Inpatient Claims Billing Requirements: Value Codes 80 & 81 and Non-Covered Charges
Inpatient Claims Billing Requirements: Value Codes 80 & 81 and Non-Covered Charges
Providers submitting inpatient hospital claims on a UB-04 are required to report covered days, non-covered days, and associated non-covered charges. This may include services that are not prior authorized or determined not to meet medically necessary requirements.
Required Billing Elements
- Value Code 80 (Covered Days)
- Report the total number of covered days included in the billing period.
- Enter Value Code 80 in Fields 39-41 of the UB-04 claim form. The total days in boxes 39-41 should equal the statement covered period.
- Value Code 81 (Non-Covered Days)
- Report the total number of non-covered days included in the billing period.
- Enter Value Code 81 in Fields 39-41 of the UB-04 claim form. The total days in boxes 39-41 should equal the statement covered period.
- Non-Covered Charges
- If Value Code 81 (Non-Covered Days) is reported on the claim, non-covered charges are required.
- Report non-covered charges in Field 48 (Non-Covered Charges) of the UB-04 claim form.
- The amount reported in Field 48 must equal the total charges associated with the non-covered days reported under Value Code 81.
Denial Information
Claims submitted without Value Code 81 when a partial authorization exists will be denied.
Denied claims will receive:
- CARC CO16: Claim/Service Lacks Information or has Submission/Billing Error(s).
- RARC N54: Claim Information is Inconsistent with Pre-Certified/Authorized Services.
Claims submitted with Value Code 81 but without non-covered charges will be denied.
Denied claims will receive:
- CARC CO16: Claim/Service Lacks Information or has Submission/Billing Error(s).
- RARC M54: Missing/Incomplete/Invalid Total Charges.
A corrected claim must be submitted with billing information that matches the authorization obtained before the claim can be reprocessed.
Reminder: Accurate reporting of Value Codes 80 and 81, along with any required non-covered charges, is necessary to ensure proper claims adjudication and payment of inpatient services.