Noncovered Admission Followed by Covered Level of Care

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.

A. - Deductible and Coinsurance 

The hospital may charge the beneficiary or other person for applicable deductible and coinsurance amounts. The deductible is satisfied only by charges for covered services. The A/B MAC (A) deducts the deductible and coinsurance first from the PPS payment. Where the deductible exceeds the PPS amount, the excess will be applied to a subsequent payment to the hospital. 

B. - Blood Deductible 

The Part A blood deductible provision applies to whole blood and red blood cells, and reporting of the number of pints is applicable to both PPS and non-PPS hospitals. (See Chapter 3 of the Medicare General Information, Eligibility, and Entitlement Manual for specific policies.) Hospitals shall report charges for red blood cells using revenue code 381, and charges for whole blood using revenue code 382.

C. - Inpatient Care No Longer Required 

The hospital may charge for services that are not reasonable and necessary or that constitute custodial care. Notification may be required under limitation of liability. See CMS Transmittal 594, Change Request3903, dated June 24, 2005, section V. of the attachment, for specific notification requirements. Note this transmittal will be placed in Chapter 30 of this manual at a future point.

In general, after proper notification has occurred, and assuming an expedited decision is received from a Quality Improvement Organization (QIO), the following entries are required on the bill the hospital prepares:

• Occurrence code 3l (and date) to indicate the date the hospital notified the patient in accordance with the first bullet above; 

• Occurrence span code 76 (and dates) to indicate the period of noncovered care for which it is charging the beneficiary; 

• Occurrence span code 77 (and dates) to indicate the period of noncovered care for which the provider is liable, when it is aware of this prior to billing; and 

• Value code 3l (and amount) to indicate the amount of charges it may bill the beneficiary for days for which inpatient care was no longer required. They are included as noncovered charges on the bill.