UB04 Condition Codes Code 46: Non-availability Statement on File

Overview

When to Use

Condition Code 46 should be used when a provider has a valid non-availability statement on file for a patient. This typically occurs in the following scenarios:

• Government Program Coordination: When a patient is covered by multiple government programs (e.g., Medicare and Medicaid, or Medicare and TRICARE) and one program requires a statement of non-availability before the other program will process the claim.

• Emergency or Urgent Care: In situations where a patient requires immediate care and the primary payer's network cannot provide timely access, a non-availability statement may be obtained retroactively or prospectively to justify billing to an alternative payer.

Providers should not use Condition Code 46 simply because the patient prefers a different facility or provider. The non-availability statement must be based on actual unavailability of services, not patient preference or convenience. ^[1]

Step-by-Step Claim Example

Scenario: A 72-year-old male Medicare beneficiary is also eligible for VA benefits. He requires a hip replacement surgery. The nearest VA hospital is 150 miles away and has a 6-month wait for elective orthopedic surgery. The patient chooses to have the surgery at a Medicare-certified community hospital 20 miles from his home.

Step 1: Obtain the Non-Availability Statement The provider contacts the VA to obtain a formal non-availability statement. The VA issues a document stating that hip replacement surgery is not available at the VA facility within a reasonable timeframe (defined as 30 days for elective surgery). The statement includes the patient's name, the specific procedure (CPT 27130), the date of issuance, and the VA facility's contact information.

Step 2: Complete the UB-04 Claim Form

• Field 18-28 (Condition Codes): Enter "46" in the first available condition code field.
• Field 1 (Provider Name, Address, and Telephone Number): Enter the community hospital's information.
• Field 2 (Pay-to Name and Address): Enter the Medicare Administrative Contractor's address.
• Field 3a (Patient Control Number): Enter the patient's account number.
• Field 4 (Type of Bill): Enter "111" for inpatient hospital.
• Field 5 (Federal Tax Number): Enter the hospital's tax ID.
• Field 6 (Statement Covers Period): Enter the admission and discharge dates.
• Field 8a (Patient Name): Enter the patient's full name.
• Field 9a (Patient Address): Enter the patient's home address.
• Field 10 (Patient Birthdate): Enter the patient's date of birth.
• Field 11 (Patient Sex): Enter "M" for male.
• Field 12 (Admission Date): Enter the admission date.
• Field 13 (Admission Hour): Enter the admission time.
• Field 14 (Type of Admission): Enter "1" for emergency.
• Field 15 (Source of Admission): Enter "1" for physician referral.
• Field 16 (Discharge Hour): Enter the discharge time.
• Field 17 (Patient Discharge Status): Enter "01" for discharged to home.
• Field 31 (Patient Reason for Visit): Enter the diagnosis code.
• Field 32 (Attending Provider): Enter the surgeon's NPI.
• Field 42-47 (Revenue Codes): Enter appropriate revenue codes for the hip replacement.
• Field 66 (Diagnosis and Procedure Codes): Enter ICD-10-CM and ICD-10-PCS codes.

Step 3: Attach Supporting Documentation Include a copy of the VA non-availability statement with the claim submission. The statement should clearly reference the patient's name, the specific service, and the date of issuance.

Step 4: Submit the Claim Submit the UB-04 claim form to the Medicare Administrative Contractor (MAC) for processing. The MAC will verify the non-availability statement and process the claim as a Medicare Part A inpatient claim.

Step 5: Maintain Records Keep the original non-availability statement in the patient's medical record for at least 7 years. Document the date the statement was obtained, the name of the VA representative who issued it, and the specific services that were unavailable. ^[1]

Common Mistakes & Audit Red Flags

Mistake 1: Using Code 46 Without a Valid Statement The most common error is reporting Condition Code 46 without actually having a non-availability statement on file. Auditors will request this documentation, and its absence can result in full claim recoupment plus penalties. Always verify that the statement is physically present in the patient's file before submitting the claim. ^[1]

Mistake 2: Using Code 46 for Patient Preference Condition Code 46 is not appropriate when the patient simply prefers a different facility or provider. The code is only valid when the primary payer's services are genuinely unavailable. Using it for convenience or preference is considered fraudulent billing.

Mistake 3: Expired or Outdated Statements Non-availability statements often have expiration dates. Using an expired statement to support a claim is a compliance violation. Ensure the statement covers the exact dates of service being billed.

Mistake 4: Incorrect Code Placement On the UB-04 form, Condition Code 46 must be entered in Field 18-28 (Condition Codes). Placing it in the wrong field or omitting it entirely will cause claim processing delays or denials.

Audit Red Flags:

• Multiple claims for the same patient using Code 46 without corresponding VA or payer documentation
• Claims with Code 46 for services that are commonly available through the primary payer
• Claims where the non-availability statement is dated after the date of service
• Claims where the provider cannot produce the original statement upon request
• Claims where the non-availability statement does not specifically reference the billed services

Best Practice: Create a tracking log for all non-availability statements, including the date obtained, expiration date, patient name, service description, and the name of the issuing entity. Conduct periodic audits to ensure all statements are current and properly filed. ^[2]

Related Codes/Fields

The following table lists related condition codes and fields that may be used in conjunction with Condition Code 46 on the UB-04 claim form.

Code/Field	Description	Relationship to Code 46
Condition Code 01	Military service related; coordinate with VA	Often used with Code 46 for VA-eligible patients
Condition Code 26	VA eligible patient chooses to receive services in a Medicare Certified Facility	Directly related; Code 46 supports the non-availability justification
Condition Code 27	Patient referred to a sole community hospital for a diagnostic laboratory test	May require non-availability statement from primary payer
Field 18-28 (Condition Codes)	Location on UB-04 where Code 46 is entered	Primary field for reporting this code
Field 31 (Patient Reason for Visit)	Diagnosis code explaining medical necessity	Supports the need for the unavailable service
Field 32 (Attending Provider)	NPI of the attending physician	Identifies the provider who obtained the statement
Field 42-47 (Revenue Codes)	Revenue codes for billed services	Must match services listed on non-availability statement
Field 66 (Diagnosis and Procedure Codes)	ICD-10 codes for the encounter	Documents the medical condition requiring the unavailable service

^[1] | ^[2]

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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