Condition Codes 49, 50 and 53
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Defines Molina Healthcare's reimbursement and billing expectations for institutional claims that report UB-04 Condition Codes 49, 50, and 53 (device replacement, recall, and trial/free-sample device reporting) across Molina Medicaid, Medicare, and Marketplace lines of business and applicable facility settings.
No material clinical or coverage changes in this revision.
Coverage and Billing Rules
COVERAGE CRITERIA
Coverage and billing rules when devices are replaced due to malfunction, recall, or provided at no cost:
Condition code selection
- Use Condition Code 49 for product lifecycle replacement earlier than anticipated due to malfunction (warranty-based replacement).
- Use Condition Code 50 for product replacement due to a manufacturer or FDA recall.
- Use Condition Code 53 for initial placement of a device provided as part of a clinical trial or as a free sample; Code 53 is limited to outpatient and ambulatory surgical center claims and must not be used on inpatient claims.
Condition Codes, Value Codes, and Modifiers
| 49 | Product lifecycle replacement earlier than anticipated due to malfunction (warranty-based replacement) |
| 50 | Product replacement for known recall by manufacturer or FDA |
| 53 | Initial placement of a medical device provided as part of a clinical trial or a free sample (outpatient/ASC only) |
| FD | Value Code FD = Credit received from manufacturer (report dollar amount when >= 50%) |
| FB (modifier) | Item provided without cost to provider or full credit received; attach to procedure CPT/HCPCS line (outpatient/ASC) |
| FC (modifier) | Partial credit received (>= 50%); attach to procedure CPT/HCPCS line (outpatient/ASC) |
Provider Billing Requirements and Audit Risk
Audit and liability stance
Molina will not be liable for the full replacement cost when a facility receives a full or partial manufacturer credit for a replaced device, and Molina reserves the right to audit any claims submitted for such services.
- Molina may reduce reimbursement when manufacturer credit is received to avoid double payment.
- Molina reserves the right to conduct audits and recover payments for improper billing.
Claim submission actions (condition codes, modifiers, Value Code FD)
For outpatient/ASC claims report Condition Codes 49, 50, or 53 in FL 39-41 and attach modifier FB for items provided at no cost or full credit or modifier FC for partial credit (≥50%) on the procedure CPT/HCPCS line in FL 44; for inpatient claims report Condition Code 49 or 50 and report Value Code FD with the dollar amount when credit is ≥50%.
- Enter condition codes in Field Locator (FL) 39-41 on the UB-04.
- Enter modifiers FB or FC immediately following the procedure CPT/HCPCS code in FL 44 (up to four modifiers).
- For inpatient claims do not use FB/FC; report Condition Code 49 or 50 and Value Code FD with the credit amount in FL 39-41 instead.
Definitions — Codes and Modifiers
OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.