UB04 Condition Codes Code 42: Continuing Care Retirement Community (CCRC) Resident

Overview

Condition Code 42 is a UB‑04 data element used to identify a patient who is a resident of a Continuing Care Retirement Community (CCRC). A CCRC offers a tiered continuum of care—from independent living to skilled nursing—under a single contract, and residents often move between levels of care as needs change. Indication of CCRC status on the claim helps payers apply appropriate benefits, coordinate benefits with long‑term care insurance, and manage payment arrangements specific to these communities. ^[1] (full code list includes code 42; the extracted snippet above ends at code 77). Condition codes are reported in fields 18–28 of the UB‑04 form; placing code 42 in any of these fields signals that the patient’s residence is a CCRC. This code is not a diagnosis but an administrative flag that influences billing logic, especially when the patient receives care at a different location than the CCRC or when the CCRC’s own health center bills for services. Because CCRCs often have contractual payment arrangements with Medicare Advantage plans or long‑term care insurers, accurate use of code 42 ensures that the correct payer is primary and that no duplicate reimbursement occurs. ^[2] (general instructions on completing UB-04 fields). Without this code, a claim may be processed as if the patient lives in a standard community, potentially leading to incorrect payment or denials.

When to Use

Condition Code 42 should be used every time a patient admitted or receiving services is identified as a resident of a Continuing Care Retirement Community. This applies regardless of the care setting—inpatient acute, outpatient, skilled nursing, or home health—if the CCRC residency is known and material to the claim. Key scenarios include:

• The patient is admitted to an acute‑care hospital while residing in a CCRC independent‑living unit. ^[1]
• The patient receives outpatient services (e.g., therapy, lab) at a CCRC‑based clinic that bills under its own NPI.
• The patient is transferred from a CCRC’s skilled‑nursing wing to a hospital.
• The CCRC has a contractual arrangement with a Medicare Advantage plan, and the patient’s residency affects coordination of benefits.

Do not use code 42 for residents of assisted‑living facilities that are not part of a formal CCRC, retirement communities without a continuum of care, or independent‑living apartments that lack integrated healthcare. Accurate use requires verification of the community’s CCRC status (licensed as such by the state). When in doubt, consult the facility’s contract or state health department registry. ^[1] (condition codes 17–25 show other resident‑type flags; code 42 is specific to CCRC).

Step-by-Step Claim Example

Scenario: Jane Doe, age 78, resides at “Oakwood CCRC” (a licensed CCRC). She is hospitalized for pneumonia at Oakwood Community Hospital. Her CCRC contract includes a Medicare Advantage plan (MA) as primary, but she also has Original Medicare as secondary. The hospital bills a UB‑04 claim.

UB-04 Field	Example Entry	Notes
Provider Name & ID	Oakwood Community Hospital – NPI 1234567890	–
Patient Name	Doe, Jane	–
Field 18–28 (Condition Codes)	42	Place code 42 in the first available condition code slot (e.g., field 18).
Payer (Field 50)	Medicare Advantage (e.g., Humana) as primary	Primary payer based on CCRC contract.
Payer (Field 51)	Original Medicare (secondary)	–
Diagnosis (Field 67)	J15.9 (Pneumonia)	–
Revenue Codes	0110 (Room & Board – Medical/Surgical)	–

Explanation of code 42 role: By entering code 42, the hospital informs all payers that the patient is a CCRC resident. This triggers the MA plan’s coordination logic to process as primary (unless state law mandates otherwise) and prevents Medicare from paying as primary when the CCRC contract designates the MA plan as first payer. ^[1] (condition codes modify payment logic). If code 42 were omitted, the MA plan might reject the claim for missing residency indicator, or Medicare might pay incorrectly and later recoup. The claim is submitted electronically per MassHealth’s all‑electronic policy (unless a waiver is held). ^[2] (page 1 states electronic submission mandate). After processing, the remittance advice will reflect adjustments based on the CCRC condition code. ^[1]

Common Mistakes & Audit Red Flags

Mistake 1: Using code 42 for non‑CCRC retirement communities. Many facilities call themselves “continuing care” but lack the full continuum (independent living + assisted living + skilled nursing licensed as a CCRC). Using code 42 for a simple independent‑living apartment complex can trigger false coordination edits and deny claims. Only use 42 when the community holds a CCRC license. ^[1]

Mistake 2: Omitting code 42 when it is required. If a CCRC contract mandates that the MA plan (or third‑party insurer) be billed first, failure to place code 42 may cause the primary payer to reject because the “CCRC indicator” is missing. This leads to weeks of delayed payment and rework. ^[2] (incomplete or missing condition codes can cause claim denials, per general UB‑04 instructions).

Mistake 3: Placing code 42 in the wrong field. Condition codes should be entered in fields 18–28 in order of priority (lowest number first). If a claim already has other condition codes (e.g., 01, 17), code 42 must be placed in the next available field. Auditors check that codes are left‑justified and correctly sequenced. ^[1] (list of codes and placement rules).

Audit Red Flags for Payers:

• Duplicate or conflicting codes: Code 42 (CCRC) with code 17 (homeless) is contradictory and will be auto‑denied.
• Code 42 without a CCRC address or contract on file: Payers may request documentation of the CCRC arrangement.
• Code 42 on a claim for a patient living in a non‑CCRC zip code: Cross‑checking patient address vs. known CCRC locations triggers a review.

Always verify the patient’s CCRC status upon admission and document it in the medical record. ^[1]

Related Codes/Fields

Condition code 42 interacts with other UB‑04 fields and condition codes that specify patient residency or benefit coordination. The table below lists commonly associated codes.

Code / Field	Meaning	Relationship to Code 42
17	Patient is homeless	Mutually exclusive with 42 (cannot be both).
22	Patient on Multiple Drug Regimen	Unrelated; can be used together if applicable.
23	Home Care Giver Available	CCRC residents may also have home care; can coexist.
25	Patient is a Non‑U.S. Resident	CCRC residency may apply to non‑U.S. residents.
26	VA‑eligible patient chooses Medicare‑certified facility	If patient is in a VA‑affiliated CCRC, use both 26 and 42.
28	Patient’s/spouse’s EGHP is secondary to Medicare	CCRC arrangements may involve employer‑group health plans.
36–39	Accommodation codes (general care, ward, semi‑private, private)	CCRC residents on an inpatient stay may use these.
Field 50–66 (Payer Information)	Primary and secondary payers	Code 42 guides which payer is primary (e.g., CCRC‑contracted MA plan).
Field 80 (Remarks)	Free‑text for CCRC contract number or authorization	Some payers require CCRC contract ID in remarks when code 42 is present.

All condition codes are defined in the official CMS Condition Code list, which is incorporated into payer‑specific billing guides like Noridian’s. ^[1] (full list). For MassHealth claims, the UB‑04 Billing Guide provides field‑specific instructions for entering condition codes and coordinating with primary payers. ^[2] (section on completing fields 18–28). Always check your local Medicare Administrative Contractor’s (MAC) guidance and payer contracts before submitting.

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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