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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
Example:
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 external pdf file, Section 40; Chapter 25 external pdf file; MLN MattersŪ article SE1117 external pdf file
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