Inpatient admission is prior to the Medicare Part A entitlement date
The Centers for Medicare & Medicaid Services (CMS) has provided guidance on reporting days of utilization for a beneficiary’s inpatient stay. Days of utilization are charged based upon actual days of coverage, including grace and waiver days. The number of covered days used is maintained by CMS to track the beneficiary's eligible days in a benefit period.
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 diagnosis codes 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
https://www.cms1500claimbilling.com/2016/10/how-to-bill-inpatient-admission-before.html