If you’ve ever received a hospital bill, you know how confusing it can be. Among the line items, procedure codes, and medical jargon, revenue codes stand as one of the most important—yet least understood—components of hospital billing. These four-digit codes categorize the services and accommodations you received during your stay, helping hospitals, insurance companies, and patients track exactly what was provided and at what cost.

Revenue codes serve as a universal language in healthcare billing. They ensure that when a hospital in California submits a claim, an insurance company in New York understands exactly what service was rendered. For hospitals, accurate revenue coding is essential for proper reimbursement. For patients, these codes determine what portion of your bill insurance will cover and what you’ll owe out-of-pocket.

Overview of Revenue Code 0113

Revenue Code 0113 specifically designates charges for private room and board in a hospital setting. When you occupy a private room during a hospital stay—meaning you have the room entirely to yourself—the daily accommodation charges typically appear under this code on your itemized bill.

This code represents more than just the physical space. It encompasses the entire suite of basic services that come with your private room: nursing care, housekeeping, meals delivered to your room, linens, and the general overhead costs of maintaining that dedicated space for you alone.

Importance for Providers, Billing Staff, and Patients

For healthcare providers and billing staff, Revenue Code 0113 is crucial for several reasons. It ensures proper categorization of room charges, which directly affects reimbursement rates from insurance companies. Different payers have different allowable amounts for private rooms, and incorrect coding can lead to claim denials, delayed payments, or compliance issues.

For patients, understanding this code empowers you to make informed decisions about your care. Private rooms often come with additional costs that may not be fully covered by insurance, especially if the private room was a patient preference rather than a medical necessity. Knowing what Revenue Code 0113 represents helps you anticipate costs, question charges that seem incorrect, and have meaningful conversations with your insurance provider.

What Readers Will Learn From This Guide

This comprehensive guide will walk you through everything you need to know about Revenue Code 0113. You’ll learn the precise definition and usage of this code, understand what services are included in private room and board charges, and discover how this code impacts your hospital bill and insurance claims.

We’ll compare Revenue Code 0113 to related codes like 0111 and 0112, helping you spot potential billing errors. Most importantly, you’ll gain practical knowledge about insurance coverage for private rooms, including what costs you might face out-of-pocket and how to navigate these charges with confidence.

Whether you’re a patient preparing for a hospital stay, a family member reviewing a loved one’s bill, or a healthcare professional refining your billing knowledge, this guide will demystify Revenue Code 0113 and help you navigate the complex world of hospital billing.

1. What is Revenue Code 0113?

Definition of Revenue Code 0113 in Medical Billing

Revenue Code 0113 is a standardized billing code used exclusively for private room and board charges in hospitals. This code falls under the broader category of accommodation codes (0100-0219), which cover various types of room charges during inpatient stays.

The “01” in 0113 indicates it’s a room and board code, while the “13” specifically designates a private room. This four-digit classification system is maintained by the National Uniform Billing Committee (NUBC) and is used on the UB-04 claim form (also known as the CMS-1450 form), which is the standard form for hospital billing.

When you see Revenue Code 0113 on your hospital bill, it represents the daily rate charged for occupying a private room. This is typically billed per day or per diem, meaning if you stay in a private room for five days, you’ll see five line items with Revenue Code 0113, or one line item with a quantity of five.

How It Differs From Other Revenue Codes

The revenue code system is extensive, with codes covering everything from operating room services (036X series) to pharmacy (025X series) to radiology (035X series). Revenue Code 0113 is distinct in that it specifically captures accommodation costs rather than medical procedures or treatments.

What makes 0113 unique is its specificity to single-occupancy rooms. While a chest X-ray might use Revenue Code 0320 regardless of where it’s performed, room codes are highly specific to the type of accommodation. The private designation of 0113 sets it apart from codes for shared accommodations.

The rate charged under Revenue Code 0113 is typically higher than codes for shared rooms because the hospital is dedicating the entire room’s resources to a single patient. This rate reflects not just the square footage, but the exclusivity of the space and the potentially higher level of privacy and comfort it provides.

Common Scenarios When Revenue Code 0113 is Used

Revenue Code 0113 appears on hospital bills in several common situations:

Medical necessity: Sometimes a private room is required for medical reasons. Patients with highly contagious infections, those requiring airborne isolation precautions (like tuberculosis), or patients with severely compromised immune systems often need private rooms. In these cases, Revenue Code 0113 is used, and insurance is more likely to cover the charges fully since the accommodation was medically necessary rather than a patient preference.

Patient request: Many patients prefer private rooms for comfort, privacy, or to accommodate visiting family members. If you request a private room and one is available, the hospital will honor your request, and your bill will reflect Revenue Code 0113. However, insurance coverage may be limited in these circumstances.

Hospital bed availability: Sometimes you’re placed in a private room simply because no semi-private rooms are available. This is often called “private room by default.” In many cases, if you’re assigned a private room due to hospital bed management rather than by request, you may only be charged the semi-private rate even though you occupy a private room.

Specific hospital units: Certain hospital departments, such as intensive care units (ICU), cardiac care units (CCU), or post-anesthesia care units, typically feature private rooms as standard. While these specialized units have their own specific revenue codes (such as 0200-0209 for ICU), when general medical-surgical private rooms are used, Revenue Code 0113 applies.

Extended hospital stays: For patients with longer hospital stays who may start in a shared room but later transfer to a private room—perhaps as their condition stabilizes or based on availability—you’ll see a mix of revenue codes on the final bill reflecting the different accommodation types throughout the stay.

Understanding when and why Revenue Code 0113 appears on your bill is the first step in verifying the accuracy of your charges and knowing what to expect from your insurance coverage.

2. Private Room and Board Explained

What Constitutes a Private Room in a Hospital Setting

A private room in a hospital is a single-occupancy patient room where you’re the sole occupant. Unlike semi-private rooms that accommodate two patients or ward rooms that may hold three or more patients, a private room is exclusively yours for the duration of your stay.

The physical characteristics of a private room typically include:

• One patient bed with full medical capabilities (adjustable positioning, nurse call button, integrated monitoring)
• A private bathroom, often equipped with safety features like grab bars and emergency call buttons
• Individual climate controls for heating and air conditioning
• A door that closes for complete privacy during examinations, procedures, or rest
• Personal storage space including a closet and drawers for your belongings
• Visitor seating area, often with a chair that converts to a sleeper for overnight guests
• Entertainment and communication options such as a television and telephone
• Window access in many cases, though not guaranteed

The square footage of private rooms varies by hospital, with newer facilities often featuring larger, more hotel-like accommodations. Some hospitals have enhanced private rooms with additional amenities like pull-out sofas, refrigerators, or upgraded bathrooms, though these luxury options might carry premium charges beyond the standard Revenue Code 0113 rate.

Services Included Under Private Room and Board

When you see Revenue Code 0113 on your bill, you’re not just paying for an empty room. The daily rate encompasses a comprehensive package of basic services and amenities:

Nursing care: The most significant component of room and board charges is routine nursing care. This includes regular vital sign monitoring, medication administration, assistance with daily activities like bathing or moving around, wound care, and general patient observation. The nursing staff-to-patient ratio and level of care is factored into the daily rate.

Meals and dietary services: Three meals per day, plus snacks, are included in your room charge. This covers not just the food itself but the dietary staff who plan meals according to your medical needs, deliver trays to your room, and accommodate dietary restrictions or preferences within medical guidelines.

Housekeeping and linens: Daily room cleaning, trash removal, and fresh linens (sheets, blankets, pillowcases, towels, and patient gowns) are part of the room and board charge. The frequency of linen changes may vary based on hospital policy and patient needs.

Basic medical supplies: Items like tissue boxes, water pitchers, cups, basic toiletries, and standard comfort items are included. However, specialized medical equipment or supplies specific to your treatment are typically billed separately under different revenue codes.

Utilities and overhead: Electricity, water, heating, air conditioning, and the general maintenance of the facility are built into the room rate. This also includes administrative costs associated with maintaining hospital operations.

Access to common facilities: While billed separately if used, your room and board charge includes access to hospital amenities like waiting areas for visitors, chapel services, and patient libraries or activity rooms where available.

Basic patient education: Nurses and staff providing general information about your condition, medications, and post-discharge care as part of routine nursing duties is included in the room rate.

What’s NOT included: It’s crucial to understand that many services are billed separately from Revenue Code 0113. Physician visits, surgical procedures, laboratory tests, diagnostic imaging, pharmacy charges for medications, physical therapy, specialized equipment like IV pumps, and emergency department services all appear as separate line items with their own revenue codes.

Differences Between Private, Semi-Private, and General Ward Billing

Understanding the distinctions between room types helps you make informed decisions about your hospital stay and anticipate costs:

Private rooms (Revenue Code 0113) offer complete privacy with single occupancy. The daily rate is the highest among standard room options because the hospital dedicates all room resources to one patient. You control noise levels, visitor schedules, and privacy during potentially embarrassing or uncomfortable moments. The typical cost premium over a semi-private room ranges from $100 to $500 per day, though this varies significantly by hospital and geographic location.

Semi-private rooms (Revenue Code 0112) accommodate two patients separated by a curtain. This is the standard room type that most insurance companies recognize as the baseline for coverage. You share a bathroom, television space (though many hospitals now provide individual TVs), and the general room environment with one other patient. While less private, semi-private rooms receive the same level of medical care and nursing attention. The cost is lower because room overhead is shared between two patients.

General ward rooms (Revenue Code 0111) house three or more patients in a single space. Once common, these are now relatively rare in American hospitals except in certain settings like post-anesthesia recovery areas or some emergency observation units. Wards offer the least privacy but the lowest daily rate. Some veterans’ hospitals and county facilities still utilize ward configurations.

Billing implications: Insurance companies typically establish their reimbursement rates based on semi-private room costs (Revenue Code 0112), considering this the standard of care. If you occupy a private room, your insurer may only reimburse up to the semi-private rate, leaving you responsible for the difference unless the private room was medically necessary.

For example, if a private room costs $2,000 per day and a semi-private room costs $1,500 per day, and your insurance covers 80% of the semi-private rate, you’d owe the $500 difference between room types plus 20% of the $1,500 semi-private rate ($300), totaling $800 per day out-of-pocket.

Some hospitals have a “private room by default” policy where if you’re placed in a private room due to lack of semi-private availability, you’re only charged the semi-private rate. This protects patients from unexpected costs due to hospital bed management decisions outside their control.

When considering room options, factor in both the financial impact and the personal benefits. For some patients, the privacy, quiet, and ability to have family stay overnight in a private room is worth the additional cost. For others, especially those with good insurance coverage, a semi-private room meets all medical needs while minimizing out-of-pocket expenses.

3. How Revenue Code 0113 Impacts Hospital Billing

Role in Overall Hospital Charges

Revenue Code 0113 often represents one of the most substantial components of your total hospital bill, particularly for extended stays. Unlike one-time charges for a surgery or diagnostic test, room and board charges accumulate daily, making them a significant driver of overall costs.

To put this in perspective, consider a typical five-day hospital stay. If the private room rate is $1,800 per day, Revenue Code 0113 alone accounts for $9,000 of your bill. Add surgical procedures, medications, lab work, and other services, and room charges might represent 20-40% of the total bill for a moderately complex hospitalization.

The compounding nature of daily charges means that room selection can have dramatic financial implications. The difference between a semi-private room at $1,300 per day and a private room at $1,800 per day might seem modest—just $500 daily. But over a week-long stay, that’s $3,500 in additional charges. For patients with high-deductible health plans or those responsible for a percentage of costs through coinsurance, this can translate to substantial out-of-pocket expenses.

Revenue Code 0113 also serves as a baseline metric for hospitals when analyzing their revenue streams. Room and board charges are considered part of “routine” services, distinct from ancillary services like surgery or pharmacy. Hospital administrators track occupancy rates and room type utilization closely, as private rooms that sit empty represent lost revenue opportunities.

From a billing perspective, Revenue Code 0113 charges are typically the most straightforward on your bill. Unlike complex surgical codes that might be disputed or require detailed documentation, room charges are usually clean-cut: you occupied the room for X days at Y rate per day. This simplicity doesn’t make them less important—it just means there’s typically less ambiguity in the billing process.

Effect on Patient Statements and Insurance Claims

When your hospital submits a claim to your insurance company, Revenue Code 0113 appears on the UB-04 claim form in the revenue code field, accompanied by the description “Private Room & Board,” the number of days, the per-day rate, and the total charge.

Insurance processing: Most insurance companies have established allowed amounts for private room charges based on regional averages and contracted rates with hospitals. If your hospital charges $2,000 per day for a private room but your insurance company’s allowed amount is $1,600, the hospital must write off the $400 difference if they’re in-network. You’re then responsible for your portion based on your plan’s deductible, coinsurance, and copayment structure.

However, there’s an important caveat: many insurance policies only cover private rooms when medically necessary. If you requested a private room for personal preference, your insurance may only reimburse up to the semi-private rate. Using our earlier example, if the semi-private allowed amount is $1,200 and the private room charge is $1,600, you could be responsible for the $400 difference per day, plus your regular cost-sharing obligations.

Patient statements: On your itemized hospital bill or patient statement, Revenue Code 0113 appears as a line item, usually near the top since room charges are fundamental to your stay. The statement shows:

• Revenue code: 0113
• Description: Private Room & Board or similar wording
• Dates of service: Each day you occupied the private room
• Units/quantity: Number of days
• Charge per unit: Daily rate
• Total charges: Per-day rate multiplied by number of days

After insurance processing, your statement will also show what your insurance paid, any adjustments or write-offs, and your remaining patient responsibility.

Explanation of Benefits (EOB): Your insurance company’s EOB will break down how they processed the Revenue Code 0113 charges. Look for notations about whether the charges were considered medically necessary, whether you stayed in-network, and what portion of the private room charge was covered. If the EOB shows a reduced payment with a patient responsibility note, this often indicates the private room wasn’t deemed medically necessary.

Examples of Revenue Code 0113 in Typical Hospital Bills

Let’s examine some real-world scenarios to illustrate how Revenue Code 0113 appears in context:

Scenario 1: Planned surgery with private room by patient choice

Sarah undergoes elective knee replacement surgery and requests a private room for her anticipated four-day stay.

Her itemized bill shows:

• Revenue Code 0113 (Private Room & Board): 4 days × $1,750/day = $7,000
• Revenue Code 0360 (Operating Room): $8,500
• Revenue Code 0250 (Pharmacy): $2,300
• Revenue Code 0301 (Laboratory): $850
• Other charges: $3,200
• Total hospital charges: $21,850

Sarah’s insurance covers 80% of allowed amounts after her $2,000 deductible. The insurance allowed amount for a semi-private room is $1,400/day (total $5,600 for 4 days) but the private room charged $7,000. Sarah’s financial responsibility:

• Deductible: $2,000
• Private room differential: $1,400 (difference between private and semi-private for 4 days)
• 20% coinsurance on remaining allowed charges: approximately $2,770
• Sarah’s estimated total out-of-pocket: $6,170

Scenario 2: Emergency admission with medically necessary private room

James is admitted through the ER with a highly contagious bacterial infection requiring airborne isolation. He’s placed in a private room with special ventilation for six days.

His bill shows:

• Revenue Code 0113 (Private Room & Board – Isolation): 6 days × $1,900/day = $11,400
• Revenue Code 0450 (Emergency Room): $3,200
• Revenue Code 0250 (Pharmacy): $4,100
• Revenue Code 0301 (Laboratory): $1,850
• Revenue Code 0320 (Diagnostic Radiology): $980
• Other charges: $2,470
• Total hospital charges: $24,000

Because James’s private room was medically necessary (documented isolation requirement), his insurance covers it at the full allowed rate with no differential. With his $1,500 deductible and 10% coinsurance:

• Deductible: $1,500
• 10% coinsurance on remaining allowed charges (approximately $20,000 after negotiated reductions): $2,000
• James’s estimated total out-of-pocket: $3,500

Scenario 3: Private room by default—hospital policy protection

Maria is admitted for observation after chest pain. The hospital has no semi-private beds available, so she’s placed in a private room for two days. The hospital has a policy that patients pay only the semi-private rate when assigned a private room due to hospital bed availability.

Her bill initially shows:

• Revenue Code 0113 (Private Room & Board): 2 days × $1,650/day = $3,300
• Revenue Code 0301 (Laboratory/Cardiac enzymes): $980
• Revenue Code 0324 (EKG): $350
• Other charges: $1,120
• Total charges: $5,750

However, the billing department applies an adjustment, reducing the Revenue Code 0113 charge to the semi-private rate:

• Adjusted Revenue Code 0113: 2 days × $1,250/day = $2,500
• Adjustment/write-off: -$800
• Revised total: $4,950

Maria’s responsibility with her 90% coverage after meeting her deductible is significantly lower thanks to this policy protection.

These examples demonstrate how Revenue Code 0113 can vary in its impact based on medical necessity, insurance coverage specifics, and hospital policies. Always review your itemized bill carefully and don’t hesitate to question charges or ask for clarification about why you were assigned a private room and how it affects your financial responsibility.

4. Revenue Code 0113 vs. Other Related Codes

Comparing 0113 to Revenue Code 0111 and 0112

The room and board revenue codes form a logical sequence, each representing a different level of accommodation. Understanding these distinctions is crucial for both accurate billing and informed decision-making as a patient.

Revenue Code 0111: General Ward (Three or Four Beds)

This code designates the most basic accommodation level—a room with three or more patient beds. While once common in hospitals, general wards are now relatively rare in modern American acute care facilities, though you might still encounter them in:

• Department of Veterans Affairs (VA) hospitals
• County or public hospitals with limited resources
• Observation units or post-anesthesia recovery areas as temporary placements
• International hospitals or medical facilities outside the U.S.

The daily rate for Revenue Code 0111 is the lowest among room options, reflecting the shared nature of space, facilities, and resources. Privacy is minimal, with curtains typically providing the only separation between patients. From a billing perspective, insurance companies view ward accommodations as the absolute baseline standard of care.

Key difference from 0113: Ward rooms offer virtually no privacy and are shared with two or more other patients, while private rooms (0113) provide complete privacy and single occupancy. The cost difference can be $500-$800 per day or more.

Revenue Code 0112: Semi-Private Room (Two Beds)

This is the standard room type in American hospitals and the benchmark against which most insurance coverage is measured. Semi-private rooms accommodate two patients, typically separated by a privacy curtain, and include:

• Shared bathroom facilities
• Two patient beds with individual medical equipment
• Shared television space (though many hospitals now provide individual TVs for each bed)
• A curtain divider for visual privacy during examinations or procedures
• Shared visitor space

Revenue Code 0112 represents the “medically appropriate” accommodation standard in the eyes of most insurance companies. This means when determining coverage, insurers base their allowed amounts on semi-private room rates. The daily charge is moderate—higher than a ward but lower than a private room.

Key difference from 0113: Semi-private rooms share space with one other patient, cutting the privacy and exclusive space available with a private room (0113). The cost differential typically ranges from $200-$500 per day, though this varies significantly by hospital and location. Crucially, insurance coverage is generally equivalent to private rooms only when private accommodations are medically necessary.

Revenue Code 0113: Private Room (One Bed)

As we’ve discussed extensively, this code represents single-occupancy accommodations with complete privacy, a private bathroom, and dedicated space. The premium pricing reflects both the exclusivity and the hospital’s decision to allocate all room resources to one patient rather than two or more.

Visual comparison:

Note: Rates shown are illustrative national averages and vary significantly based on geographic location, hospital type, and facility amenities.

Situations Where Other Codes Might Apply

While 0111, 0112, and 0113 cover standard medical-surgical floor rooms, many other revenue codes apply to specialized accommodations and situations:

Revenue Code 0114: Private Room – Deluxe

Some hospitals offer enhanced private rooms with premium amenities such as larger square footage, upgraded furniture, better views, separate sitting areas, pull-out sofas for guests, mini-refrigerators, or premium entertainment systems. These “deluxe” or “VIP” private rooms carry a higher daily rate than standard private rooms.

Revenue Code 0114 is used for these upgraded accommodations. Be aware that insurance typically won’t cover any portion of the upgrade premium—you’ll be responsible for the difference between a standard private room (0113) or semi-private room (0112) rate and the deluxe charge.

Revenue Code 0116: Other Room and Board

This catch-all code covers special accommodations that don’t fit neatly into the other categories, such as bariatric patient rooms (designed for patients requiring specialized larger beds and equipment) or rooms adapted for patients with disabilities.

Revenue Code 0120-0129: Coronary Care

When you’re in a coronary care unit (CCU) or cardiac intensive care unit, your accommodation charges use the 0120 series codes rather than the general room codes. CCU rooms are nearly always private and include continuous cardiac monitoring and higher nurse-to-patient ratios. Revenue Code 0124 specifically designates CCU private rooms.

Revenue Code 0200-0209: Intensive Care

Intensive care units (ICUs) have their own revenue code series. ICU private rooms use Revenue Code 0204, while surgical ICU private rooms might use 0214. These rates are significantly higher than general medical-surgical private rooms (0113) because they include:

• Continuous monitoring and life-support equipment
• Very high nurse-to-patient ratios (often 1:1 or 1:2)
• Immediate access to specialized medical equipment
• Intensivist physicians making daily rounds

ICU private room rates can range from $3,000 to $10,000 or more per day, compared to $1,600-$2,500 for standard private rooms.

Revenue Code 0179: Other Nursery

For newborns requiring accommodation separate from mother (such as in special care nurseries but not full NICU), room charges use the 0170 series codes rather than adult room codes.

Revenue Code 0720-0729: Labor and Delivery Rooms

Birthing rooms and labor/delivery accommodations have dedicated codes in the 0720 series, not the standard room and board codes.

Avoiding Common Coding Errors

Both hospitals and patients can fall prey to revenue code errors. Being aware of common mistakes helps you catch billing problems early:

Error 1: Billing private room rates when semi-private was provided

Sometimes billing systems default to private room codes when in fact you occupied a semi-private room. If your medical records indicate a shared room but your bill shows Revenue Code 0113, this is worth questioning. Check your discharge paperwork or ask for your room assignment history.

Error 2: Continuing private room charges after transfer

If you started in a private room but later transferred to a semi-private room (or vice versa), ensure your bill reflects the change. Your statement should show Revenue Code 0113 for the days in the private room and Revenue Code 0112 for days in the semi-private room, not a single code for the entire stay.

Error 3: Charging private rates for ICU stays

Occasionally, billing errors occur where ICU accommodations are billed under Revenue Code 0113 (general private room) instead of the appropriate ICU code (such as 0204). While both are private rooms, the ICU code is appropriate and comes with higher rates that reflect the intensive level of care. However, billing general private room rates for ICU care incorrectly understates the services provided and may cause reimbursement issues.

Error 4: Duplicate room charges

System errors sometimes result in duplicate billing for the same days. If your statement shows more days of Revenue Code 0113 charges than you actually spent in the hospital, this needs immediate correction. Count the actual days from admission to discharge and verify they match your bill.

Error 5: Charging private room differential when medically necessary

If your private room was medically necessary (isolation precautions, infectious disease, immune suppression), you shouldn’t be charged more than the semi-private rate. If your insurance reduces coverage or your bill shows you owing the differential, verify whether medical necessity was properly documented and communicated to the insurance company. Your physician should note the medical necessity in your records.

How to catch errors:

1. Request an itemized bill showing each day’s charges separately rather than a summary
2. Compare your bill to your medical records regarding room assignments and transfers
3. Cross-reference dates to ensure room charges don’t extend before admission or after discharge
4. Check for consistency in revenue codes throughout your stay unless you actually changed room types
5. Verify medical necessity documentation if you occupied a private room for clinical reasons

If you identify an error, contact the hospital’s billing department promptly. Most hospitals have patient advocates or billing specialists who can review your concerns. Bring specific documentation: your itemized bill, discharge papers, and any room assignment information. Most legitimate errors are corrected quickly once identified.

Understanding the distinctions between revenue codes and knowing which situations call for specific codes protects you from billing errors and helps ensure you’re charged appropriately for the accommodations you actually received.

5. Insurance Considerations for Revenue Code 0113

How Private Room Charges Are Covered by Insurance

Insurance coverage for Revenue Code 0113 charges varies significantly based on whether the private room was medically necessary or a patient preference. Understanding these nuances can save you hundreds or even thousands of dollars.

Medical necessity—the key to full coverage:

Insurance companies typically cover private room charges at the same level as semi-private rooms when the private room is medically necessary. Medical necessity means your physician has determined that a private room is required for your medical treatment, safety, or the safety of others. Common medically necessary situations include:

• Infectious disease requiring isolation: Patients with tuberculosis, COVID-19 during peak pandemic periods, MRSA, C. difficile, or other highly contagious conditions often require private rooms with special air handling systems
• Immunocompromised status: Cancer patients undergoing chemotherapy, organ transplant recipients, or patients with severely weakened immune systems may need private rooms to minimize infection exposure
• Behavioral or psychiatric reasons: Patients with severe agitation, confusion, or conditions where privacy is therapeutically important might require private accommodations
• Medical equipment requirements: Some specialized monitoring or treatment equipment requires dedicated room space
• End-of-life care: Hospice or palliative care situations where privacy is important for the patient and family

When a private room is medically necessary, your physician must document this in your medical records. The hospital then communicates this to your insurance company, typically through diagnosis codes and supporting documentation. In these cases, Revenue Code 0113 charges are processed as if they were standard semi-private accommodations—your insurance pays according to your policy’s normal terms without penalizing you for the private room.

Patient preference—limited or no additional coverage:

When you request a private room for personal comfort, privacy, or convenience rather than medical necessity, most insurance companies will only reimburse up to the semi-private room rate. You become responsible for the difference between the two rates, called the “private room differential.”

Here’s how this typically works:

• Private room daily rate (Revenue Code 0113): $2,000
• Semi-private room daily rate (Revenue Code 0112): $1,500
• Your insurance’s allowed amount for semi-private: $1,400
• Your insurance pays their percentage of: $1,400
• You pay the differential of: $600 per day (the $500 difference between room types, plus your cost-sharing on the semi-private rate)

This differential is generally not counted toward your out-of-pocket maximum because it’s considered an upgraded service beyond medical necessity, similar to how you might pay extra for premium cable channels in your room.

Insurance plan variations:

• Medicare: Original Medicare (Parts A and B) covers semi-private room rates. If you want a private room for personal reasons, you pay the difference. However, if the hospital has no semi-private rooms available and places you in a private room by default, Medicare prohibits the hospital from charging you more than the semi-private rate.
• Medicare Advantage plans: Coverage varies by plan, but most follow similar principles to original Medicare. Some Medicare Advantage plans offer enhanced coverage that may include private room upgrades as a benefit—check your specific plan documents.
• Commercial insurance (employer-sponsored or individual market): Most commercial plans cover semi-private rooms as standard and only cover private rooms when medically necessary. However, some premium plans or executive health plans may include private room coverage as a benefit. Review your Summary of Benefits and Coverage (SBC).
• Medicaid: Coverage varies by state, but most state Medicaid programs cover semi-private rooms only, with private rooms requiring medical necessity documentation.
• TRICARE (military insurance): Generally covers private rooms only when medically necessary or when semi-private rooms aren’t available.

Out-of-Pocket Costs and Copayments

Your financial responsibility for Revenue Code 0113 charges depends on several factors: your insurance plan structure, whether you’ve met your deductible, your coinsurance percentage, and whether the private room was medically necessary.

Deductible considerations:

If you haven’t met your annual deductible, you’ll typically pay the full allowed amount for room charges until you reach that threshold. For example, with a $3,000 deductible and a semi-private allowed amount of $1,500 per day:

• Day 1: You pay $1,500 (applying to deductible)
• Day 2: You pay $1,500 (meeting your $3,000 deductible)
• Day 3 and beyond: You pay your coinsurance percentage

If the private room was by preference, you’d also pay the daily differential ($400-600 typically) on top of these amounts.

Coinsurance and copayments:

After meeting your deductible, you typically pay a percentage of allowed charges (coinsurance) or a flat daily amount (copayment), depending on your plan structure:

• Coinsurance model: If you have 80/20 coinsurance (insurance pays 80%, you pay 20%) and the allowed amount for your private room is $1,600/day, you’d pay $320 per day after meeting your deductible, plus any private room differential
• Copayment model: Some plans charge a flat daily copayment for hospital stays, such as $500 per day for the first five days. This copayment covers all room and board charges regardless of room type, though you’d still owe any private room differential if the room wasn’t medically necessary

Out-of-pocket maximum protection:

Most insurance plans have an annual out-of-pocket maximum (often $8,000-$9,000 for individual coverage, higher for family coverage). Once you reach this amount in a calendar year, your insurance covers 100% of allowed charges for covered services.

However—and this is crucial—private room differentials typically don’t count toward your out-of-pocket maximum because they’re considered upgrades beyond medical necessity. This means you could reach your $8,000 out-of-pocket max but still owe $500/day for a seven-day stay ($3,500) if you chose a private room for personal preference.

Special considerations for high-deductible health plans (HDHPs):

If you have an HDHP paired with a Health Savings Account (HSA), be aware that:

• Your deductible might be $5,000 or higher before insurance coverage begins
• Room and board charges count toward this deductible
• You can use HSA funds tax-free to pay for medically necessary private rooms
• Private room differentials (when not medically necessary) may not be HSA-eligible expenses—check IRS guidelines or consult your tax advisor

Real-world cost scenarios:

Scenario A: Maria has commercial insurance with a $2,000 deductible (already met), 20% coinsurance, and $7,000 out-of-pocket maximum. She stays in a medically necessary private room for 4 days. Private room allowed amount: $1,700/day.

• Days 1-4: $1,700 × 20% = $340/day
• Maria’s total out-of-pocket: $1,360

Scenario B: Same as above, but Maria requested the private room for personal comfort, not medical necessity. Semi-private allowed amount: $1,300/day; private room charges: $1,700/day.

• Days 1-4: ($1,300 × 20%) + ($400 differential) = $260 + $400 = $660/day
• Maria’s total out-of-pocket: $2,640

Scenario C: John has Medicare and stays in a private room (not medically necessary) for 6 days. Medicare semi-private allowed amount: $1,200/day; hospital private room charge: $1,800/day. John hasn’t met his Part A deductible of $1,632 (2024 amount).

• Day 1: $1,632 deductible + $600 differential = $2,232
• Days 2-6: $600 differential per day = $3,000
• John’s total out-of-pocket: $5,232

These examples illustrate why understanding the medical necessity distinction is so financially important.

Tips for Patients to Understand Their Coverage

Navigating insurance coverage for Revenue Code 0113 doesn’t have to be overwhelming. These practical strategies help you understand your coverage and minimize surprises:

Before your hospital stay:

1. Contact your insurance company proactively: Before any planned hospital admission (surgery, procedure, etc.), call your insurance company’s customer service number (on the back of your insurance card) and ask specific questions:

• “Does my plan cover private hospital rooms?”
• “Under what circumstances are private rooms covered at the same rate as semi-private rooms?”
• “If I request a private room for personal preference, what will my additional cost be per day?”
• “What documentation is needed for a private room to be considered medically necessary?”

Document the date, time, and representative’s name for your records.

2. Review your Summary of Benefits and Coverage (SBC): Your insurance plan’s SBC document outlines coverage for hospital stays. Look for sections on:

• Inpatient hospital services
• Room and board coverage
• Deductible and coinsurance amounts
• Out-of-pocket maximums

While the SBC might not specifically address private vs. semi-private rooms, it gives you the framework for understanding your cost-sharing.

3. Discuss room options with your physician: If you have a medical condition that might warrant a private room (compromised immunity, infection risk, anxiety disorder, etc.), talk with your doctor before admission. Ask if they would document medical necessity for a private room given your condition. This documentation can be included in your admission orders, making insurance approval more straightforward.

4. Understand your facility’s policies: Call the hospital’s admissions or patient financial services department and ask:

• “What is your policy when a patient is placed in a private room because no semi-private rooms are available?”
• “What are your daily rates for private vs. semi-private rooms?”
• “If I request a private room, can you provide a written estimate of the additional costs?”

Many hospitals will provide good-faith estimates of your total costs, including the impact of room choice.

During your hospital stay:

5. Request documentation: If you’re placed in a private room for medical reasons (isolation, immune suppression, etc.), ensure this is clearly documented in your medical records. You can ask your nurse or physician, “Is the private room medically necessary for my condition, and is this documented in my chart?”

6. Understand room changes: If you transfer between room types during your stay (ICU to step-down unit, private to semi-private as you stabilize, etc.), note the dates of each transfer. This helps you verify billing accuracy later.

7. Ask about downgrade options: If you initially requested a private room but costs are concerning, you can typically request a transfer to a semi-private room if one becomes available. Talk to your care team or patient services coordinator.

After your hospital stay:

8. Review your itemized bill carefully: Compare the number of days billed for Revenue Code 0113 against your actual stay dates. Verify the daily rates match what the hospital quoted. Check for any adjustments or write-offs if you were placed in a private room by default.

9. Understand your Explanation of Benefits (EOB): When you receive your EOB from insurance, look for:

• How they processed the Revenue Code 0113 charges
• Whether they reduced payment due to “upgraded accommodations” or “not medically necessary”
• What amount they’re counting toward your deductible and out-of-pocket maximum
• Any denial codes or notes about the room charges

10. Appeal if appropriate: If you believe your private room was medically necessary but your insurance company didn’t cover it as such, you have the right to appeal. Gather supporting documentation:

• Physician orders showing medical necessity
• Clinical notes explaining why you needed a private room
• Hospital infection control or isolation protocols if applicable
• Any pre-authorization documentation

Submit a formal appeal to your insurance company with this documentation. Many initially denied claims are approved on appeal when medical necessity is properly documented.

11. Negotiate payment plans: If you face significant out-of-pocket costs for Revenue Code 0113 charges, contact the hospital’s billing department. Most hospitals offer:

• Payment plans with no or low interest
• Financial assistance programs based on income
• Discounts for prompt payment or financial hardship
• Charity care for qualifying patients

Don’t hesitate to ask. Hospitals often prefer to work out a payment arrangement rather than send bills to collections.

12. Consider future planning: If you have ongoing health issues requiring frequent hospitalizations, consider this when selecting insurance during open enrollment. Plans with lower deductibles and coinsurance might have higher premiums but could save money overall if you frequently occupy private rooms for medical necessity.

Red flags to watch for:

• Your EOB shows reduced payment for “upgraded services” but you never requested an upgrade
• You’re charged private room rates but your discharge papers indicate a semi-private room
• Your bill shows more days in a private room than you actually spent there
• You were told the private room was medically necessary but insurance didn’t process it that way

Address these issues promptly by contacting both the hospital’s billing department and your insurance company.

Additional resources:

• Hospital patient advocate or ombudsman: Most hospitals have patient advocates who can help you understand bills and navigate insurance issues
• State insurance commissioner: If you’re having disputes with your insurance company, your state’s insurance department may be able to assist
• Healthcare billing advocates: Professional advocates can review bills and negotiate on your behalf, usually for a percentage of money saved
• Nonprofit counseling services: Organizations like the Patient Advocate Foundation offer free help understanding medical bills and insurance

Understanding insurance coverage for Revenue Code 0113 empowers you to make informed decisions about your hospital room accommodations. By asking the right questions before, during, and after your stay, you can minimize financial surprises and ensure you’re receiving all the coverage your insurance plan provides. Remember, knowledge is power when it comes to healthcare billing—don’t hesitate to ask questions, request documentation, and advocate for accurate billing and appropriate coverage.