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When are we required to begin reporting new condition codes 90 and 91?

On October 29, 2020, the National Uniform Billing Committee (NUBC) announced the creation of two new condition codes, 90 and 91. We have provided the full descriptions below for your convenience.

90: Service provided as part of an Expanded Access approval

91: Service provided as part of an Emergency Use Authorization

On November 20, 2020, CMS released MLN Matters Article, MM12049, which clarifies the effective date as well as outlines the appropriate use for each of the new condition codes.

Per CMS, condition code 90 should be reported on claims when patients receive services provided as part of an FDA Expanded Access approval. The Expanded Access (EA) program, which is sometimes referred to as the “compassionate use” program, allows patients to receive investigational drugs, biologicals and/or medical devices outside of an established clinical trial when there is no comparable alternative to treat the patient’s condition.

Condition code 91 should be reported on claims when patients receive drugs, biologicals and/or medical devices granted an Emergency Use Authorization (EUA) by the FDA. An EUA allows patients to receive treatments that have not yet been granted full FDA approval during a public health emergency when there are no adequate, approved or available treatment alternatives. In the context of the COVID-19 PHE there have been a handful of therapies granted an EUA to treat COVID-19 including; convalescent plasma, Remdesivir, Bamlanivimab and Regeneron’s “monoclonal antibody cocktail” of casirivimab and imdevimab. (Please note this listing is not intended to be exhaustive as additional FDA EUAs can be issued at any time)

CMS states both condition codes are effective for claims received on or after February 1, 2021. It is important to highlight the effective date for these condition codes is based on the date of claim submission and not the admit/discharge date reported on the claim.

To ensure these condition codes are applied appropriately providers will need to establish ongoing communication channels between Pharmacy, Materials Management, Finance and Coding teams as EA or EAU status may not be explicitly documented in the medical record by clinical staff.

NUBC Announcement of Condition Codes 90 and 91:
https://www.nubc.org/nubc-announces-new-condition-codes-effective-february-1-2021

CMS MLN Article MM12049, “Implementation of Two (2) New NUBC Condition Codes. Condition Code “90”, “Service Provided as Part of an Expanded Access Approval (EA)” and Condition Code “91”, “Service Provided as Part of an Emergency Use Authorization (EUA)””:
https://www.cms.gov/files/document/mm12049.pdf