Private Room Care

Payment for medically necessary private room care is included in the prospective payment. Where the beneficiary requests private room accommodations, the hospital must inform the beneficiary of the additional charge. (See the Medicare Benefit Policy Manual, Chapter 1.) When the beneficiary accepts the liability, the hospital will supply the service, and bill the beneficiary directly. If the beneficiary believes the private room was medically necessary, the beneficiary has a right to a determination and may initiate a Part A appeal.

Deluxe Item or Service

Where a beneficiary requests a deluxe item or service, i.e., an item or service which is more expensive than is medically required for the beneficiary's condition, the hospital may collect the additional charge if it informs the beneficiary of the additional charge. That charge is the difference between the customary charge for the item or service most commonly furnished by the hospital to private pay patients with the beneficiary's condition, and the charge for the more expensive item or service requested. If the beneficiary believes that the more expensive item or service was medically necessary, the beneficiary has a right to a determination and may initiate a Part A appeal.

Inpatient Acute Care Hospital Admission Followed By a Death or Discharge Prior To Room Assignment

A patient of an acute care hospital is considered an inpatient upon issuance of written doctor’s orders to that effect. If a patient either dies or is discharged prior to being assigned and/or occupying a room, a hospital may enter an appropriate room and board charge on the claim. If a patient leaves of their own volition prior to being assigned and/or occupying a room, a hospital may enter an appropriate room and board charge on the claim as well as a patient status code 07 which indicates they left against medical advice. A hospital is not required to enter a room and board charge, but failure to do so may have a minimal impact on future DRG weight calculations.

Determining Covered and Noncovered Charges - Pricer and PS&R

Accommodation charges for days covered by Medicare are covered charges. Ancillary charges incurred on these days are also covered charges as long as these services are covered under Medicare. The A/B MAC (A) enters them into its PS&R unless it or the QIO denies them as exclusions from coverage or as medically unnecessary. For PPS hospitals, the A/B MAC (A) counts these charges for Pricer unless the charges are included as pass-through costs.

The A/B MAC (A) does not count for Pricer or the PS&R:

 • Charges the provider has shown as noncovered. (If the provider has complied with the notice requirements in Chapter 30, it may bill the beneficiary.); 

• Services on noncovered days; 

• Charges for personal comfort and/or convenience items; 

• Accommodations and routine charges for the day of discharge, death, or beginning of a leave of absence, unless it is also the day of admission; and 

• Charges for ancillary services on the day of discharge, death, or beginning of a leave of absence if the preceding day is noncovered under §40.2.B.

MSP Issues

 The A/B MAC (A) resolves any MSP issues not handled by §40.1.G using the instructions in the Medicare Secondary Payer Manual specific for reasonable cost providers and the instructions in specifically for PPS providers.

Determining Covered and Noncovered Charges - Part B

The A/B MAC (A) counts as covered under Part B, for cost report and deductible purposes, the charges for which Part B payment may be made, except as follows:

 • It counts as covered for deductible, but not cost report purposes, those charges for which the provider is liable for technical reasons; and 

• It does not count charges for which the provider is liable because services are not medically necessary for either deductible or cost report purposes.