Private Room Billing
The Medicare program will pay the same amount for routine inpatient hospital accommodations regardless of whether the patient has a private room, semi-private room or ward accommodations. Medicare will cover private room charges in the following instances:
- A private room was medically necessary because isolation was required to avoid jeopardizing the patient's health or recovery, or that of other patients
- The stay is medically necessary and there are only private rooms available
- The stay is in a facility which has only private accommodations
In the absence of a written order, a patient who requests a private room should be advised that they are responsible for the difference between the semi-private and private room rates. The private room differential may not exceed the difference between the customary charge for the accommodations and the most common semi-private accommodation rate at the time of admission.
Below are guidelines for hospitals, including critical access hospitals, to follow when billing medically necessary and non-medically necessary inpatient private room accommodations.
Medically Necessary Private Room:
- Revenue code 0110: Room and board - private room
- Condition code (select one)
- 38 - Semi-private room not available
- 39 - Private room medically necessary
- No remarks are required
Non-Medically Necessary Private Room:
- Revenue code 0110: Room and board - private room
- Remarks should reflect: private room rate minus semi-private room rate equals private room differential (e.g., $500 - $400 = $100)
- No condition code or value code
Non-medically necessary private room rate claims that do not include the appropriate calculation in remarks will be returned to the provider.
Facilities With Only Private Rooms:
- Revenue code 0110: Room and board - private room
- Value code
- 02 - Hospital has no semi-private rooms
- Entering this value code requires $0.00 amount
- No remarks are required
Reference