UB04 Condition Codes Code 28: Patient and/or Spouse's EGHP is Secondary to Medicare

Overview

Condition Code 28 indicates that the patient and/or their spouse’s Employer Group Health Plan (EGHP) is secondary to Medicare. This code is used when Medicare is the primary payer for a claim, and the patient or their spouse has EGHP coverage that should be billed as secondary insurance. The code is part of the UB-04 claim form’s condition code field (Field 18-28) and is essential for proper coordination of benefits between Medicare and employer-sponsored health plans. ^[1]

This code applies specifically to Medicare beneficiaries who are age 65 or older and have EGHP coverage through their own or their spouse’s current employment. In these situations, Medicare is the primary payer, and the EGHP is secondary. The code helps ensure that claims are processed correctly, with Medicare paying first and the EGHP paying any remaining covered amounts. ^[1]

It is important to distinguish Code 28 from Code 06, which applies to ESRD patients in the first 30 months of entitlement covered by EGHP. Code 28 is specifically for non-ESRD patients where Medicare is primary due to age or disability, and the EGHP is secondary. ^[1]

When to Use

Use Condition Code 28 when the patient is a Medicare beneficiary (age 65 or older or disabled) and has EGHP coverage through their own or their spouse’s current employment, making Medicare the primary payer. This typically occurs when the patient or spouse is actively employed and covered by an employer group health plan with 20 or more employees. ^[1]

Do not use Code 28 if the patient is not employed and has no EGHP coverage (use Code 09 or 10 instead). Also avoid using it for ESRD patients in the first 30 months of entitlement (use Code 06). For disabled beneficiaries with Large Group Health Plans (LGHP), use Code 29 instead. ^[1]

The code should be entered in Field 18 of the UB-04 form, which is the Condition Code field. Multiple condition codes can be entered if applicable, but Code 28 should be listed when the EGHP is secondary to Medicare. ^[2]

Step-by-Step Claim Example

Scenario: A 68-year-old Medicare beneficiary is admitted to an acute inpatient hospital for a hip replacement. The patient is still employed and has EGHP coverage through their employer (a company with 200 employees). Medicare is the primary payer.

Step 1: Complete the UB-04 claim form header with patient demographics, including Medicare as the primary insurance (enter Medicare information in Field 50-66 as appropriate).

Step 2: In Field 18 (Condition Codes), enter Code 28 to indicate that the patient’s EGHP is secondary to Medicare. If other condition codes apply (e.g., Code 01 for military service), list them in additional positions.

Step 3: In Fields 50-66 (Payer Information), list Medicare as the primary payer (Payer A) and the EGHP as the secondary payer (Payer B). Enter the EGHP policy number and group number in the appropriate fields.

Step 4: In Field 39-41 (Value Codes and Amounts), enter any applicable value codes, such as Code 12 (Working Aged Beneficiary/Spouse with EGHP) to further clarify the coordination of benefits.

Step 5: Submit the claim to Medicare first. Medicare will process the claim and pay its portion. The remaining balance should then be billed to the EGHP as secondary payer.

Step 6: If the EGHP denies or pays partially, the provider may need to submit a corrected claim or appeal with appropriate documentation, including Code 28 to confirm the payer order. ^[1]

Common Mistakes & Audit Red Flags

Mistake 1: Using Code 28 when the patient is not employed or has no EGHP coverage. This can lead to claim denials or incorrect payment. Use Code 09 (neither patient nor spouse employed) or Code 10 (employed but no EGHP) instead. ^[1]

Mistake 2: Confusing Code 28 with Code 06 (ESRD patient in first 30 months). Code 06 is for ESRD patients where EGHP is primary, while Code 28 is for non-ESRD patients where Medicare is primary. Using the wrong code can cause coordination of benefits errors. ^[1]

Mistake 3: Failing to list Code 28 when the patient has EGHP coverage but Medicare is primary. This may result in the EGHP being incorrectly billed as primary, leading to claim rejections or payment delays.

Audit Red Flag: Claims with Code 28 but no corresponding secondary payer information in Fields 50-66. Auditors will look for consistency between condition codes and payer information. Ensure that if Code 28 is used, the EGHP is listed as a secondary payer.

Audit Red Flag: Using Code 28 for patients who are disabled but have LGHP (use Code 29 instead). Medicare’s coordination of benefits rules differ for disabled beneficiaries with large group health plans. ^[1]

Related Codes/Fields

Code/Field	Description	Relationship to Code 28
Code 06	ESRD patient in first 30 months of entitlement covered by EGHP	Used for ESRD patients where EGHP is primary; opposite of Code 28
Code 09	Neither patient nor spouse employed	Used when no EGHP exists; alternative to Code 28
Code 10	Patient and/or spouse employed but no EGHP coverage	Used when employed but no EGHP; alternative to Code 28
Code 29	Disabled beneficiary and/or family members LGHP is secondary to Medicare	Used for disabled beneficiaries with LGHP; similar to Code 28 but for disabled
Field 18	Condition Codes (UB-04)	Location where Code 28 is entered
Fields 50-66	Payer Information (UB-04)	Must list Medicare as primary and EGHP as secondary when using Code 28
Value Code 12	Working Aged Beneficiary/Spouse with EGHP	Supplementary code to clarify coordination of benefits with Code 28

^[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