Revenue Code 0117: When to Use It and What It Covers in Oncology

For those of you working in a hospital, you have a lot on your plate. Then you get a claim back and it has “0117” on the UB 04 and you may wonder what that means for payment. Revenue Code 0117 is the line that tells the payer your patient stayed in a private room on the oncology unit. In other words, it is the room and board charge for a one bed cancer floor room.

This guide walks you through what 0117 covers and what it does not, when to use it and when to choose a different code, and how to place it correctly on the UB 04. We will also examine how Medicare, Medicaid and commercial plans treat private rooms, what the correct documentation should be for medical necessity, and how to split days of care if the patient moves from one unit to another.

What Is Revenue Code 0117 In Medical Billing?

Revenue Code 0117 is used when the patient is a private inpatient in a room that is specifically for oncology care. This tells the payer that this patient was admitted to the hospital and stayed at least one night in a room with one bed that is in the cancer unit. So this code is not just telling the payer where the patient slept. It also tells the payer about the level of care that comes along with an oncology floor.

For instance, oncology units often need:

• Nurses who are trained to administer chemotherapy and other hazardous cancer drugs
• Infection precautions, since many cancer patients are immunocompromised
• Greater staffing and special equipment requirements compared to a general medical or surgical floor

That is why it is so important to use revenue code 0117 correctly. It has an impact on hospital payment, cost reporting and quality tracking.

Where Does Revenue Code 0117 Show Up?

Revenue Code 0117 is reported by hospitals on the UB 04 claim form, which is the claim form used for inpatient facility billing. The reporting of this code lets the patient’s insurance company know that the hospital is billing for room and board in a private oncology room which means a one bed inpatient room that is in the oncology unit.

When Should You Use Revenue Code 0117 in Medical Billing?

Use 0117 if all of the following are true:

• the patient is an inpatient,
• the patient is assigned a private room with one bed,
• the room is on an oncology unit or otherwise designated for cancer care,
• you are billing for that day’s room and board.

If all of this is true, 0117 is the correct room and board revenue code for that day.

When Should You Not Use Revenue Code 0117?

Do not use 0117 in the following situations:

• The patient is in the ICU. ICU days are billed with the 020X series for intensive care.
• The patient is in a semi private oncology room with two beds. In that case you would generally use 0127, which is oncology semi private.
• The patient is on a general medical or surgical floor instead of an oncology unit. In this case facilities would commonly utilize 0110 for general private room and board in a hospital or else 0111 for medical or surgical private room and board, depending on the setup.
• The patient is not an inpatient. For example, if the patient is coming in for outpatient chemotherapy and then going home, it would not be appropriate to bill any room and board revenue codes.

What Revenue Code 0117 Does Not Cover

Revenue Code 0117 is only for the inpatient oncology room and board part. It does not cover charges other than this. So it is still necessary to bill the other services separately on their own revenue codes, for example:

❌ Chemotherapy administration. IV Chemo administration is usually billed under revenue code 0335.

❌ Radiation therapy. Radiation therapy is customarily billed under revenue code 0333.

❌ Medications. Pharmacy medications are billed under the 025X pharmacy revenue codes, not under 0117.

❌ Laboratory, imaging. etc. These are billed on their own revenue code lines such as those in the 030X range for laboratory.

❌ Physician or professional fees. The physician’s professional services are billed separately, as on a CMS 1500 claim, not under the facility’s 0117 line.

So think of 0117 this way. It pays for the bed, basic nursing, and the inpatient oncology environment. It does not pay for drugs, chemo, labs, x-rays or for the physician.

Examples of Revenue Code 0117

Example #1 – Oncology Admission in a private room.

Example #2 – ICU first, then oncology floor.

Medical Reimbursement Rates for Revenue Codes 0117

How much a hospital gets paid for Revenue Code 0117 revolves around the payer, the contract, and whether or not the private room was medically necessary. The basics are about the same among payers, but the rules differ with each payer.

➜ Medicare

For Medicare patients, inpatient oncology stays fall under the MS-DRG system. That means room and board charges under 0117 are part of the bundled payment the hospital receives for the entire admission. Even though the room and board are bundled, hospitals still list 0117 on the UB-04 claim form because it’s used for cost reporting and tracking.

Medicare will pay for private room only where there is medical necessity (for example, if a patient goes on neutropenic precautions, airborne isolation or contact isolation which require the privacy of a private room for the patient and family). Documentation should indicate this, such as neutropenic precautions and infection control. If there is no documentation for the private room, usually Medicare will limit its payment to the semi-private room rate.

➜ Medicaid

Medicaid reimbursement varies by state and by plan. Some pay a flat per-day rate, others have DRG-based bundles, and still others have managed care plans with their own case-rate arrangements. Regardless of the arrangement, there will usually be a need for medical necessity for a private room if you are billing under 0117. Confirm in your state Medicaid manual or in your managed care plan where more details may be found.

➜ Commercial Payers

Private insurers follow the terms of their contract with the hospital billing for RC 0117. This payment may be based on a per-diem payment basis, a case rate basis, or a percentage of charges. Medical necessity will often be required to be documented if a private room is occupied by a patient instead of a semi-private room.

Some plans even require authorization prior to treatment or inpatient notification. It may be worth checking with your office for this prior to billing. Because the rates differ so much, always refer to specific contracts and not public estimates or benchmarks for information.

Yet here’s a rough idea of what you might see for 0117 reimbursement per day, according to national billing benchmarks:

Payer	Approximate Per-Day Reimbursement
BCBS	$1,500–$2,800
Aetna	$2,000–$3,800
UnitedHealthcare	$2,200–$4,200
Cigna	$2,500–$5,000

How Do You Bill Revenue Code 0117 On The UB-04 Claim Form?

Think about this is like a clear story: who is the patient, why were they admitted, where did they stay, and how much it cost. This can be simply done without tripping you up on the claim.

1). Start with the patient and provider information.

Enter the patient and provider information in the regular fields of the UB-04 form. Use the demographics that go with the medical record and the insurance card.

On the top of the form (Form Locators 1-8) enter:

• The patient’s full name and date of birth
• The patient’s address
• The hospital or facility name and address
• The hospital’s National Provider Identifier (NPI)
• The date of admission and types of admission

Carefully enter the provider’s information and NPI in the proper fields. Any minor discrepancies and differences can cause payments to be delayed.

2). Enter the stay dates.

In Field 6 of the form, enter the statement covers period, from the admit date through the discharge date. This frames the normal admission pattern for the payer.

3). Enter the revenue code line for the room.

Now go to Field 42, and enter revenue code 0117. In Field 43, enter a short description like Oncology private room. That tells the payer the patient was in a one bed oncology room and that you are billing room and board for those days.

Note: Revenue code 0117 does not automatically increase the reimbursement. How its reimbursement is determined is based on the payer and contract. In Medicare, it is included in the DRG bundle. With others, it may be part of a per diem or case rate.

4). Add dates and units for that line item.

List in Field 45 and Field 46 when and for how many days the patient occupied that oncology private room.

• FL 45 Service date: Some payers want a date for each revenue line.
• FL 46 Units: Put here the number of room days on that unit.

5). Enter the total charges.

In Field 47 of the UB 04 Form, enter the total room and board charge for the 0117 line. Use the same amount that is in your chargemaster. Do not round off.

If any part is noncovered, for example, a private room not medically necessary when a semi-private could be used, place that noncovered part in Field 48 as per your policy and given payer rules.

6). Entering HCPCS on the room line.

Most payers do not now require HCPCS next to 0117. Leave Field 44 blank, unless requested from the payer for a rate or code. Placeholder like A9270 should not be used unless actually billing for a noncovered item, and this is not the case for routine room and board.

7). Add the diagnosis to support the stay.

In Field 67, report the principal ICD-10 diagnosis that most closely explains why the patient was admitted. Add secondary diagnoses and present on admission indicators as indicated. For an oncology admission, the principal diagnosis could be the acute problem that required inpatient stay, with the cancer diagnosis as a secondary one, when applicable. Make sure that the documentation supports any medical necessity for a private room.

8). Submit the claim.

The UB 04 is sent in via your billing software or clearinghouse and a copy is kept of the claim and submission trace or reference number of the claim for the follow-up. If you outsource billing, ask your medical billing company to submit the claim, then share the clearinghouse and payer acknowledgments with you and handle any follow up on rejections or denials.

FAQs

Will I need a HCPCS code with 0117?

Usually, no. Most payers recognize Revenue Code 0117 as a stand-alone item that they will accept. Some commercial carriers, however, may require a HCPCS code in Form Locator 44 to explain the service. These services are not typically required by Medicare. If in doubt, always check the payer’s written billing policy before adding anything extra.

How does 0117 get paid under Medicare?

Medicare pays inpatient oncology stays under an MS-DRG payment system. Thus the room and board charges for the private oncology room, such as those under 0117, are added into the payment that is been lumped together for the entire admission day. You will continue to report the 0117 on the UB-04 since it benefits the hospital for cost reporting purposes and serves to complete your bill detail.

What kind of documentation supports a private oncology room under 0117?

The chart should adequately document why the patient was in need of a private oncology room. Some examples might be protective isolation for a stem cell transplant patient, radiation safety requirements, or privacy for a patient receiving palliative care. If there’s no documented medical reason and a semi-private room was available, most payers will only cover the semi-private rate.

How many units do I bill on 0117?

Bill one unit for each inpatient day the room was used. Even if a patient checks in late at night or leaves early the next morning, it still counts as one day because the bed was occupied during that date of service.

What are the other codes that should go with 0117?

Room and board are charged under 0117. Ancillary services should be reported under other lines. These would include services for drugs 025X, laboratory work 030X, chemotherapy administration 0335 and imaging services 032X and/or 035X. Professional fees for the physician’s services are billed on a separate CMS-1500 form.

What if the patient moves through different units during the same admission?

Bill different parts of the admission utilizing the correct revenue code for the unit. For example, if the patient spends two days in a cardiac step-down unit, then utilize the 021X series of codes for that medication, utilizing the 0117 revenue code when moved to the private oncology room. The dates and units should match the medical record precisely.

What are some of the common reasons for a denial for a claim with 0117?

Denials often result from not having clear documentation for the private room, from diagnosis codes that do not justify the need for an oncology level of care or when the dates and units of service do not match the hospital stay.  You can avoid problems by verifying payer rules in advance, documenting isolation or special care needs, and reviewing your FL 42–47 entries before submission.