Last Modified: 11/8/2017 Location: FL, PR, USVI Business: Part A
Inpatient admit prior to entitlement
Q: What are the claim submission rules for a beneficiary who is admitted into a hospital prior to their Medicare Part A effective date?
A: There are special billing guidelines to follow when the beneficiary becomes entitled to Part A benefits in the middle of an inpatient stay. Pre-entitlement days are not counted for utilization or for the hospital’s inpatient prospective payment system (PPS) pricer. Furthermore, pre-entitlement days are not used for the cost report or for utilization in non-PPS hospitals, exempt units or skilled nursing facilities (SNFs). In this situation, the days are calculated based on the beneficiary’s Medicare Part A entitlement date through discharge/transfer/death.
The hospital may not bill the beneficiary or other persons for days of care preceding entitlement, except for days in excess of the outlier threshold. The hospital may charge the beneficiary or other persons for applicable deductible and/or coinsurance amounts.
Listed below are the claim submission guidelines for inpatient hospital admit to discharge claims (no outlier):
• Type of bill (TOB) -- Enter 111
• Admit date -- Enter the actual date of admission
• Do not enter the Medicare Part A entitlement date as the admit date
• Statement coverage period “From” date -- Enter the Medicare Part A entitlement effective date
• Do not enter the admit date as the coverage period “From” date
• Statement coverage period “Through” date -- Enter the end date of the inpatient stay
• Utilization days -- Enter the total number of days for the statement coverage period
• Do not report any pre-entitlement days as covered or non-covered
• Covered and non-covered days are reported utilizing value codes 80, 81, 82, and/or 83
Value code 80 -- Covered days
Value code 81 -- Non-covered days
Value code 82 -- Co-insurance days
Value code 83 -- Lifetime reserve days
• Diagnosis codes -- enter all ICD-10-CM diagnosis codes from admission to discharge/transfer/death
• Procedure codes -- enter all ICD-10-PCS procedure codes and dates from admission to discharge/transfer/death
• Accommodation days/units -- Enter the appropriate number of units and charges as covered and/or non-covered for the statement coverage period
• Do not report the pre-entitlement days as covered or non-covered room and board units or charges
• Revenue codes -- 010X – 016X are appropriate for billing room and board
• Revenue code -- 018X is appropriate for billing a leave of absence (non-covered days and charges)
• Remarks -- Medicare Part A effective xx/xx/xx
The patient is admitted on April 25, 2016, and discharged on May 13, 2016. The patient’s Medicare Part A entitlement effective date is May 1, 2016. The claim should be billed as follows:
• TOB -- 111
• Admit date -- April 25, 2016
• Statement coverage period “From” date – May 1, 2016
• Statement coverage period “Through” date -- May 13, 2016
• Utilization days -- 12 covered days
• Accommodation days/units -- 12 covered units and covered charges
• Remarks -- Medicare Part A effective May 1, 2016
Source: CMS internet-only manual, Publication 100-04, Chapter 3 , Section 40; Chapter 25 ; MLN MattersŪ article SE1117
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