What are the different types of CMS claim type codes?

CMS (Centers for Medicare & Medicaid Services) uses different claim type codes depending on the data system or file format (such as the National Claims History [NCH], MEDPAR, or Type of Bill [TOB] codes).

NCH Claim Type Codes

In standard Medicare claims data (like the ResDAC NCH Claim Type Code and CMS Blue Button API), the primary health care provider categories use these codes:

• 10: Home Health Agency (HHA) claim
• 20: Non-swing bed Skilled Nursing Facility (SNF) claim
• 30: Swing-bed SNF claim
• 40: Hospital outpatient claim
• 50: Hospice claim
• 60: Inpatient claim
• 61: Medicare Inpatient Full Encounter claim (MEDPAR version)
• 62: Medicare Advantage IME/GME claims (MEDPAR version)
• 63: Medicare Advantage No-Pay claims (MEDPAR version)
• 64: Medicare Advantage Paid-as-FFS claims (MEDPAR version)
• 71: Local carrier non-durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS) claim
• 72: Local carrier DMEPOS claim
• 81: Durable Medical Equipment Regional Carrier (DMERC) non-DMEPOS claim
• 82: DMERC DMEPOS claim

Type of Bill (TOB) Codes

Institutional claims often use a 4-digit alphanumeric code (UB-04 / Form CMS-1450) where the leading zero is ignored, leaving 3 core digits defined via the Noridian Medicare Bill Types Guide and CMS Manual System:

1. First Digit (Type of Facility):
   • 1: Hospital
   • 2: Skilled Nursing Facility (SNF)
   • 3: Home Health Agency (HHA)
   • 4: Religious Nonmedical Health Care Institution (Hospital)
   • 5: Religious Nonmedical Health Care Institution (Extended Care)
   • 6: Intermediate Care
   • 7: Clinic or Hospital-Based Renal Dialysis Facility
   • 8: Specialty Facility / Critical Access Hospital (CAH) / Ambulatory Surgical Center (ASC)
   • 9: National / Reserved
2. Second Digit (Type of Care / Service Classification): Varies based on the facility type (e.g., inpatient, outpatient, subacute, rural health clinic, or hospice).
3. Third Digit (Frequency Code): Indicates the sequence of the bill in an episode of care (e.g., 0 for non-payment, 1 for admit-through-discharge, 7 for replacement of prior claim, 8 for void/cancel).

T-MSIS Claim Type Codes (Medicaid / CHIP)

In Medicaid and CHIP Analytic Files (TAF), the payment kinds are represented by the ResDAC TAF Claim Type Code:

• 1: FFS Medicaid / expansion
• 2: Capitated Payment
• 3: Managed Care Encounter
• 4: CHIP Service Tracking
• 5: Supplemental Payment
• A – E: Separate CHIP FFS, Capitated, Encounter, Tracking, and Supplemental
• U – Y: Other FFS, Capitated, Managed Care, Tracking, and Supplemental

A claim type code is a short alphanumeric identifier used in databases and medical billing to classify the specific category or setting of a submitted insurance, healthcare, or government benefit claim.

Common Examples

• Healthcare & Medicare (ResDAC): Codes separate claims by provider or service category, such as inpatient hospital stays (e.g., code 60), home health agency services (code 10), or skilled nursing facility care (code 20).
• HL7 / FHIR Standards (HL7 Terminology): Standardized digital health codes categorize records into broad groups like institutional, professional, pharmacy, oral, and vision.
• Veterans Affairs (VA): Codes track the administrative status or nature of a benefit submission, such as new or increased disability claims.

Medicare uses several categories of service and billing codes to process claims, track treatments, and identify where and what type of care was given.

1. Procedure and Supply Codes (CPT and HCPCS Level II)

These codes describe the specific medical procedures, services, or items provided to a patient.

• CPT (Current Procedural Terminology) Codes: Five-digit numeric codes used to report medical, surgical, and diagnostic services performed by physicians and healthcare professionals.
• HCPCS Level II (Healthcare Common Procedure Coding System) Codes: Alpha-numeric codes (starting with a letter) used for items not covered by standard CPT codes, such as ambulance rides, durable medical equipment, injections, and specific supplies.

2. Type of Service (TOS) Indicators

TOS indicators are single-digit numbers or letters assigned by Medicare to group claims into broad categories of care. They help the system apply specific payment rules.

• Numeric Codes (0–9): Cover fundamental services like Whole Blood (0), Medical Care/Office Visits (1), Surgery (2), Consultations (3), Diagnostic Radiology (4), Diagnostic Laboratory (5), Therapeutic Radiology (6), Anesthesia (7), Assistants at Surgery (8), and Other Medical Items (9).
• Alpha Codes (A–W): Cover specialized items and settings like Durable Medical Equipment (A), Ambulance (D), Ambulatory Surgical Center usage (F), Hospice (H), Hearing Items (K), Vision (Q), and Physical/Occupational Therapy (W, U).

3. Place of Service (POS) Codes

POS codes are two-digit numbers put on professional claims to show the physical setting where a patient received treatment.

• Common Examples: Office (11), Home (12), Inpatient Hospital (21), Emergency Room (23), Ambulatory Surgical Center (24), and Telehealth in Home (10).

4. Type of Bill (TOB) Codes

Type of Bill codes are four-digit alphanumeric codes used on institutional provider claims (like hospitals or skilled nursing facilities).

• Structure: The first digit is a leading zero (ignored by Medicare), the second digit indicates the facility type, the third digit shows the classification of care, and the fourth digit serves as a frequency code for the billing sequence.

5. Diagnosis Codes (ICD-10-CM)

While not "service" codes in the procedural sense, diagnosis codes explain the patient's medical condition and prove the medical necessity of the service rendered.

X12 service type codes are standardized alphanumeric codes used in electronic data interchange (EDI) to identify specific business groupings and classifications for healthcare services, benefits, and coverage types.

You can view the full, up-to-date registry of definitions on the X12 Service Type Codes page.

Overview of Service Type Codes

• Purpose: They categorize medical, surgical, dental, psychiatric, and other clinical care categories during eligibility or benefit inquiries (such as ASC X12 270/271 transactions).
• Scope: The comprehensive list spans numbers (1–99) and letters/combinations (like A4 through UT) to define exact operational scopes for claims and coverage.
• Maintenance: These lists are actively maintained and updated by the X12 External Code Lists directory.

Claim frequency codes are single-digit characters at the end of an institutional type of bill code or electronic claim field that tell an insurance payer the status or sequence of a medical claim.

Common Claim Frequency Codes

• 0 (Non-payment / Zero Claim): Used when no payment is expected, such as a notice of non-payable confinement or a denial request.
• 1 (Admit Through Discharge): Used for a standard, complete claim covering an entire stay or course of treatment.
• 2 (Interim – First Claim): Used for the first bill in an expected series of ongoing claims.
• 3 (Interim – Continuing Claim): Used for middle bills in a continuous series.
• 4 (Interim – Last Claim): Used for the final bill in an ongoing series.
• 5 (Late Charges Only): Used to submit additional charges left off the original bill.
• 7 (Replacement of Prior Claim): Used to replace or correct an entire previously submitted claim.
• 8 (Void / Cancel Prior Claim): Used to completely cancel a previously submitted claim.
• 9 (Final Claim): Used for the final claim in specific contexts like home health episodes.