UB04 Condition Codes Code D1: Changes in Provider Number

Overview

This prevents claim rejections or duplicate billing errors that might occur if the payer's system expects the old provider number. ^[1]

It is a payer-facing code that helps claims processing systems reconcile provider records. ^[2]

When to Use

The code should also be used when a provider has been revalidated by Medicare and assigned a new provider number, or when a provider changes their tax identification number (TIN) and receives a corresponding new provider number. If the provider has multiple locations and one location receives a new number while others remain unchanged, Code D1 applies only to claims from the affected location. ^[1]

Step-by-Step Claim Example

Scenario: A hospital (formerly "City General Hospital") was acquired by "Regional Health System" and received a new Medicare provider number (e.g., 123456 changed to 789012). The hospital is submitting a UB-04 claim for a patient who was admitted after the acquisition.

Step 1: In Form Locator 1 (Provider Name, Address, and Telephone Number), enter the new provider name and address: "Regional Health System, 100 Main Street, Anytown, USA." ^[1]

Step 2: In Form Locator 56 (National Provider Identifier – NPI), enter the hospital's NPI (e.g., 1234567890). This NPI may remain the same even if the Medicare provider number changed. ^[2]

Step 3: In Form Locator 51 (Health Plan ID), enter the new Medicare provider number (789012). This is the number that changed. ^[1]

Step 4: In Form Locator 18-28 (Condition Codes), enter "D1" in the first available condition code field. For example, if no other condition codes apply, enter "D1" in the first box of Form Locator 18. ^[2]

Step 5: Complete all other required fields on the UB-04, including patient demographics (Form Locators 8-17), admission/discharge dates (Form Locators 12-13), and revenue codes (Form Locators 42-47). ^[1]

Step 6: Submit the claim electronically (or on paper if a waiver is approved). The payer's system will recognize Code D1 and reconcile the old provider number (123456) with the new one (789012), preventing a rejection. ^[2]

Common Mistakes & Audit Red Flags

Mistake 1: Using Code D1 for patient-related changes. Code D1 is specifically for provider number changes, not for changes to the patient's insurance, name, or condition. Using it incorrectly can cause claim processing delays. ^[2]

Mistake 2: Omitting Code D1 when the provider number has changed. If a provider fails to include Code D1, the payer's system may reject the claim as a duplicate or mismatch, leading to denials and delayed payment. ^[1]

Mistake 3: Using Code D1 for every claim after a provider number change. Code D1 should only be used on the first claim submitted after the change, or until the payer's system has been updated. Using it repeatedly may cause confusion or unnecessary edits. ^[2]

Audit Red Flag: Multiple claims with Code D1 from the same provider over an extended period. This may indicate that the provider has not properly updated their enrollment records with the payer, or that the payer has not processed the change. Auditors may request documentation of the provider number change. ^[1]

Audit Red Flag: Claims with Code D1 but no corresponding change in Form Locator 51 (Health Plan ID). If the provider number in Form Locator 51 matches the old number, the claim may be rejected. Ensure the new number is entered correctly. ^[2]

Related Codes/Fields

Code/Field	Description	Relationship to D1
Condition Code 20	Beneficiary requested billing	Used when patient requests billing; not related to provider number changes
Condition Code 44	Inpatient admission changed to outpatient	Used for status changes; not related to provider number changes
Form Locator 51	Health Plan ID	Contains the provider number that changed; D1 should accompany a new number here
Form Locator 56	National Provider Identifier (NPI)	May remain unchanged even when provider number changes; D1 does not affect NPI
Condition Code 02	Workers compensation	Used for employment-related injuries; unrelated to provider number changes
Condition Code 03	Insurance not reflected here	Used for other insurance coverage; unrelated to provider number changes
Condition Code 04	Informational billing	Used for informational purposes; unrelated to provider number changes
Condition Code 05	Lien filed	Used when a lien is on file; unrelated to provider number changes
Condition Code 06	ESRD patient in first 30 months	Used for ESRD coverage; unrelated to provider number changes

^[2] | ^[1]

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References

[1] MassHealth UB-04 Guide — https://www.mass.gov/doc/ub-04-billing-guide-0/download

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