UB04 Condition Codes Code 48: Psychiatric Residential Treatment Centers

Overview

Condition Code 48 is designated for "Psychiatric Residential Treatment Centers" and is specifically used for children and adolescents under TRICARE. ^[1] The code is primarily relevant for TRICARE beneficiaries, as noted in the Noridian source: "48: Psychiatric RTC for children and adolescents (TRICARE)." ^{[1] [2]}

When to Use

Condition Code 48 should be used when the patient is a TRICARE beneficiary receiving care in a psychiatric residential treatment center (RTC) for children and adolescents. ^[1] This code is specifically applicable to TRICARE claims, not Medicare or other payers. Providers must ensure that the patient is enrolled in TRICARE and that the facility is a certified psychiatric residential treatment center. The code should not be used for general psychiatric inpatient hospital stays, partial hospitalization, or outpatient services. It is also not appropriate for adult patients or for non-TRICARE beneficiaries. When submitting claims with Condition Code 48, providers should verify that all other required fields (e.g., revenue codes, diagnosis codes, procedure codes) accurately reflect the psychiatric RTC services provided. ^[2]

Step-by-Step Claim Example

Scenario: A 14-year-old TRICARE beneficiary is admitted to a certified psychiatric residential treatment center for a 30-day stay due to severe depression and suicidal ideation. The facility provides 24-hour nursing care, individual therapy, group therapy, and medication management.

Step 1: Patient Information (Fields 1-13)
Enter the patient's name, address, date of birth, sex, and TRICARE identification number. Ensure the TRICARE beneficiary ID is correctly entered in Field 9a (Patient's ID Number).

Step 2: Condition Codes (Fields 18-28)
Enter Condition Code 48 in Field 18 (Condition Code). This indicates the claim is for a psychiatric residential treatment center for a child/adolescent TRICARE beneficiary. ^[1]

Step 3: Revenue Codes (Field 42)
Enter revenue codes for psychiatric residential treatment services. Common codes include:

• 1002 (Psychiatric Residential Treatment - Room and Board)
• 0900 (Psychiatric/Psychological Services)
• 0910 (Psychiatric/Psychological Services - Individual Therapy)
• 0911 (Psychiatric/Psychological Services - Group Therapy)
• 0912 (Psychiatric/Psychological Services - Family Therapy)
• 0914 (Psychiatric/Psychological Services - Medication Management)

Step 4: Diagnosis Codes (Fields 67-75)
Enter the primary diagnosis (e.g., F32.2 - Major Depressive Disorder, Single Episode, Severe Without Psychotic Features) and any secondary diagnoses (e.g., F41.1 - Generalized Anxiety Disorder).

Step 5: Procedure Codes (Field 44)
Enter HCPCS/CPT codes for specific services provided, such as:

• 90837 (Individual Psychotherapy, 60 minutes)
• 90853 (Group Psychotherapy)
• 90846 (Family Psychotherapy without patient present)
• 90847 (Family Psychotherapy with patient present)
• 90862 (Medication Management)

Step 6: Dates of Service (Fields 6, 12, 45)
Enter the admission date (e.g., 01/15/2024) in Field 12 (Admission Date) and the discharge date (e.g., 02/14/2024) in Field 6 (Statement Covers Period - Through). For each revenue code line, enter the specific service date in Field 45 (Service Date).

Step 7: Charges (Fields 47-48)
Enter the total charges for each revenue code line in Field 47 (Total Charges). For example:

• Revenue Code 1002: $15,000 (30 days at $500/day)
• Revenue Code 0900: $3,000 (10 individual therapy sessions at $300 each)
• Revenue Code 0911: $1,500 (10 group therapy sessions at $150 each)

Step 8: Payer Information (Fields 50-66)
Enter TRICARE as the primary payer in Field 50 (Payer Name). Enter the TRICARE contract number in Field 51 (Health Plan ID). Enter the patient's TRICARE ID number in Field 60 (Insured's ID Number).

Step 9: Certification (Field 80)
Enter the attending physician's NPI number and signature in Field 80 (Remarks). Include any required TRICARE authorization numbers.

Step 10: Submit the Claim
Submit the completed UB-04 claim form to the appropriate TRICARE fiscal intermediary or contractor. ^[2]

Common Mistakes & Audit Red Flags

1. Using Code 48 for non-TRICARE patients: Condition Code 48 is specifically for TRICARE beneficiaries. Using it for Medicare, Medicaid, or commercial insurance patients will result in claim denials. ^[1]

2. Using Code 48 for adult patients: The code is explicitly for "children and adolescents." Using it for adult psychiatric residential treatment will be rejected. ^[1]

3. Using Code 48 for inpatient hospital psychiatric care: Psychiatric residential treatment centers are distinct from inpatient psychiatric hospitals. Do not use this code for general inpatient psychiatric admissions.

4. Missing or incorrect revenue codes: Ensure revenue codes accurately reflect psychiatric RTC services (e.g., 1002 for room and board, 0900 series for therapy). Incorrect revenue codes may trigger audits.

5. Incomplete diagnosis coding: Psychiatric RTC claims require accurate primary and secondary diagnosis codes. Missing or vague diagnoses (e.g., "mental disorder NOS") may lead to denials.

6. No prior authorization: TRICARE often requires prior authorization for psychiatric RTC admissions. Failure to obtain authorization will result in claim rejection.

7. Incorrect patient identification: Ensure the TRICARE ID number matches the beneficiary's eligibility. Mismatched IDs will cause claim processing delays.

8. Duplicate billing: Do not bill Condition Code 48 alongside other condition codes that may conflict (e.g., Code 41 for partial hospitalization). Verify code compatibility.

9. Missing service dates: Each revenue code line must have a corresponding service date in Field 45. Missing dates will cause claim rejection.

10. Incorrect charge amounts: Ensure charges are reasonable and consistent with TRICARE fee schedules. Unusually high charges may trigger medical review. ^[2]

Related Codes/Fields

Code/Field	Description	Relationship to Code 48
Condition Code 41	Partial Outpatient Hospitalization Services	Alternative for less intensive psychiatric care; do not use simultaneously with Code 48
Condition Code 42	Continued Care Plan Not Related to Inpatient Admission	May apply if psychiatric RTC care is unrelated to prior inpatient stay
Condition Code 44	Inpatient Admission Changed to Outpatient	Relevant if psychiatric RTC admission is converted to outpatient status
Revenue Code 1002	Psychiatric Residential Treatment - Room and Board	Primary revenue code for psychiatric RTC stays
Revenue Code 0900	Psychiatric/Psychological Services	Used for therapy services within psychiatric RTC
Revenue Code 0910	Individual Therapy	Specific therapy service in psychiatric RTC
Revenue Code 0911	Group Therapy	Common therapy modality in psychiatric RTC
Revenue Code 0912	Family Therapy	Often provided in psychiatric RTC settings
Revenue Code 0914	Medication Management	Psychiatric medication services in RTC
Field 12 (Admission Date)	Date of admission to psychiatric RTC	Required for all inpatient claims
Field 6 (Statement Covers Period)	Dates of service for the claim	Must match psychiatric RTC stay dates
Field 80 (Remarks)	Additional claim information	Use for TRICARE authorization numbers and special instructions

^[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