Master Revenue Code 0120 for Semi Private Room and Board Claims

Understanding how and when to apply the inpatient billing revenue code “0120” (for semi-private room & board) can help ensure that your claims are billed accurately for a patient’s stay and avoid additional problems with reimbursements.

We’ll take a closer look at what “0120 revenue code” represents, the conditions under which you should use it, and how to properly bill for its application.

What Is Revenue Code 0120 In Medical Billing?

Revenue code 0120 is assigned when a patient has been formally admitted to a hospital as an inpatient and is housed in a semi-private inpatient room, which means the room contains two beds and is shared by two patients. This revenue code informs the insurance payer that the charge being submitted is for basic room and board in that type of setting.

All of the 012X revenue codes pertain to semi-private rooms (rooms with two beds), and the final digit in the code only relates to the category of the charge. In the case of 0120, the category is “general,” meaning it does not point to a specialty type of care.

When Should You Use Revenue Code 0120?

To use 0120 revenue code, the following conditions must be met:

• The patient has been formally admitted for inpatient care.
• The patient is being housed in a semi-private room with two beds.
• You are submitting a bill for standard room and board only, AND you are not attempting to identify a specific type of inpatient service area.

Example:

A patient was hospitalized for dehydration, is staying in an ordinary 2-bed hospital room and is being treated by a generalist physician (not an OB/GYN, pediatrician, psychiatrist). Since the stay is in a basic semi private room and the care is general, the hospital would use RC 0120.

When Should You Not Use Revenue Code 0120?

You would select a different revenue code if any of the following apply:

• The patient is housed in a private room. In that case, you would select a code from the 011X family.
• The patient is housed in a specialized unit, such as an ICU, a nursery, a burn unit, etc. Specialized units have their own revenue code families.
• The patient is not an inpatient. Charges for outpatient procedures, emergency visits, observation services do not use inpatient room and board codes.
• The inpatient room does not meet the criteria for the selected revenue code. For instance, a room containing more than two beds is typically assigned a code in the 013X family.

Reimbursement Rates for Revenue Code 0120

Reimbursement for revenue code 0120 can vary a lot, and every payer handles it a little differently. Insurance companies may reimburse hospitals on the basis of many different variables including, but not limited to:

• a negotiated contract between the insurance company and the hospital;
• the location of the hospital;
• and the overall severity of the patient’s illness.

Therefore, the reimbursement received by one hospital for a semi-private room may be very different than the reimbursement received by another hospital for the same type of room.

The reimbursement rates for commercial insurance carriers, such as Blue Cross Blue Shield, United Health Care, Cigna and Aetna generally tend to be greater than those provided by governmental programs. Each contract between an insurance carrier and a hospital is unique and therefore, there is no national standard rate for revenue code 0120.

Medicare & Medicaid Payment For Revenue Code 0120

Unlike commercial insurance carriers, the way government payers handle payments for room and board is quite different.

Medicare

Medicare does not provide payment for room and board as a separate line item on a claim. Medicare provides a Diagnosis Related Group (DRG) payment for the entire in-patient stay of the patient. Room and board are bundled together in the DRG payment.

As such, the payment made by Medicare is dependent on the patient’s diagnosis, any complications associated with the patient’s diagnosis, and the duration of the in-patient stay.

Since Medicare bundles room and board together within the DRG payment, the reimbursement for revenue code 0120 cannot be separated out or identified as a distinct payment.

Medicaid

Payment for Medicaid is determined by the state in which the care was rendered. While some states follow the Medicare DRG system, others have implemented their own systems for determining payment. Like Medicare, room and board charges for a semi-private room are also typically bundled together in the payment method and therefore, do not receive reimbursement as a separate charge.

Obtaining Correct Reimbursement Amounts

If you wish to determine the correct reimbursement amounts of 0120 revenue code for your hospital:

• Review your contracts with payers
• Check the hospital’s price transparency files
• Check previous remittances for similar cases

These documents will provide you with actual, contract-specific figures that will be much more accurate than general reimbursement rates.

How to Bill Revenue Code 0120 Correctly?

There are several steps you must take to ensure that the Room and Board charges for Semi Private Rooms that you submit for reimbursement using Revenue Code 0120 are accurate and payable by the Payer:

Step #1: Verify Patient Coverage

Verify that the patient’s insurance plan covers an inpatient stay in a semi private room:

• Confirm that the plan covers inpatient hospital stays and includes semi private rooms (not just private rooms or special arrangements).
• Compare the patient’s expected or actual length of stay to any limits that may exist on the plan. For example, some plans limit the number of inpatient days that they will pay for.
• Some payers require preauthorization for planned inpatient admissions or certain procedures. If required, verify that preauthorization was obtained, and that the authorization number is on file.

Step #2: Bill the UB-04 Claim Form

Hospitals bill their inpatient room and board charges for semi private rooms on the UB-04 Institutional Claim Form (CMS-1450), which is the standard institutional claim form used for most commercial payers and Medicare/Medicaid.

To complete the UB-04, you must:

• Enter “0120” in the Revenue Code field to indicate Semi Private Room and Board, General Category.
• List the ICD-10 Diagnosis Codes that explain why the patient had to be admitted.
• List ICD-10 PCS Procedure Codes that relate to the inpatient care provided. Some payers may also request CPT or HCPCS codes for certain services. Please refer to your facility and payer-specific rules.

Remember, the Revenue Code, Diagnoses, and Procedure Codes should all tell the same story about why the patient was in the hospital and what occurred during the inpatient stay.

Step #3: List Diagnoses and Procedure Codes

Revenue Code 0120 typically does not require a separate HCPCS Code. However, payers still need to see why the patient was in the hospital and what care was provided:

➜ Use ICD-10 diagnosis codes to explain why the patient was in the hospital. For example, if a patient is admitted for a hip replacement, you would list the Diagnosis Code that describes the Hip Condition that led to the surgery.

➜ Use ICD-10 procedure codes to explain what care was provided during the inpatient stay. Some payers may also request CPT or HCPCS codes for certain services.

➜ For a total hip replacement, you would list the appropriate procedure code for that surgery, as defined in your coding rules.

These codes support medical necessity and assist the payer in understanding that the inpatient stay and semi private room charges were appropriate.

Step #4: Identify Number of Units (Days)

On the UB-04, the units for revenue code 0120 normally represents the number of inpatient days spent in the semi-private room.

For example, if the patient spent three days in a semi-private room, you would input 3 into the units field for revenue code 0120.

Be sure the number of units matches the documented length of stay in that room type. For instance, if the chart shows three days in a semi-private room, do not accidentally charge two or four days.

Step #5: Report Total Charges

Next, you would calculate the total room and board charges for the semi-private room.

Example:

• Semi-Private Room Daily Rate = $1200
• Length of Stay in Semi-Private Room = 3 Days

Calculation:

• $1200 per Day x 3 Days = $3600

You would report $3600 as the total charges for revenue code 0120 on the UB-04.

Step #6: Complete the Key UB-04 Fields

As you fill out the UB-04, be particularly careful to fill out the following fields for revenue code 0120:

• Revenue Code Field (FL 42): Enter 0120 to show semi-private room and board, general category.
• Units Field (FL 46): Enter the number of semi-private room days. For a 3-day semi-private stay, enter 3.
• Total Charges Field (FL 47): Enter the total dollar amount for those days. Using the example above, that would be $3600.

Take a moment to review your entries against the patient’s chart and internal billing report prior to proceeding.

Step #7: Ensure Documentation Supports the Claim

The patient’s medical record must substantiate what you are billing for the claim:

➜ Admitting Diagnosis and Reason for Admission: The chart must clearly document why the patient had to be admitted to the hospital.

➜ Orders and Progress Notes: These orders and progress notes must document that the patient received treatment as an inpatient and stayed in a semi-private room from the date(s) that you are billing.

➜ Operative Reports and Other Significant Documents: If the admission was related to surgery or another procedure, ensure that the operative reports are in the chart and available to the payer upon request.

If a payer requests records, they must be able to review the chart and see that the room and board charges under revenue code 0120 make sense.

Step #8: Review Payer Specific Requirements

Before submitting your claim, consider the following:

• Did the payer require preauthorization, and is the authorization number on file?
• Is there any additional documentation that the payer requires, including a narrative, detailed procedure list, or specific coding combinations?
• Are there any special rules specified by the payer regarding the counting of room and board days or how same day transfers are billed?

Reviewing payer policies ahead of time can prevent avoidable claim denials.

Step #9: Submit the Claim and Keep Copies

Once everything appears to be in order:

• Submit the claim electronically whenever possible, as it is generally faster and easier to track.
• Send the completed UB-04 and any necessary supporting documentation via mail, if electronic submission is not permitted by the payer.
• Maintain copies of the claim and supporting documentation, so you can provide timely responses if the payer requests further information or documentation at a later date.

FAQs

How is 0120 different from other 012X codes?

0120 is the generic semi-private room code, while others (such as 0121, 0122, etc.) are more specific semi-private room codes, based on the type of care provided (e.g., medical/surgical, obstetric, pediatric, etc.), based on how the provider maps to the payer’s system.

Does 0120 revenue code provide the payer with information regarding the diagnosis or procedure performed?

No, 0120 provides the payer with information regarding the room and board only. The ICD-10-CM diagnosis codes and CPT/HCPCS procedure codes inform the payer of the reason for the visit and treatment provided.

What does “general classification” actually mean for 0120?

General Classification for 0120 simply refers to the fact that this revenue code is not associated with any particular specialty unit. As a result, 0120 is considered the “catch-all” code for semi-private rooms that do not fit within a specialty unit.

Do hospitals with only private rooms have to use a semi-private revenue code?

Yes, however, most hospitals will bill the appropriate private room revenue code (i.e., 0110), and include Value Code 02 on the UB-04 to advise the payer that the hospital does not have any semi-private rooms. This allows the payer to understand that no semi-private rate is being applied to the claim and assists in application of their payment rules.

Can I bill both 0120 and 0110 on the same claim if the patient is transferred from a semi-private room to a private room?

Yes. If the patient is admitted to a semi-private room, but then transfers to a private room, it is possible to bill the UB-04 separately for each type of room using the appropriate units. However, please ensure that you do not overlap the same calendar date units for semi-private and private room billing unless the bed assignment records indicate the room change occurred during the same calendar date.

Will the use of revenue code 0120 affect the DRG or inpatient reimbursement?

No. The DRG is primarily determined by the ICD-10-CM diagnosis and procedure codes, as well as whether or not the patient has any complications or comorbid conditions. Revenue code 0120 is used to describe and price the room and board component of the inpatient stay. While the use of 0120 will support the claim, it will not determine the DRG assigned to the case.

What supporting documentation is required to demonstrate the use of 0120 over a more specific semi-private code?

In addition to standard clinical documentation, your hospital’s bed management and admission records must clearly demonstrate that the patient was located in a semi-private room. Typically, this documentation includes:

• The unit or floor name in the admission, discharge, and transfer (ADT) system
• The bed number and room type showing a two bed semi private room
• Any internal room rate tables that map that bed to the general semi private category rather than a specialized unit 

If the records clearly show a specialty unit such as obstetrics, urology, pediatrics, psychiatric, hospice, endocrinology, or rehabilitation, that is a sign you may need one of the more specific 0121 to 0129 codes instead of 0120.

Are there common denial triggers for revenue code 0120?

Yes, payers commonly challenge or deny 0120 claims when:

• There is no valid inpatient admission order on file, but 0120 is billed as room and board.
• Revenue code 0120 is billed on a claim that appears to be either outpatient or observation.
• The units billed for 0120 do not correlate to the documented length of stay.
• A private room is clearly documented, but only semi-private revenue code is billed, or vice versa.
• Use of the generic 0120 code on what is clearly a specialty unit when the payer is expecting a more specific 0121-0129 code.

Most of these issues arise from a lack of correlation between clinical documentation, bed assignment records, and the chargemaster mapping, and not the revenue code itself.

Does 0120 relate to private room upgrades that are not medically necessary?

Yes. If a patient chooses a private room for personal comfort, many payers will consider the patient’s entire length of stay to be eligible for coverage under the semi-private rate, and will only reimburse for the amount typically paid for a semi-private room. The patient may be billed the difference as a private room differential, as long as they were informed of the option prior to selection.