UB04 Condition Codes Code 60: Day Outlier

Overview

Condition Code 60 is a payer-only code used on the UB-04 claim form to indicate an Operating cost day outlier. According to Noridian Healthcare Solutions, the official definition is “Operating cost day outlier. (Payer code only)”. ^[1] This means the code is assigned by the Medicare Administrative Contractor (MAC) or other payer, not submitted by the provider. It signals that the inpatient stay has exceeded the geometric mean length of stay for the DRG and qualifies for an additional operating cost outlier payment. The code is part of the standardized condition code set maintained for Medicare and other third‑party payers.

When to Use

Condition Code 60 is not entered by the provider — it is a payer‑only designation. ^[1] A MAC will append this code to a claim when the inpatient stay meets the criteria for a day outlier (i.e., the length of stay exceeds a predetermined threshold, triggering an additional operating cost payment). Providers should be aware that if they see code 60 on a remittance advice or in claim status, it indicates the payer has recognized the stay as an outlier. The code does not require any action from the billing office; it is strictly an informational payer code. Accurate coding of the length of stay on the UB-04 (fields 32–35) is critical because the payer uses those data to determine outlier eligibility before applying code 60.

Step-by-Step Claim Example

Step 1 – Provider submits a UB-04 for an inpatient admission. The claim includes the admission and discharge dates (fields 32–33), total days (field 34), and the appropriate diagnosis‑related group (DRG). The provider does not enter Condition Code 60, as it is a payer‑only code. ^[1]

Step 2 – The MAC processes the claim. The payer calculates the patient’s actual length of stay against the DRG geometric mean. If the stay exceeds the outlier threshold (commonly the geometric mean plus a fixed number of days or a cost‑based threshold), the claim qualifies for an operating cost day outlier.

Step 3 – The MAC adds Condition Code 60 to the claim. The code is placed in one of the condition code fields (18–28) on the claim record. This indicates the outlier determination. The MAC also calculates the additional outlier payment due.

Step 4 – The provider receives the remittance advice. The document shows Condition Code 60, confirming the outlier status. No additional action is required from the provider.

Common Mistakes & Audit Red Flags

• Provider‑submitted code 60: A frequent error is a provider knowingly or unknowingly placing Condition Code 60 on the original UB‑04. Because it is a payer‑only code, this can trigger an audit or claim rejection. ^[1] The code should never appear on a provider‑submitted claim.
• Incorrect length of stay reporting: If the admission/discharge dates or total days are inaccurate, the payer may incorrectly apply (or fail to apply) code 60. Auditors will compare the condition code to the stay data.
• Mismatch with value codes: Day outlier payments often require supporting value codes (e.g., value code 17 for outlier days). If code 60 is present without the corresponding value code, the claim may be flagged for review.
• Payer assignment without medical necessity review: Some audits examine whether the outlier stay was medically necessary. Code 60 alone does not guarantee payment if documentation does not support the extended length of stay.

Related Codes/Fields

The following condition codes from the Noridian list are closely related to Code 60 and appear in the same family of payment/outlier indicators. ^[1]

Code	Description
60	Operating cost day outlier (payer code only)
61	Operating cost outlier not reported by provider
62	PIP bill not reported by providers
63	Bypass CWF edit for incarcerated beneficiaries
64	Other than clean claim
65	Non‑PPS bill not reported by providers
69	IME/DGME/N&AH payment only billing

These codes are used by payers to communicate outlier status, payment method, or special billing conditions. Providers should understand each code to correctly interpret payer‑added data on remittance advices.

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References

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