How to Use Revenue Code 0119 for Private Room Billing

Are you one of the many who have looked at an inpatient stay and said, “This has to be a private room, but it’s nothing I’ve seen before.”

There are many different types of private rooms including; medical, post-operative recovery, maternal services, pediatric, mental health, cancer care, substance abuse detoxification, rehabilitation or hospice.

Every once in a while, however, a patients situation just does not fit into one of these broad categories.

That’s when revenue code 0119 can be used.

Revenue code 0119 is for private rooms that do not fit into any of the other revenue codes for private rooms.

In this guide, we will go over the specifics of 0119 as well as provide examples of when and how to correctly bill this type of service.

What is Revenue Code 0119 in Medical Billing?

Revenue code 0119 is used by hospitals to charge for Inpatient Private Room and Board when a patient is in a single-bedded private room and does not meet any of the general criteria for Private Rooms. Most private rooms will be classified as Medical/Surgical, Obstetrics (OB), Pediatrics, Psychiatric, Rehabilitation (Rehab), Oncology, Hospice etc. However, when a patient’s stay falls outside these categories, 0119 can be used as a “catch-all” to allow billing for the private room.

For example, let us say a patient was placed in a private room mostly for observation and support after undergoing a minor surgical procedure. This patient did not have an obstetric or pediatric condition, nor were they a rehabilitation or oncology patient, nor a psychiatric patient. Despite being in a private room, the patient could still be billed for the private room using revenue code 0119.

Therefore, when a patient is in a private room and it cannot be coded with a specific type of care, 0119 is used to charge for the room and board.

How to Use Revenue Code 0119 for Patient Billing?

Before placing 0119 on a claim, determine whether two basic questions can be answered affirmatively.

• Is the patient in a regular inpatient private room with one bed?
• Is there another, more specific private room and board code that would best fit the patient’s needs?

If the answer is yes to the first and no to the second, then 0119 may be the right choice.

When Should You Use Revenue Code 0119?

Revenue code 0119 should be used:

➜ When the patient is utilizing a general private room with one bed, yet their stay is not tied to a specific clinical program such as hospice, oncology, rehabilitation, psychiatry or detoxification.

➜ When the private room is being used for routine, non-specialty inpatient care; however, a private room is either clinically required or is medically indicated for the safety of the patient or others.

Examples of such conditions include:

• Infection Control/ Isolation due to documented medical reason
• Immune compromised patients requiring isolation to protect others from potential infection

➜ Your other private room codes do not effectively describe the type of treatment provided or unit where the patient received treatment, and your billing policies and/or payer agreements allow 0119 as an “Other Private Room and Board” option.

When Should You Not Use Revenue Code 0119?

Do not use 0119 revenue code if a more specific private room and board code fits the patient’s stay. Examples of more specific private room and board codes available within the 011X series include:

• 0111 Medical/Surgical
• 0112 Obstetrics
• 0113 Pediatrics
• 0114 Psychiatry
• 0115 Hospice
• 0116 Detoxification
• 0117 Oncology
• 0118 Rehabilitation

In these cases, 0119 is inappropriate to use:

➜ The patient is on a distinct, designated specialty unit or program, such as:

• Hospital-based inpatient hospice
• Hospital-based inpatient rehabilitation
• Hospital-based psychiatric units
• Detox units
• Hospital-based inpatient oncology units

➜ Payer agreements specify a particular revenue code that corresponds to the patient’s diagnosis or unit location. For example, some payers require hospice days to be reported using revenue code 0115, while others require detox stays to be reported using revenue code 0116 when the patient is receiving services in those programs. Always refer to payer and contract specifications.

➜ You are attempting to bill for a private room that is only for the convenience of the patient, without a documented clinical necessity for that room. Most payers will not cover the additional costs associated with a private room unless the medical record indicates the room was medically necessary.

Use 0119 only when the patient has a legitimate need to be in a private room, there is a documented clinical reason for the room and when there is no private room and board revenue code that describes the patient’s services any better than 0119. If a specialty unit or program is involved, use the corresponding specialty revenue code rather than 0119.

Revenue Code 0119 Reimbursement Rates (Fee Schedule)

The amount that is reimbursed for Revenue Code 0119 varies greatly based on the Payer, Contract and Patient’s Plan. When you look at the National Average data, you’ll see a considerable difference in average payments for 0119. The approximate average payment is:

• BlueCross BlueShield approximately $429.50
• UnitedHealthcare approximately $5,376.00
• Aetna approximately $15,080.58
• Cigna approximately $26,881.61

Please keep in mind these are national averages and should be used as a ball-park figure as every hospital’s contract is different and payers have varying levels of policy.

To determine what your organization is actually being reimbursed for Revenue Code 0119, review your claims data. Here are a couple of simple methods to accomplish this:

• Review recent Remittance Advice or 835 Files from claims that include Revenue Code 0119.
• Sort by Payer to see what each Payer actually allows and pays.
• Compare the actual payment amounts to your contracted rate(s) or Fee Schedules.
• If an amount appears to be incorrect, your Contracting/Revenue Integrity Teams can assist in verifying the Payer Rules.

Reviewing your actual data will provide you with a better understanding of what you get paid than any National Average; however, reviewing National Average data can give you an idea of the vast range of reimbursement that exists among payers.

How to Bill with Revenue Code 0119?

To bill using Revenue Code 0119, you must accurately categorize the service on a Uniform Bill (UB-04) claim form. Here’s how you can bill this revenue code correctly:

Step #1 – Confirm this was a private room

Verify that the patient was in a single-bed room (private) for all the dates you intend to submit for billing.

You should ask yourself simple questions:

• Was the patient actually in a one bed private room for these dates of service
• Was that room used for general inpatient care, not a clearly labeled specialty unit like psych, rehab, oncology, or hospice
• Are admission records, bed assignments and nursing notes documented to confirm the patient was treated in the private room alone?

If the patient was treated in a specialty unit that has a specific room and board revenue code, you would typically use that specific code and not 0119.

Step #2 – Is the private room medically required?

Private rooms, just because the patient prefers them, usually are not covered. The patient’s physician must document a medical reason for a private room.

Some examples of medically required private rooms include:

• Infection control or isolation
• High risk of infection, for example, neutropenia or significant immunosuppression
• Behavior or safety issues which could place other patients at risk while the patient is not being cared for in a psych unit
• Other clinical or safety issues documented by the provider

In the patient’s chart, you want to see:

• Medical reason for the private room noted in the physician’s orders or documentation in the chart
• Documentation from the provider that supports the medical reason for the private room

If the private room is only for comfort/convenience and there is no documentation of a medical reason for the private room, most payers will deny the higher room charge.

Step #3 – Assign the revenue code 0119

When you verify two things:

• Patient was treated in a private room, and
• Room was medically required,

then you can assign 0119 – Room and Board, Private, Other on the UB-04 or in your billing system.

Before you finalize, review:

• Is there a more specific private room code that fits better than the general 0119 code, i.e., medical/surgical, OB, pediatric, psych, hospice, rehabilitation, detox, or oncology?
• Is the patient being treated on a specialty unit/program listed above?

If the answer to these questions is no, then 0119 is most likely the correct code.

Also ensure:

• The amount charged for room and board for the patient’s length of stay corresponds to the daily rate/fee established by your facility for the private room.

Step #4 – Associate the proper charges

Revenue code 0119 will only attach to the room and board charges for those specific days. This typically includes:

• Daily room rate
• Meals
• Standard nursing care
• Standard supplies provided as part of routine inpatient care

Make sure that the number of days billed using 0119 matches the actual length of time the patient was treated in that private room.

Step #5 – Attach HCPCS/CPT code if payer requires it

Many payers do not require HCPCS/CPT codes with 0119 for standard room and board. However, some payers have specific requirements.

To protect yourself:

• Refer to the payer billing guide or online policies
• Follow Medicare/Medicaid guidance if billing either of them
• Only add HCPCS/CPT code(s) when the payer specifically states they require them

Step #6 – Ensure the diagnosis codes accurately reflect the reason for the hospitalization and the private room

The ICD-10-CM diagnosis codes submitted should tell the story of why the patient was hospitalized and, if applicable, why a private room was medically necessary.

Ensure:

• Principal diagnosis indicates the primary reason for the inpatient hospital stay
• Secondary diagnoses indicate possible reasons for the private room including but limited to, infectious diseases requiring isolation or high-risk for developing an infection
• Diagnosis codes submitted and documentation in the chart match each other and are reasonable

If the submitted diagnosis codes do not align with documentation in the chart, you increase the likelihood of denials or audit.

Step #7 – Be aware of payer-specific rules

Payers can treat private rooms slightly different. When submitting or reviewing the claim, try to:

• Determine if prior authorization was required for the hospital stay or the private room
• Review payer-specific rules regarding private rooms or 0119, i.e., limitations, documentation requirements, etc.
• Review and stay current with payer-specific rule changes since payer rules can change over time

Step #8 – Submit the claim and follow-up

Once coding and reviews are complete:

• Submit the claim electronically or on a UB-04 based upon how your facility submits claims
• Ensure dates, units, and charges align throughout the entire claim
• Maintain copies of key documentation that supports the private room and the use of 0119

Following submission, do not forget to:

• Verify the claim was processed and paid as expected
• Review any denial(s) or request for additional information
• Be prepared to submit supporting documentation or an appeal if the private room charge is denied.