UB04 Condition Codes Code 59: Non-primary ESRD Facility

Overview

Condition code 59, defined as “Non-primary ESRD facility,” is a UB‑04 claim indicator used to identify that the facility providing services is not the patient’s designated primary ESRD (End‑Stage Renal Disease) facility. This code is part of the Medicare Part A condition code set maintained by Noridian Healthcare Solutions ^[1]. Although the Noridian source does not provide additional detail beyond the code‑to‑description mapping, the code is listed alongside other ESRD‑related condition codes (e.g., codes 06, 70–76) on the same page, confirming its role in ESRD billing ^[1]. On the UB‑04 claim form, condition codes are entered in fields 18–28, as described in general UB‑04 billing guides such as the MassHealth UB‑04 Billing Guide, which explains that condition codes “are used to identify special circumstances of the bill” ^[2] (see “Code Sets for the UB-04 Claim Form” section). Thus, code 59 signals to payers that the current billing facility is not the beneficiary’s primary ESRD facility, which may affect reimbursement, bundling rules, or primary payer coordination.

When to Use

Condition code 59 should be applied when a Medicare‑eligible ESRD patient receives dialysis or other ESRD‑related services at a facility that is not his or her established primary ESRD facility. According to the Noridian list, code 59 means “Non-primary ESRD facility” ^[1]. Common scenarios include a patient traveling (e.g., on vacation or for temporary relocation) and receiving backup dialysis, or a patient receiving dialysis at a different facility due to capacity issues at the primary site. The code helps payers distinguish routine treatment at the primary facility from ad‑hoc or transient encounters at other locations. The Noridian source also lists other ESRD condition codes such as 06 (“ESRD patient in the first 30 months of entitlement covered by employer group health insurance”) and 70–76 (dialysis care types), indicating that code 59 is part of a suite of ESRD‑specific indicators ^[1]. As with all condition codes, the MassHealth UB‑04 guide notes that these codes are entered in fields 18–28 of the claim form and must accurately reflect the circumstances of the bill ^[2] (see “How to Complete the UB-04 Claim Form” section). Providers should use code 59 only when the facility is not the patient’s primary ESRD facility and must ensure that the primary facility code is not also applied to the same line.

Step-by-Step Claim Example

Consider a Medicare‑covered ESRD patient who is on a two‑week vacation and requires in‑center hemodialysis at a hospital‑based dialysis unit that is not his or her usual primary ESRD facility. The outpatient hospital billing department prepares the UB‑04 claim for the dialysis service. On the UB‑04 form, the biller completes field 18–28 (Condition Codes) with code 59 to indicate “Non-primary ESRD facility” ^[1]. Additional required form fields are populated per the MassHealth UB‑04 guide: e.g., field 4 (type of bill) with appropriate outpatient code, field 42 (revenue code) for dialysis services, and field 44 (HCPCS/Rate) for the dialysis procedure code ^[2] (see “How to Complete the UB-04 Claim Form” section). The biller also ensures that no other ESRD-related condition code (such as code 06 or 70–76) that would conflict with code 59 is entered unless separately applicable ^[1]. After review, the claim is submitted electronically (or on paper if a waiver exists, per MassHealth rules) ^[2] (see “General Instructions for Submitting Paper Claims”). The presence of code 59 alerts the Medicare administrative contractor that the dialysis was performed outside the patient’s primary ESRD facility, which may affect payment calculation or coordination with the primary facility.

Common Mistakes & Audit Red Flags

One frequent mistake is omitting condition code 59 when providing dialysis at a non‑primary facility, which can lead to incorrect payment or denial because the payer may assume the claim is for the primary facility. Another error is using code 59 for a patient’s own primary facility; the code must only be used when the facility is not the primary one, as defined by the Noridian mapping ^[1]. Audit red flags include inconsistent use of code 59 across multiple claims for the same patient – for example, billing every dialysis session with code 59 even when most are at the primary facility, which may raise questions about beneficiary residency or primary facility designation. Additionally, combining code 59 with other ESRD condition codes that imply a different care setting (e.g., code 74 “Home dialysis” or code 71 “Full care in unit”) without proper rationale can trigger review ^[1]. The MassHealth UB‑04 guide notes that condition codes are essential for “special circumstances” and incorrect use may jeopardize payment ^[2] (see “Code Sets for the UB-04 Claim Form” section). To avoid audits, providers should maintain documentation showing the reason for service at a non‑primary facility (e.g., travel records, referral notes) and ensure the condition code matches the patient’s status.

Related Codes/Fields

Code / Field	Description	Source
Code 06	ESRD patient in the first 30 months of entitlement covered by employer group health insurance	[1]
Code 70	Self-administered EPO (home dialysis)	[1]
Code 71	Full care in unit (dialysis)	[1]
Code 72	Self-Care in unit (dialysis)	[1]
Code 73	Self-Care training (dialysis)	[1]
Code 74	Billing is for a patient who received dialysis services at home	[1]
Code 75	Billing for home dialysis with machine purchased under 100% payment program	[1]
Field 18–28	Condition Codes on the UB‑04 claim form	[2] (see “How to Complete the UB-04 Claim Form” – Code Sets section)

These related codes help providers correctly identify the ESRD care setting and payer circumstances; code 59 should be used only when the facility is not the primary ESRD facility, and it may be combined with other ESRD codes if applicable (e.g., code 72 for self-care in a non‑primary unit).

---

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