UB04 Condition Codes Code 26: VA Eligible Patient Chooses to Receive Services in a Medicare Certified Facility

Overview

Condition Code 26 indicates that a patient who is eligible for care through the Department of Veterans Affairs (VA) has voluntarily chosen to receive services in a Medicare-certified facility instead of a VA facility. This code is used to document the patient’s election to use non-VA services, which may affect billing and coordination of benefits between Medicare and the VA. ^[1]

The code is part of the UB-04 condition code set, which is used to convey special circumstances about a patient’s stay or services that may impact payment, coverage, or processing. Condition Code 26 specifically addresses situations where a VA-eligible patient opts for care in a Medicare-certified setting, such as a hospital or skilled nursing facility, rather than seeking care at a VA medical center. ^[1]

This code is distinct from Condition Code 01 (“Military service related; coordinate with the Department of Veterans Affairs”), which is used when the care is directly related to military service and requires coordination with the VA. Code 26 focuses on the patient’s choice to receive services in a Medicare-certified facility, which may have implications for Medicare coverage and reimbursement. ^[1]

Providers should ensure that the patient’s VA eligibility status is documented in the medical record and that the patient has made an informed choice to receive services in a Medicare-certified facility. This code helps payers understand the billing context and avoid duplicate payments or coordination errors. ^[1]

When to Use

Use Condition Code 26 when a patient who is eligible for VA benefits chooses to receive care in a Medicare-certified facility, such as a hospital, skilled nursing facility, or outpatient clinic. ^[1]

This code is appropriate for any service type where the patient has VA eligibility but opts for non-VA care in a Medicare-certified setting. Examples include inpatient hospital stays, outpatient surgeries, diagnostic tests, or skilled nursing facility care. The code is not limited to specific service categories and can be used across various provider types. ^[1]

Providers should verify the patient’s VA eligibility through the patient’s self-report or through VA systems, and document the patient’s choice in the medical record. The code should not be used if the patient is not VA-eligible or if the services are provided in a VA facility. ^[1]

If the patient’s care is directly related to military service and requires VA coordination, use Condition Code 01 instead. Code 26 is specifically for the patient’s choice to receive services in a Medicare-certified facility, not for care that is automatically coordinated with the VA. ^[1]

Step-by-Step Claim Example

Scenario: A 68-year-old male patient is admitted to a Medicare-certified acute care hospital for a hip replacement. The patient is a veteran and is eligible for VA benefits, but he chooses to have the surgery at the local hospital rather than at the VA medical center. The hospital bills Medicare as the primary payer.

Step 1: Verify Patient Eligibility – The admitting staff confirm the patient’s VA eligibility through the patient’s VA ID card or self-report. The patient states he wants to use his Medicare benefits for this admission. ^[1]

Step 2: Document Patient Choice – The patient signs a form or the provider documents in the medical record that the patient is VA-eligible but chooses to receive services in a Medicare-certified facility. This documentation supports the use of Condition Code 26. ^[1]

Step 3: Complete the UB-04 Claim Form – Ensure no other condition codes conflict (e.g., do not also use Code 01 unless the care is military service-related). ^[1]

Step 4: Submit the Claim – The claim is submitted to Medicare as the primary payer. The condition code alerts Medicare that the patient is VA-eligible but chose a Medicare-certified facility, which may affect coordination of benefits or payment. ^[1]

Step 5: Follow Up – If Medicare denies the claim due to VA eligibility, the provider may need to submit a corrected claim or appeal with documentation of the patient’s choice. The condition code helps justify why Medicare should process the claim. ^[1]

Common Mistakes & Audit Red Flags

Mistake 1: Using Code 26 without verifying VA eligibility. Providers sometimes assume a patient is VA-eligible based on age or military service, but the patient may not have active VA benefits. Always confirm eligibility before using this code. ^[1]

Mistake 2: Using Code 26 when the patient is receiving care in a VA facility. This code is only for services in a Medicare-certified facility. If the patient is in a VA hospital or clinic, use a different condition code or none. ^[1]

Mistake 3: Confusing Code 26 with Code 01. Code 01 is for military service-related care that requires VA coordination. Code 26 is for the patient’s choice to use a Medicare-certified facility. Using the wrong code can lead to claim denials or incorrect payment. ^[1]

Audit Red Flag: Missing documentation of patient choice. Auditors will look for evidence that the patient made an informed decision to receive services in a Medicare-certified facility. If the medical record lacks this documentation, the claim may be denied or recouped. ^[1]

Audit Red Flag: Using Code 26 on claims for services that are not covered by Medicare. If the service is not a Medicare-covered benefit, the condition code may be irrelevant and could confuse payers. Ensure the service is Medicare-covered before using this code. ^[1]

Related Codes/Fields

Code/Field	Description	Relationship to Code 26
Condition Code 01	Military service related; coordinate with the VA	Used when care is directly related to military service; do not use with Code 26 unless both apply
Condition Code 02	Workers’ compensation related	Not related; used for employment-related injuries
Condition Code 03	Patient covered by insurance not reflected here	Not related; used for other insurance coverage
Condition Code 04	Bill submitted for informational purposes only	Not related; used for informational billing
Condition Code 05	Lien has been filed	Not related; used for legal liens
Condition Code 06	ESRD patient in first 30 months of entitlement	Not related; used for ESRD coverage
Condition Code 07	Treatment of non-terminal condition for hospice patient	Not related; used for hospice patients
Condition Code 08	Beneficiary would not provide other insurance info	Not related; used for missing insurance info
Condition Code 09	Neither patient nor spouse is employed	Not related; used for employment status
Condition Code 10	Patient/spouse employed but no EGHP coverage	Not related; used for employment-based insurance
Condition Code 11	Disabled beneficiary but no LGHP	Not related; used for disability insurance
Condition Code 15	Clean claim delayed in CMS processing	Not related; used for processing delays
Condition Code 16	SNF transition exemption	Not related; used for SNF transitions
Condition Code 17	Patient is homeless	Not related; used for homeless patients
Condition Code 18	Maiden name retained	Not related; used for name changes
Condition Code 19	Child retains mother’s maiden name	Not related; used for child names
Condition Code 20	Beneficiary requested billing	Not related; used for patient billing requests
Condition Code 21	Billing for denial notice	Not related; used for denial notices
Condition Code 22	Patient on Multiple Drug Regimen	Not related; used for drug regimens
Condition Code 23	Home Care Giver Available	Not related; used for home care
Condition Code 24	Home IV Patient Also Receiving HHA Services	Not related; used for home IV
Condition Code 25	Patient Is a Non-U.S. Resident	Not related; used for residency status
Condition Code 27	Patient referred to sole community hospital for diagnostic lab test	Not related; used for sole community hospitals
Condition Code 28	Patient’s and/or spouse’s EGHP is secondary to Medicare	Not related; used for employer group health plans
Condition Code 29	Disabled beneficiary’s LGHP is secondary to Medicare	Not related; used for large group health plans
Condition Code 30	Non-research services in qualified clinical trial	Not related; used for clinical trials
Condition Code 31-34	Student status codes	Not related; used for student status
Condition Code 36	General care patient in special unit	Not related; used for special units
Condition Code 37	Ward accommodation at patient’s request	Not related; used for room accommodations
Condition Code 38	Semi-private room not available	Not related; used for room availability
Condition Code 39	Private room medically necessary	Not related; used for medical necessity
Condition Code 40	Same day transfer	Not related; used for transfers
Condition Code 41	Partial outpatient hospitalization services	Not related; used for outpatient services
Condition Code 42	Continued care plan not related to inpatient admission	Not related; used for continued care
Condition Code 43	Continued care not provided within post-discharge window	Not related; used for continued care timing
Condition Code 44	Inpatient admission changed to outpatient	Not related; used for status changes
Condition Code 45	Ambiguous sex category	Not related; used for sex classification
Condition Code 46	Nonavailability statement on file	Not related; used for nonavailability
Condition Code 48	Psychiatric RTC for children and adolescents (TRICARE)	Not related; used for TRICARE
Condition Code 49	Product lifecycle replacement	Not related; used for product replacement
Condition Code 50	Product replacement for known recall	Not related; used for product recalls
Condition Code 51	Unrelated outpatient non-diagnostic services not bundled	Not related; used for unbundled services
Condition Code 52	Hospice beneficiary moves out of service area	Not related; used for hospice moves
Condition Code 53	Initial placement of medical device as part of clinical trial	Not related; used for clinical trial devices
Condition Code 55	SNF bed is not available	Not related; used for SNF bed availability
Condition Code 56	Medical appropriateness condition code (SNF)	Not related; used for SNF medical appropriateness
Condition Code 57	SNF readmission within 30 days	Not related; used for SNF readmissions
Condition Code 58	SNF patient terminated MA Plan enrollment	Not related; used for MA plan termination
Condition Code 59	Non-primary ESRD facility	Not related; used for ESRD facilities
Condition Code 60	Operating cost day outlier	Not related; used for cost outliers
Condition Code 61	Operating cost outlier not reported by provider	Not related; used for unreported outliers
Condition Code 62	PIP bill not reported by providers	Not related; used for PIP billing
Condition Code 63	Bypass CWF edit for incarcerated beneficiaries	Not related; used for incarcerated patients
Condition Code 64	Other than clean claim	Not related; used for claim status
Condition Code 65	Non-PPS bill not reported by providers	Not related; used for non-PPS billing
Condition Code 67	Beneficiary elects not to use LTR days	Not related; used for LTR days
Condition Code 68	Beneficiary elects to use LTR days	Not related; used for LTR days
Condition Code 69	IME/DGME/N&AH payment only billing	Not related; used for medical education payments
Condition Code 70	Self-administered EPO (home dialysis)	Not related; used for home dialysis
Condition Code 71	Full care in unit (dialysis)	Not related; used for dialysis care
Condition Code 72	Self-Care in unit (dialysis)	Not related; used for dialysis self-care
Condition Code 73	Self-Care training (dialysis)	Not related; used for dialysis training
Condition Code 74	Billing for home dialysis patient	Not related; used for home dialysis
Condition Code 75	Billing for home dialysis with machine purchased	Not related; used for dialysis machine
Condition Code 76	Back-up dialysis in-facility	Not related; used for backup dialysis
Condition Code 77	Provider accepts primary payer payment as payment in full	Not related; used for payment acceptance

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References

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