Where a beneficiary receives noncovered care at admission, and is notified as such, but
subsequently is furnished covered level of care during the same hospital stay, the
admission is deemed to have occurred when covered services became medically needed
and rendered. This is applicable to PPS and non-PPS billings.
The following billing entries identify this situation:
• Admission date (not the deemed date).
• Occurrence code "31" and the date the hospital provided notice to the beneficiary.
• Occurrence span code 76 indicates the noncovered span from admission date
through the day before covered care started.
• Value code 31 is used to indicate the amount which was charged the beneficiary
for noncovered services.
• Noncovered charges related to the noncovered services.
• The principal diagnosis is shown as the diagnosis that caused the covered level of
care.
• Only procedures performed during the covered level of care are shown on the bill
If a no payment bill for the noncovered level of care has been processed, the hospital
prepares and forwards a new initial bill.
Charges to Beneficiaries for Part A Services
The hospital submits a bill even where the patient is responsible for a deductible which
covers the entire amount of the charges for non-PPS hospitals, or in PPS hospitals, where
the DRG payment amount will be less than the deductible.
A hospital receiving payment for a covered hospital stay (or PPS hospital that includes at
least one covered day, or one treated as covered under guarantee of payment or limitation
on liability) may charge the beneficiary, or other person, for items and services furnished
during the stay only as described in subsections A through H. If limitation of liability
applies, a beneficiary's liability for payment is governed by the limitation on liability
notification rules in Chapter 30 of this manual. For related notices for inpatient hospitals,
see CMS Transmittal 594, Change Request3903, dated June 24, 2005.
