UB04 Condition Codes Code 43: CCRC Resident Not Residing in Skilled Nursing Facility (SNF) at Time of Admission

Overview

Condition Code 43 on the UB-04 claim form indicates that continued care was not provided within the post-discharge window. This code is used by Medicare administrative contractors (such as Noridian for Jurisdiction A) to flag claims where a planned course of care following an inpatient admission did not actually occur within the timeframe expected after discharge. The code helps payers identify situations where the patient did not receive follow-up services, such as skilled nursing, home health, or outpatient therapy, as originally anticipated. It is distinct from Condition Code 42 (continued care plan not related to the inpatient admission) and Condition Code 16 (SNF transition exemption). Use of this code is generally limited to provider- or payer-initiated edits and may trigger medical review or payment adjustments. ^[1]

When to Use

Condition Code 43 should be applied when:

• A patient was discharged from an inpatient setting with a documented plan for continued care (e.g., SNF, home health, outpatient rehab) but that care did not begin within the clinically expected window (typically 30 days for a SNF stay or as defined by the payer’s policy).
• The provider knows at the time of billing that the patient never received the planned post‑discharge services.
• The claim is being submitted for informational or adjustment purposes to indicate that the continuation of care was not provided.

The code is not used for initial billing of an inpatient stay; it is typically added when a payer requests clarification or when submitting a corrected/denied claim. Providers should only apply Code 43 if they have documented evidence that the patient did not receive the planned services within the required timeframe. The code is not intended for routine use—most claims will not carry this condition code. ^[1]

Step-by-Step Claim Example

Scenario: A Medicare beneficiary is admitted to an acute care hospital for hip replacement surgery. The discharge plan includes transfer to a skilled nursing facility (SNF) for rehabilitation. The patient is discharged on Day 5, but due to a bed shortage and patient preference, the SNF admission does not occur until 45 days later—beyond the Medicare “post-discharge window” (typically 30 days). The hospital submits the inpatient claim.

Steps:

1. Primary claim submission: The hospital submits the inpatient claim without Condition Code 43, assuming SNF care will follow quickly.
2. Payer request for correction: The Medicare contractor (e.g., Noridian) issues a request for additional information, noting that the SNF admission date is outside the post-discharge window.
3. Claim adjustment: The hospital resubmits the claim with Condition Code 43 in Field 18‑28 (Condition Codes) to indicate that continued care was not provided within the required post‑discharge window.
4. Documentation: The hospital attaches a note explaining that the SNF admission occurred late and that the patient did not receive timely continued care.
5. Payer outcome: The contractor processes the claim with Code 43, potentially adjusting reimbursement (e.g., reducing DRG payment) to reflect the absence of timely follow‑up care.

Throughout this process, the provider must ensure that the UB-04 accurately reflects the condition code and that supporting records are available for audit. ^[1]

Common Mistakes & Audit Red Flags

• Misapplication of Code 43: Some providers incorrectly use this code for any delayed post‑discharge care, even when the delay is within the allowed window. Only use Code 43 when the care did not occur within the specific post‑discharge timeframe defined by the payer (e.g., 30 days for SNF).
• Confusion with Code 42: Code 42 (“Continued care plan not related to the patient’s inpatient admission”) is sometimes mistaken for Code 43. Code 42 applies when the care plan exists but is unrelated to the admission; Code 43 applies when the planned care never happened on time.
• Missing documentation: Auditors frequently flag claims with Condition Code 43 that lack a clear statement in the medical record about the planned continued care and the reason it was not provided.
• Use on non‑applicable claim types: Code 43 is primarily used for inpatient hospital claims (Type of Bill 11X or 12X) and should not be applied to outpatient or SNF claims unless specifically directed by a payer.
• Red flag for “gaming” payment: If a provider consistently uses Code 43, the payer may suspect that the hospital is billing for inpatient stays that should have been observation or outpatient because follow‑up care never occurred. This can trigger a probe audit.

To avoid these pitfalls, providers should maintain robust discharge planning documentation and only apply Code 43 when supported by clear evidence. ^[1]

Related Codes/Fields

Code/Field	Description	Relationship to Code 43
Code 42	Continued care plan is not related to the patient’s inpatient admission.	Different reason for missing continued care; used when a plan exists but is not connected to the admission.
Code 16	SNF transition exemption (payer only code).	Exemption for SNF care; contrasts with Code 43 where care was planned but not provided.
Field 18–28 (Condition Codes)	Used to report up to 11 condition codes. Code 43 is entered here.	Same field location.
Field 66 (Diagnosis Code)	Principal diagnosis and other diagnoses.	The diagnosis must support the need for continued care; otherwise Code 43 may be irrelevant.
Type of Bill (Field 4)	Inpatient (11X), outpatient (13X), SNF (21X).	Code 43 is most common on 11X bills when SNF follow‑up is expected.
Value Code 61 (Number of SNF Days)	Reports days in SNF if transferred.	Used together if SNF care was provided but delayed; Code 43 may still apply if outside the window.

All condition codes are reported in Field 18–28 of the UB-04. Providers should check their Medicare contractor’s specific requirements before billing. ^[1]

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References

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