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Last Modified: 5/3/2024 Location: FL, PR, USVI Business: Part A, Part B

Guidelines for billing acute inpatient noncovered days

Billing acute inpatient noncovered provider liable days

If an acute care hospital determines the entire admission is non-covered and the provider is liable, bill as follows:
Type of bill – 11X (Full provider liable claim)
Admit date – Date the patient was actually admitted (not the deemed date)
From & through dates - This span of dates should include all days
Noncovered days - The entire length of stay should be entered as noncovered
Occurrence span code M1 – The first provider liable day through the last provider liable day
Revenue code - Room & board revenue code line report as follows:
Total units should equal the total number of days
Noncovered units should equal the total days
Total charge should equal the rate times the total number of units
Noncovered charge should equal the rate times the number of noncovered days

Billing acute partial inpatient noncovered provider liable days

If an acute care hospital determines a portion of the admission is noncovered and the provider is liable, bill as follows:
Type of bill – 11X
Admit date – Date the patient was actually admitted (not the deemed date)
From & through dates - This span of dates should include all days, both covered and noncovered
Covered Days – The portion of the stay in which the patient received medically necessary services
Noncovered days – The portion of the stay in which the provider is liable due to the services rendered were not medically necessary
Occurrence span code M1 – The first provider liable day through the last provider liable day Revenue code - Room & board revenue code line report as follows:
Total units should equal the total number of days
Covered units should equal the total days minus the noncovered days (Provider Liable Days)
Total charge should equal the rate times the total number of units
Noncovered charge should equal the rate times the number of noncovered days

Billing acute inpatient noncovered beneficiary liable days

If an acute care hospital determines that a portion of the admission, or the entire admission, is noncovered and the beneficiary is liable, bill as follows:
Type of bill – 11X
Admit date – Date the patient was actually admitted (not the deemed date)
From & through dates - This span of dates should include all days, both covered and noncovered
Covered days – Report only days the patient was at a covered level of care. If the entire stay is noncovered, report zero covered days
Noncovered days – Report all the days that are noncovered for the duration of the stay
Occurrence span code 76 - The first beneficiary liable day through the last beneficiary liable day
Occurrence code 31 – The date the facility provided notice to the beneficiary
Value code 31 – The amount charged to the beneficiary for noncovered services
Revenue code - Room & board revenue code line report as follows:
Total units should equal the total number of days
Covered units should equal the total days minus the noncovered days
Total charge should equal the rate times the total number of units
Noncovered charges should equal the rate times the number of noncovered days.
The above instructions do not apply to benefits exhaust billing. Please refer to the CMS IOM Pub. 100-04 Medicare Claims Processing Manual, Chapter 3, section 190.12.1 external pdf file and CMS IOM Pub. 100.04 Medicare Claims Processing Manual, Chapter 4, section 240.2 external pdf file for benefit exhaust billing.
To assist us with understanding the reason for noncovered billing, you may include one of these recommended remarks:
Benefits exhausted
Direct Graduate Medical Education (DGME)
Does not meet medical necessity for inpatient stay criteria
Lower level of care, non-acute Care, non-skilled, MCR rejection or cardiac rehab
Provider/beneficiary liable
No Part A entitlement
No pay, noncovered or non-billable procedure
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