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TRICARE Systems Manual 7950.3-M, April 1, 2015
TRICARE Encounter Data (TED)
Chapter 2
Addendum N
UB-04/UB-92 Conversion Table - To Be Used For Reporting Non-Institutional TRICARE Encounter Data (TED) Records
Copyright:  CPT only © 2006 American Medical Association (or such other date of publication of CPT). All Rights Reserved.
Revision:  C-30, September 27, 2019
Note:  Providers are not to use this addendum for billing purposes. The contractors shall use the following codes for reporting purposes only and only in those rare occurrences where an appropriate Current Procedural Terminology (CPT)/Healthcare Common Procedure Coding System (HCPCS) code is not available. If a hospital outpatient claim is submitted by the provider with a Level III HCPCS code, the claim shall be rejected as these codes are not Health Insurance Portability and Accountability Act of 1996 (HIPAA) compliant.
The revenue codes listed below are authorized by the National Uniform Billing Committee (NUBC). See the National Uniform Billing Data Element specifications-Form Locator (FL) 42 for UB-04/UB-92. The codes are required for reporting to the Defense Health Agency (DHA), but do not indicate TRICARE payment policy. Refer to the 32 Code of Federal Regulations (CFR) 199, the TRICARE Policy Manual (TPM), the Reimbursement Manual (TRM), or TRICARE Operations Manual (TOM) to determine the TRICARE payment policy.
Revenue Code
Description
Value If Appropriate CPT/HCPCS Code Is Not Available1
1  Must use appropriate CPT/HCPCS codes.
0001-0239
Not Valid For Reporting
024X
All Inclusive Ancillary
0240
General Classification
99499
0241
Basic
0242
Comprehensive
0243
Specialty
0249
Other Inclusive Ancillary
025X
Pharmacy
0250
General Classification
99070
0251
Generic Drugs
0252
Non-Generic Drugs
0253
Take Home Drugs
0254
Drugs Incident to Other Diagnostic Services
0255
Drugs Incident to Radiology
0256
Experimental Drugs
T5999
0257
Non-Prescription
99070
0258
IV Solutions
0259
Other Pharmacy
026X
IV Therapy
0260
General Classification
99070
0261
Infusion Pump
99499
0262
IV Therapy/Pharmacy Services
99070
0263
IV Therapy/Drug/Supply Delivery
0264
IV Therapy/Supplies
0269
Other IV Therapy
027X
Medical/Surgical Supplies and Devices
0270
General Classification
99070
0271
Non-Sterile Supply
0272
Sterile Supply
0273
Take Home Supplies
0274
Prosthetic/Orthotic Devices
99499
0275
Pacemaker
99070
0276
Intraocular Lens
0277
Oxygen - Take Home
0278
Other Implants
0279
Other Supplies/Devices
028X
Oncology
0280
General Classification
99078
0289
Other Oncology
029X
Durable Medical Equipment (Other Than Renal)
0290
General Classification
99499
0291
Rental
0292
Purchase of New DME
0293
Purchase of Used DME
0294
Supplies/Drugs for DME Effectiveness (Home Health Agency only)
0299
Other Equipment
030X
Laboratory
0300
General Classification
99499
0301
Chemistry
0302
Immunology
0303
Renal Patient (home)
0304
Non-Routine Dialysis
0305
Hematology
0306
Bacteriology & Microbiology
0307
Urology
0309
Other Laboratory
031X
Laboratory Pathological
0310
General Classification
99499
0311
Cytology
0312
Histology
0314
Biopsy
0319
Other Laboratory Pathological
032X
Radiology - Diagnostic
0320
General Classification
99499
0321
Angiocardiography
0322
Arthrography
0323
Arteriography
0324
Chest X-Ray
0329
Other Radiology - Diagnostic
033X
Radiology - Therapeutic
0330
General Classification
99499
0331
Chemotherapy - Injected
0332
Chemotherapy - Oral
0333
Radiation Therapy
0335
Chemotherapy - IV
0339
Other Radiology - Therapeutic
034X
Nuclear Medicine
0340
General Classification
99499
0341
Diagnostic Procedures
0342
Therapeutic Procedures
0343
Diagnostic Radiopharmaceuticals (Effective 10/01/2004)
0344
Therapeutic Radiopharmaceuticals (Effective 10/01/2004)
0349
Other Nuclear Medicine
035X
CT Scan
0350
General Classification
99499
0351
Head Scan
0352
Body Scan
0359
Other CT Scan
036X1
Operating Room Services
0360
General Classification
99499
0361
Minor Surgery
0362
Organ Transplant - Other than Kidney
0367
Kidney Transplant
0369
Other Operating Room Services
1 These must be reported as “Other Medical Services” in Type of Services, position 2.
037X2
Anesthesia
0370
General Classification
01999
0371
Anesthesia Incident to Radiology
0372
Anesthesia Incident to Other Diagnostic Services
0374
Acupuncture
T5999
0379
Other Anesthesia
01999
2 These must be reported as “Other Medical Services” in Type of Services, position 2.
038X
Blood
0380
General Classification
99499
0381
Packed Red Cells
0382
Whole Blood
0383
Plasma
0384
Platelets
0385
Leukocytes
0386
Other Components
0387
Other Derivatives (cryoprecipitates)
0389
Other Blood
039X
Blood Storage and Blood Component Administration, Storage, and Processing
0390
General Classification
85396
0391
Blood Administration (e.g., Transfusions)
99499
0392
Blood Storage
85396
0399
Other Blood Storage and Processing
040X
Other Imaging Services
0400
General Classification
99499
0401
Diagnostic Mammography
0402
Ultrasound
0403
Screening Mammography
0404
Positron Emission Tomography
0409
Other Imaging Services
041X
Respiratory Services
0410
General Classification
99499
0412
Inhalation Services
0413
Hyperbaric Oxygen Therapy
0419
Other Respiratory Services
042X
Physical Therapy
0420
General Classification
99499
0421
Visit Charge
0422
Hourly Charge
0423
Group Rate
0424
Evaluation or Re-Evaluation
0429
Other Physical Therapy
043X
Occupational Therapy
0430
General Classification
99499
0431
Visit Charge
0432
Hourly Charge
0433
Group Rate
0434
Evaluation or Re-Evaluation
0439
Other Occupational Therapy
044X
Speech - Language Pathology
0440
General Classification
99499
0441
Visit Charge
0442
Hourly Charge
0443
Group Rate
0444
Evaluation or Re-Evaluation
0449
Other Speech - Language Pathology
045X
Emergency Room
0450
General Classification
99499
0451
Emergency Medical Treatment & Active Labor Act (EMTALA) Emergency Medical Screening Services
0452
ER Beyond EMTALA Screening
0456
Urgent Care
0459
Other Emergency Room
046X
Pulmonary Function
0460
General Classification
99499
0469
Other Pulmonary Function
047X
Audiology
0470
General Classification
99499
0471
Diagnostic
0472
Treatment
0479
Other Audiology
048X
Cardiology
0480
General Classification
99499
0481
Cardiac Catheterization Laboratory
0482
Stress Test
0483
Echocardiology
0489
Other Cardiology
049X
Ambulatory Surgical Care
0490
General Classification
99499
0499
Other Ambulatory Surgical Care
050X
Outpatient Services
0500
General Classification
99499
0509
Other Outpatient Services
051X
Clinic
0510
General Classification
99499
0511
Chronic Pain Center
0512
Dental Clinic
0513
Psychiatric Clinic
0514
OB-GYN Clinic
0515
Pediatric Clinic
0516
Urgent Care Clinic
0517
Family Practice Clinic
0519
Other Clinic
052X
Freestanding Clinic
0520
General Classification
99499
0521
Rural Health Clinic (RHC)/Federally Qualified Health Center (FQHC)
0522
RHC/FQHC - Home
0523
Family Practice Clinic
0524
RHC/FQHC (SNF Stay Covered in Part A)
0525
RHC/FQHC (SNF Stay Not Covered in Part A)
0526
Urgent Care Clinic
0527
RHC/FQHC Visiting Nurse Service - Home
0528
RHC/FQHC Visit To Other Site
0529
Other Freestanding Clinic
053X
Osteopathic Services
0530
General Classification
99499
0531
Osteopathic Therapy
0539
Other Osteopathic Services
054X
Ambulance
0540
General Classification
99499
0541
Supplies
0542
Medical Transport
0543
Heart Mobile
0544
Oxygen
0545
Air Ambulance
0546
Neonatal Ambulance Service
0547
Pharmacy
0548
Telephone Transmission EKG
0549
Other Ambulance
055X
Skilled Nursing
0550
General Classification
99499
0551
Visit Charge
0552
Hourly Charge
0559
Other Skilled Nursing
056X
Medical Social Services
0560
General Classification
T5999
0561
Visit Charge
0562
Hourly Charge
0569
Other Medical Social Services
057X
Home Health Aide (Home Health)
0570
General Classification
99499
0571
Visit Charge
0572
Hourly Charge
0579
Other Home Health Aide
058X
Other Visits (Home Health)
0580
General Classification
99499
0581
Visit Charge
0582
Hourly Charge
0583
Assessment
0589
Other Home Health Visit
059X
Units of Service (Home Health)
0590
General Classification
99499
0599
Home Health Other Units (Terminated 10/01/2007)
060X
Oxygen (Home Health)
0600
General Classification
99499
0601
Oxygen - State/Equip/Supply/or Cont
0602
Oxygen - State/Equip/Supply Under 1 LPM
0603
Oxygen - State/Equip/Over 4 LPM
0604
Oxygen - Portable Add-On
0609
Other Oxygen
061X
Magnetic Resonance Technology (MRT)
0610
General Classification
99499
0611
Brain (including brainstem)
0612
Spinal Cord (including spine)
0614
MRI - Other
0615
MRA - Head and Neck
0616
MRA - Lower Extremities
0618
MRA - Other
0619
Other MRT
062X
Medical/Surgical Supplies and Devices - Other
0621
Supplies Incident to Radiology
99070
0622
Supplies Incident to Other Diagnostic Service
0623
Surgical Dressings
0624
FDA Investigational Devices
063X
Pharmacy
0631
Single Source Drug
99070
0632
Multiple Source Drug
0633
Restrictive Prescription
0634
Erythropoietin (EPO) Less Than 10,000 Units
99499
0635
Erythropoietin (EPO) 10,000 or More Units
0636
Drugs Requiring Detailed Coding (Blood Clotting Factor Only)
Note: Detail is not required for TRICARE.
0637
Self-Administrable Drugs
99070
064X
Home IV Therapy Services
0640
General Classification
99499
0641
Non-Routine Nursing, Central Line
0642
IV Site Care, Central Line
0643
IV Site/Change, Peripheral Line
0644
Non-Routine Nursing, Peripheral Line
0645
Training Patient/Caregiver, Central Line
0646
Training, Disabled Patient, Central Line
0647
Training, Patient/Caregiver Peripheral Line
0648
Training, Disabled Patient, Peripheral Line
0649
Other IV Therapy Services
065X
Hospice Service
0650
General Classification
99499
0651
Routine Home Care
0652
Continuous Home Care
0655
Inpatient Respite Care
0656
General Inpatient Care (Non-Respite)
0657
Physician Services
0658
Hospice Room and Board Nursing Facility
0659
Other Hospice Services
066X
Respite Care (HHA Only)
0660
General Classification
99499
0661
Hourly Charge/Nursing
0662
Hourly Charge/Home Health Aide/Home Maker/Companion
0663
Daily Respite Charge
0669
Other Respite Care
067X
Outpatient Special Residence Charge
0670
General Classification
99499
0671
Hospital-Based
0672
Contracted
0679
Other Special Residence Charges
068X
Trauma Response
0681
Level I
99499
0682
Level II
0683
Level III
0684
Level IV
0689
Other Trauma Response
069X
Pre-Hospice
0690
General Classification
99499
0691
Visit Charge
0692
Hourly Charge
0693
Evaluation
0694
Consultation and Education
0695
Inpatient Care
0696
Physician Services
0697
RESERVED
0698
RESERVED
0699
Other Pre-hospice/Palliative
070X
Cast Room
0700
General Classification
99078
0709
Other Cast Room (Terminated 10/01/2007)
071X
Recovery Room
0710
General Classification
99078
0719
Other Recovery Room (Terminated 10/01/2007)
072X
Labor Room/Delivery
0720
General Classification
99078
0721
Labor
0722
Delivery
99499
0723
Circumcision
0724
Birthing Center
0729
Other Labor Room/Delivery
073X
EKG/ECG (Electrocardiogram)
0730
General Classification
99499
0731
Holter Monitor
0732
Telemetry
0739
Other EKG/ECG
074X
EEG (Electroencephalogram)
0740
General Classification
99499
0749
Other EEG (Terminated 10/01/2007)
075X
Gastro-intestinal Services
0750
General Classification
99499
0759
Other Gastro-intestinal (Terminated 10/01/2007)
076X
Treatment or Observation Room
0760
General Classification
99499
0761
Treatment Room
0762
Observation Room
G0378
0769
Other Treatment Room/Observation Room
99499
077X
Preventive Care Services
0770
General Classification
99078
0771
Vaccine Administration
0779
Other (Terminated 10/01/2007)
078X
Telemedicine
0780
General Classification
99499
0789
Other Telemedicine (Terminated 10/01/2007)
079X
Lithotripsy
0790
General Classification
99499
0799
Other Lithotripsy (Terminated 10/01/2007)
080X
Inpatient Renal Dialysis
0800
General Classification
99499
0801
Inpatient Hemodialysis
0802
Inpatient Peritoneal (non-CAPD)
0803
Inpatient Continuous Ambulatory Peritoneal Dialysis (CAPD)
0804
Inpatient Continuous Cycling Peritoneal Dialysis
0809
Other Inpatient Dialysis
081X
Acquisition of Stem Cell and Body Components
0810
General Classification
S2152
0811
Living Donor
0812
Cadaver Donor
0813
Unknown Donor
0814
Unsuccessful Organ Search - Donor Bank Charges
0815
Cadaver Donor - Heart (Terminated 10/01/2000)
0815
Allogeneic Stem Cell Acquisition Services (Effective 01/01/2017)
0816
Other Heart Acquisition (Terminated 10/01/2000)
0817
Donor - Liver (Terminated 10/01/2000)
0819
Other Donor
082X
Hemodialysis - Outpatient or Home
0820
General Classification
99499
0821
Hemodialysis/Composite or Other Rate
0822
Home Supplies
0823
Home Equipment
0824
Maintenance/100%
0825
Support Services
0829
Other Outpatient Hemodialysis
083X
Peritoneal Dialysis - Outpatient or Home
0830
General Classification
99499
0831
Peritoneal/Composite or Other Rate
0832
Home Supplies
0833
Home Equipment
0834
Maintenance/100%
0835
Support Services
0839
Other Outpatient Peritoneal Dialysis
084X
Cont. Ambulatory Peritoneal Dialysis (CAPD) - Outpatient or Home
0840
General Classification
99499
0841
CAPD/Composite or Other Rate
0842
Home Supplies
0843
Home Equipment
0844
Maintenance/100%
0845
Support Services
0849
Other Outpatient CAPD
085X
Cont. Cycling Peritoneal Dialysis (CCPD) - Outpatient or Home
0850
General Classification
99499
0851
CCPD/Composite or Other Rate
0852
Home Supplies
0853
Home Equipment
0854
Maintenance/100%
0855
Support Services
0859
Other Outpatient CCPD
086X
Magnetoencephalography (MEG) - An imaging technique that identifies brain activity to pinpoint the source of seizures.
0860
General Classification
99070
0861
Magnetoencephalography (MEG)
087X
Cell/Gene Therapy (Effective 01/01/2018)
0870
General Classification
99499
0871
Cell Collection
0872
Specialized Biologic Processing and Storage - Prior to Transport
0873
Storage and Processing after Receipt of Cells from Manufacturer
0874
Infusion of Modified Cells
0875
Injection of Modified Cells
0876
RESERVED
0877
RESERVED
0878
RESERVED
0879
RESERVED
088X
Miscellaneous Dialysis
0880
General Classification
99499
0881
Ultrafiltration
0882
Home Dialysis Aid Visit
0889
Other Miscellaneous Dialysis
089X
Pharmacy - Extension of 025X and 063X (Effective 01/01/2018)
0890
RESERVED (Use 0250 for General Classification)
99070
0891
Special Processed Drugs - FDA Approved Cell (Charges for drugs and biologics for modified cell therapy requiring specific identification as required by the payer. If using a HCPCS to describe the drug, enter the HCPCS code in the appropriate HCPCS column.)
99499
0892
RESERVED
99070
0893
RESERVED
0894
RESERVED
0895
RESERVED
0896
RESERVED
0897
RESERVED
0898
RESERVED
0899
RESERVED
090X
Behavioral Health Treatments/Services
0900
General Classification
99499
0901
Electroshock Treatment
0902
Milieu Therapy
T5999
0903
Play Therapy
0904
Activity Therapy
0905
Intensive Outpatient Services - Psychiatric (Effective 10/16/2003)
99499
0906
Intensive Outpatient Services - Clinical Dependency (Effective 10/16/2003)
0907
Community Behavioral Health Program (Day Treatment) (Effective 10/16/2003)
0908
RESERVED for National Use (Effective 10/16/2003)
0909
RESERVED for National Use
091X
Behavioral Health Treatments/Services
0910
RESERVED for National Use
99499
0911
Rehabilitation
0912
Partial Hospitalization - Less Intensive
H0035
0913
Partial Hospitalization - Intensive
H0037
0914
Individual Therapy
99499
0915
Group Therapy
0916
Family Therapy
091X
Behavioral Health Treatments/Services (Continued)
0917
Biofeedback
99499
0918
Testing
0919
Other Behavioral Health Treatments/Services
092X
Other Diagnostic Services
0920
General Classification
99499
0921
Peripheral Vascular Laboratory
0922
Electromyogram
0923
Pap Smear
0924
Allergy Test
0925
Pregnancy Test
0929
Other Diagnostic Services
093X
Medical Rehabilitation Day Program
0931
Half Day
T5999
0932
Full Day
094X
Other Therapeutic Services
0940
General Classification
T5999
0941
Recreational Therapy
0942
Education/Training
99499
0943
Cardiac Rehabilitation
T5999
0944
Drug Rehabilitation
0945
Alcohol Rehabilitation
0946
Complex Medical Equipment - Routine
0947
Complex Medical Equipment - Ancillary
0948
Pulmonary Rehabilitation
0949
Other Therapeutic Service
095X
Other Therapeutic Services (cont)
0950
RESERVED for National Use
0951
Athletic Training
T5999
0952
Kinesiotherapy
0953
Chemical Dependency
99499
096X
Professional Fees
0960
General Classification
99499
0961
Psychiatric
0962
Ophthalmology
0963
Anesthesiologist (MD)
0964
Anesthetist (CRNA)
0969
Other Professional Fees
097X
Professional Fees (cont)
0971
Laboratory
99499
0972
Radiology - Diagnostic
0973
Radiology - Therapeutic
0974
Radiology - Nuclear Medicine
0975
Operating Room
0976
Respiratory Therapy
0977
Physical Therapy
0978
Occupational Therapy
0979
Speech Pathology
098X
Professional Fees (cont)
0981
Emergency Room
99499
0982
Outpatient Services
0983
Clinic
0984
Medical Social Services
0985
EKG
0986
EEG
0987
Hospital Visit
0988
Consultation
0989
Private Duty Nursing
T5999
099X
Patient Convenience Items
0990
General Classification
T5999
0991
Cafeteria/Guest Tray
0992
Private Linen Service
0993
Telephone/Telegraph
0994
TV/Radio
0995
Non-Patient Room Rentals
0996
Late Discharge Charge
0997
Admission Kits
0998
Beauty Shop/Barber
0999
Other Patient Convenience Items
100X
Behavioral Health Accommodations
1000
General Classification (Effective 10/16/2003)
T5999
1001
Residential Treatment - Psychiatric (Effective 10/16/2003)
1002
Residential Treatment - Chemical Dependency (Effective 10/16/2003)
1003
Supervised Living (Effective 10/16/2003)
1004
Halfway House (Effective 10/16/2003)
1005
Group Home (Effective 10/16/2003)
1006
Outdoor/Wilderness Behavioral Health (Effective 07/01/2017)
101X to 209X
RESERVED for National Assignment
210X
Alternative Therapy Services
2100
General Classification
T5999 (Outpatient)
2101
Acupuncture
2102
Acupressure
2103
Massage
2104
Reflexology
2105
Biofeedback
T5999 (Outpatient/Inpatient)
2106
Hypnosis
2109
Other Alternative Therapy Services
T5999 (Outpatient)
211X to 309X
RESERVED for National Assignment
310X
Adult Care
3101
Adult Day Care, Medical and Social - Hourly
T5999
3102
Adult Day Care, Social - Hourly
3103
Adult Day Care, Medical and Social - Daily
3104
Adult Day Care, Social - Daily
3105
Adult Foster Care - Daily
3109
Other Adult Care
311X to 999X
RESERVED for National Assignment
- END -

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