Examples
Worked examples
- Is an instance
A hospital submits an inpatient UB-04 claim for a patient enrolled in an NIH-funded oncology trial that meets NCD 310.1's qualifying criteria. Because the admission includes routine standard-of-care items billed to Medicare alongside the trial, the claim carries Condition Code 30, diagnosis code Z00.6, and the trial's NCT number in value code D4 — signaling the MAC to apply Clinical Trial Policy coverage rules rather than deny the claim as investigational.
- Is an instance
An outpatient facility claim for a patient in a qualifying device trial includes both routine services (modifier Q1) and the investigational device itself (modifier Q0). The facility claim still carries Condition Code 30 because it is an institutional claim tied to a qualifying trial, regardless of the fact that not every individual line item is trial-specific.
Counter-examples
Looks similar, but isn't
- Not an instance
A hospital claim for a patient enrolled in a trial that does not meet any of NCD 310.1's deeming criteria and has not been independently confirmed to qualify does not carry Condition Code 30 — applying it to a non-qualifying trial risks a false claim, since the code asserts to the MAC that Medicare's Clinical Trial Policy coverage rules apply.
- Not an instance
A professional (physician) claim on a CMS-1500 form does not use Condition Code 30 at all — condition codes are a UB-04/837I institutional-claim field; professional claims signal trial participation through the Q0/Q1 modifiers and the NCT number instead.
Editorial commentary
Condition Code 30 is a two-character code entered on a Medicare institutional claim (UB-04 / CMS-1450) to indicate that the billed item or service was furnished as part of a Medicare-qualifying clinical trial. It signals to the Medicare Administrative Contractor that the claim should be evaluated under Medicare’s clinical-trial coverage policy rather than rejected as investigational or experimental.
Why the code matters for research billing
Under Medicare’s National Coverage Determination 310.1, Medicare covers the routine costs of care associated with a qualifying clinical trial — items and services a beneficiary would need regardless of trial participation — even though it does not cover the investigational item or service itself, or costs borne by the trial sponsor. Condition Code 30, together with the trial’s clinical-trial number reported elsewhere on the claim, is how a hospital or research billing office documents that a given claim falls under this routine-costs coverage rather than Medicare’s general exclusion for experimental treatment.
Who applies it
Hospital and health-system billing offices, often working with a clinical trials office or research billing compliance team, are responsible for correctly flagging qualifying-trial claims with Condition Code 30 — incorrect use in either direction (omitting it on a qualifying claim, or applying it to a non-qualifying trial) creates billing compliance risk.
References
- CMS National Coverage Determination 310.1, Routine Costs in Clinical Trials
- CMS UB-04 / CMS-1450 claim form instructions, condition codes
Frequently Asked Questions
Where on a claim does Condition Code 30 go?
Condition Code 30 is entered in the condition codes field of the UB-04 (CMS-1450), the standard institutional claim form used for Medicare facility billing.
What is a condition code on a UB-04 claim?
A condition code is a two-character field on the UB-04 (CMS-1450) that flags a special circumstance affecting how a claim should be processed. Condition Code 30 is one such code, used specifically to flag a claim as containing Medicare-qualifying clinical trial costs.
Does Condition Code 30 need to be reported alongside other information on the claim?
Yes. It is typically reported together with the trial’s clinical-trial number (NCT number) and, on the diagnosis side, ICD-10 code Z00.6, so the Medicare Administrative Contractor can confirm the claim relates to a specific qualifying trial under NCD 310.1.
Who is responsible for applying Condition Code 30 on a claim?
Hospital and health-system billing offices apply it, typically working with a clinical trials office or research billing compliance team to confirm which claims qualify under NCD 310.1.
What happens if Condition Code 30 is applied incorrectly?
Incorrect use in either direction creates billing compliance risk: omitting it from a qualifying claim, or applying it to a claim for a non-qualifying trial, are both errors billing offices need to avoid.
Machine-readable encodings
Use in your systems
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"description": "Condition Code 30 is the two-digit value (\"30 – Qualifying Clinical Trial\") entered in the condition codes field of an institutional Medicare claim (UB-04 / CMS-1450, or the equivalent field on the electronic 837I transaction) to flag that the claim includes items or services furnished in connection with a qualifying clinical trial under Medicare's Clinical Trial Policy (National Coverage Determination 310.1). A claim requires Condition Code 30 when the trial meets NCD 310.1's qualifying criteria (falls within a Medicare benefit category, has therapeutic intent, and satisfies one of the NCD's deeming criteria — including NIH, FDA IND, or VA/DOD/CDC/AHRQ/CMS-funded/-supported studies) and the provider is billing Medicare for routine patient-care costs alongside the trial. It is reported on ALL clinical-trial-related institutional claims from a qualifying study, whether or not every line item on that particular claim is trial-related, and is submitted together with ICD-10 diagnosis code Z00.6 (encounter for examination for normal comparison and control in clinical research) and the trial's eight-digit National Clinical Trial (NCT) number — reported as UB-04 value code D4, or in loop 2300, REF02 (REF01 = P4) on the 837I. It functions purely as a claims-processing flag: it does not itself create coverage, it tells the Medicare Administrative Contractor (MAC) which coverage rules to apply to the claim.",
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