage denials.

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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