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 and CMS IOM Pub. 100.04 Medicare Claims Processing Manual, Chapter 4, section 240.2 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