You will see 0116 revenue code on inpatient claims when a patient has been placed in a private room for detoxification treatment and not limited to a single-day stay. The use of 0116 only indicates that the patient was receiving private room and board during their inpatient detox admission.
If you’ve ever wanted to know specifically what services the revenue code 0116 includes and what it doesn’t, then you’ll be happy to find yourself in the right place. We’ll cover everything else you need to know about 0116 RC on a claim, including how to properly utilize it, what to bill as a separate service and how to steer clear of the most common pitfalls to ensure your claim is processed correctly.
What is Revenue Code 0116 in Medical Billing?
Revenue Code 0116 is used by a hospital or facility when billing the insurance payer. This indicates to the payer that a specific patient was admitted to the hospital for detox services, and the charge is for room and board in a private inpatient room in which the detox care was provided.
In other words, this identifies that this was not an admission for some other reason, such as pneumonia or for surgery, and furthermore that this was an inpatient visit with the purpose of managing the withdrawal of a substance under medical supervision.
Detoxification, or detox, is a treatment where a patient is under medical supervision for the purpose of ridding the body of harmful substances and managing withdrawal safely. These substances generally include alcohol, opioids or other drugs. It might be a one day hospitalization, or it can run several days, depending upon the status of a patient’s condition.
What Does Revenue Code 0116 Cover?
When you use Revenue Code 0116 on a hospital billing claim form, you are charging for the private inpatient room and board during the detoxification stay. That would pretty well include the following:
✅ The patient’s room for each day covered by the stay
✅ Meals provided during the stay
✅ Routine nursing care and monitoring
✅ General inpatient supplies, such as linens, toiletries, etc.
In essence, 0116 is designed to cover basically the “room and care” aspects of an inpatient detoxification stay.
What Does Revenue Code 0116 Not Cover?
While 0116 involves the room charge, meals and routine nursing care, it does not cover specialized treatment or services which a patient might receive during the time of detox. These generally would be billed separately under their own revenue codes or professional claims. Examples include:
❌ Medications given to ease withdrawal, or control symptoms in the patient
❌ Any lab tests or imaging (bloodwork tests or scans)
❌ Therapy or counseling sessions provided
❌ Physician fees or specialist charges
❌ Intensive Care services (if the patient required a greater degree of monitoring)
When to Use Revenue Code 0116 for Patient Billing
The situations in which you should use 0116 are when the patient has had admission as an inpatient of medically necessary detoxification, and has been placed in a private room.
The following are examples of when its use is indicated:
- A patient who is admitted for alcohol withdrawal and requires 24 hour monitoring.
- A patient going through opioid withdrawal, who requires 24 hour supervision by nursing staff.
- An inpatient detox program in which the patient adheres to structured medical protocol for substance withdrawal.
Note: If the patient is in a semi-private room or shared room, the revenue code which corresponds with that situation should be utilized, and 0116 should not be used.
Provider Reimbursement Rates for Revenue Code 0116 (Room and Board for Inpatient Detox)
How much you get paid for Revenue Code 0116 depends on the payer and your contract with that payer.
Room and board costs can be higher than other levels of care because many detox patients require closer supervision. This ultimately results in a wide range of possible payments for this line item.
The reimbursement amount for each line item comes from either the payer’s rules, the terms of your contract with the payer, or both.
Medicare
When a Medicare beneficiary is treated for detox in an inpatient setting, Medicare typically pays a single bundled payment for the entire length of the inpatient stay using the MS-DRG payment system. Therefore, the payment for room and board under 0116 is generally included in the single payment for the entire stay, rather than being paid out as a separate line item.
There are two key elements that can help ensure correct payment:
- Document in the chart why the patient required inpatient detoxification and how a less intensive level of care would have been unsafe for the patient.
- Maintain consistency between the diagnosis and service coding used on the claim and the documentation in the patient’s chart, particularly to demonstrate that the patient received appropriate detoxification care.
Note: If Medicare determines that the hospital did not provide medically necessary care for the inpatient stay, room and board will not be reimbursed.
Medicaid
Each state has its own Medicaid policies. Many states use managed care plans to administer their Medicaid programs. These plans may pay a fixed daily (per diem) rate for detoxification services, while others may pay based on Diagnosis Related Groups (DRGs), Level of Care (LOC), or by a program-specific rate.
To ensure proper reimbursement from Medicaid:
- Review your state’s current Medicaid policies and managed care contract(s).
- Document medical necessity and the level of care provided, for example, using criteria similar to ASAM if the plan requires them.
Commercial Payers
Commercial insurance payers’ reimbursement policies are based on the contracts they have established with hospitals or healthcare providers. Some commercial payers may pay a fixed daily (per diem) rate for detox days, while others may pay a case rate for the entire length of the inpatient admission. Prior authorization and medical necessity reviews are typical.
Here are some average commercial payer reimbursement rates for RC 0116 according to PayPrice:
| Insurance Company | Approx. Reimbursement Rates |
| BCBS | $1,097.51 |
| Aetna | $2,014.49 |
| UnitedHealthcare | $1,563.15 |
| Cigna | $20,712.36 |
As mentioned earlier, the amounts listed above are examples of average commercial payer reimbursement rates for RC 0116 and should be reviewed in conjunction with the terms of your specific payer contracts for the most accurate and up-to-date reimbursement information.
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How to Submit Revenue Code 0116 on the UB-04 Form
Detox charges aren’t difficult to submit once you know how to input the data into the UB-04 form correctly. The UB-04 form has several different sections, and each section has a different purpose. To create a clear picture for the payer of why the patient was admitted, what type of room they were in, and what type of care they received, follow the steps below.
Step 1: Enter 0116 in the Right Place
Enter 0116 in Field 42 on the UB-04 form. This is where all revenue codes are listed. Entering 0116 will tell the payer that this patient was admitted for detoxification and the charge is for room and board in a private detox unit.
Accuracy is important here. Enter the code in the wrong location, and the claim may be delayed or denied. Therefore, prior to submitting the claim, review the form quickly to ensure that the code is located in the proper location.
Step 2: Ensure Your Diagnoses Are Consistent with the Diagnosis Codes
The next step is to verify that the diagnosis codes are consistent with the “story” of why the patient needed inpatient detox. The diagnosis codes indicate why the patient needed inpatient detoxification and, therefore, are important in establishing medical necessity.
In Form Locator 67, list the principal diagnosis that best describes the reason for the detox stay. For instance, if the patient was admitted for opioid withdrawal, then use an ICD-10 code that indicates opioid withdrawal.
Then, in Form Locators 67A through 67Q, add any secondary diagnoses that give more context. For instance, if the patient’s substance abuse problems included both alcohol use disorder and other withdrawal symptoms that impacted the treatment provided, then include those diagnoses as well.
Using specific codes helps. Many payers reject general terms like “withdrawal,” so select the diagnosis that best describes the patient’s condition.
Step 3: Verify the Room Type Matches the Code
Revenue Code 0116 is only for private rooms that are used for detoxification. If the patient stayed in a semi-private room, then use Revenue Code 0126.
The difference in the room type and the code is significant since the two are directly related. A mismatch in the room type and the code may result in either incorrect billing or underpayment.
Prior to processing the claim, confirm that the chart accurately reflects the type of room assigned to the patient. This will minimize unnecessary reimbursement delays after the claim is processed by the insurer.
Step 4: Document the Claim with Complete Medical Record Documentation
Complete and accurate documentation is crucial in ensuring that your claims are reimbursed properly. Documentation should establish why the patient required inpatient detoxification and support the coding decisions made.
Examples of documentation that should be included are:
- Withdrawal symptoms and their severity, including examples like tremors, hallucinations, and unstable vital signs
- History of substance use, such as chronic use of alcohol or opioids
- Documentation regarding the level of medical supervision required, which should demonstrate that continuous monitoring was required during the detoxification process
Documenting the above information consistently from the admission note to the discharge summary will ensure that the entire medical record supports the claim.
Step 5: Review the DRG
If the payer uses the MS-DRG system (like Medicare does), the DRG will determine the amount of money that will be paid for the entire length of the patient’s stay. Once you have coded the claim, verify that the DRG is appropriate for a detoxification admission and that it matches the diagnoses that you used in the coding process.
If the DRG does not match, the claim may be underpaid or rejected, so it is worth the time to verify this.
Step 6: Know When (and When Not) to Use Modifiers
For most claims for detoxification room and board, modifiers will not be required. However, some Medicaid programs or managed care plans have their own rules regarding the utilization of modifiers. If your payer has its own rules regarding modifiers for complex detoxification cases, utilize them exactly as instructed.
Also, be prepared to send additional documentation to the payer if requested. Examples of documentation that may be requested include:
- A treatment plan outlining the detox protocol
- A medication list for withdrawal management
- A discharge summary describing the course of treatment and outcome
FAQs about Revenue Code 0116
Can I use 0116 for observation or outpatient detox?
No, 0116 is only used for inpatient room and board. If your patient is in observation or receiving outpatient detox, you’ll need to use the revenue codes your payer accepts for those specific settings.
Does 0116 get paid on its own under Medicare?
Not exactly. Under Medicare, inpatient detox stays are paid through the MS-DRG system, which bundles everything into one payment for the entire admission. You’ll still list 0116 on the claim to show the room and board charges, but it won’t be reimbursed separately.
Do I need to use a modifier with 0116?
Most of the time, no. Modifiers aren’t usually required for this revenue code. However, some Medicaid or managed care plans have their own rules, so always double-check the payer’s billing policy just in case.
What ICD-10 codes support an inpatient detox stay?
Use diagnosis codes that specifically describe the withdrawal or substance-use condition you’re treating. For instance, if the patient is withdrawing from alcohol or opioids, use the matching ICD-10 code for that. Try to avoid general or “unspecified” withdrawal codes if a more precise one fits the case.
What if my patient changed rooms during the stay?
That happens often. Just bill each part of the stay under the right revenue code. Private room days go under 0116, semi-private under 0126, and so on. The dates and number of units should match your chart.
Can I still use 0116 if the patient got detox care on a medical floor instead of a detox unit?
Yes, as long as the patient was in a private room and the chart clearly shows that detox care was provided. The revenue code reflects the type of care, not necessarily the name of the unit.
What kind of documentation do payers usually ask for?
They often want to see the admission note explaining why inpatient detox was necessary, nursing notes showing frequent monitoring, the medication record for withdrawal management, progress notes, and the discharge summary that outlines how the patient did and what the next steps are.
What are the most common reasons claims with 0116 get denied?
The big ones are mismatched room types, weak documentation of medical necessity, vague or incorrect diagnosis codes, or missing pre-authorization when it was required.
How do commercial payers usually reimburse for detox stays?
It really depends on the contract. Many pay a flat per-day rate (per diem), while others use a case-rate model that covers the entire stay. The safest move is to check your contract or payer portal before billing.
How can I tell if the DRG on my claim is right for a detox admission?
After coding, review the DRG to make sure it matches a substance-use or withdrawal diagnosis and accurately reflects the level of medical complexity. If something doesn’t line up, double-check your documentation and diagnoses.
Should I include therapy or counseling sessions under 0116?
No. 0116 is strictly for the room and board portion of the stay. Therapy, counseling, or other professional services should each be billed with their own revenue codes.
What if the stay was very short, like just one night?
If the admission met inpatient criteria and your utilization review supports it, you can still bill it as inpatient. Just make sure your documentation clearly explains why inpatient monitoring was necessary, even for a short stay.
