CMS releases guidance on pre-entitlement billing

CMS released compliance tips for pre-entitlement billing in a recent edition of its MLN Connects® newsletter. The agency instructed providers to use these billing instructions for inpatient admissions when the patient is admitted before their Medicare Part A entitlement date and discharged after that date.

CMS calculates the number of utilization days from a patient’s Part A entitlement date through their discharge, transfer, or death date and reimburses providers based on the amount of billed covered charges, according to the guidance. For Inpatient Prospective Payment System claims, the agency calculates the diagnosis-related group from the patient’s admission date.

Room and board charges should only be included for the days that the patient had Part A entitlement, according to the guidance.

Revenue codes 010x–016x are to be used for room and board charges, according to CMS. All revenue codes should be reported from the admission date through the discharge, transfer, or death date as covered charges. In addition, providers must include all surgical procedure and diagnosis codes from that time frame on the claim.

CMS provided the following information for providers to reference during pre-entitlement billing:

• Admission date: Formal inpatient admission date
• Statement covered period from date: Effective date of Part A entitlement
• Statement covered period through date: End date of the inpatient stay
• Covered days with value code (VC) 80: Number of days in the covered from to covered through date range
• Accommodation days/units: Number of days reported in VC 80

Revenue integrity professionals can find more information on pre-entitlement billing in Chapter 4 of the Medicare Benefit Policy Manual and Chapter 3, Section 40 of the Medicare Claims Processing Manual.

Editor’s note: Find more NAHRI resources on billing and claims here.