HMSA plans cover private rooms when medically appropriate for the member's condition. The payment from HMSA plus any applicable member copayment for a medically appropriate private room should be considered payment in full. Under HMSA plan benefits, members are not liable for additional out-of-pocket costs for a medically appropriate private room.
The charts below list ICD-10 CM diagnosis codes and ICD-10 CM procedure codes for which a private room is considered medically appropriate.
Diagnoses for which a private room is considered medically appropriate
| Description | ICD‑10‑CM Diagnosis Code | ICD-10-CM Description |
|---|---|---|
| Bacterial meningitis | G00.0 | Hemophilus meningitis |
| G00.1 | Pneumococcal meningitis | |
| G00.2 | Streptococcal meningitis | |
| G00.3 | Staphylococcal meningitis | |
| G01 | Meningitis in bacterial diseases classified elsewhere | |
|
Bordetella pertussis Whooping Cough |
A37.00 | Whooping cough due to Bordetella pertussis without pneumonia |
| A37.01 | Whooping cough due to Bordetella pertussis with pneumonia | |
| A37.10 | Whooping cough due to Bordetella parapertussis without pneumonia | |
| A37.11 | Whooping cough due to Bordetella parapertussis with pneumonia | |
| A37.80 | Whooping cough due to other Bordetella species without pneumonia | |
| A37.81 | Whooping cough due to other Bordetella species with pneumonia | |
| A37.90 | Whooping cough, unspecified species without pneumonia | |
| A37.91 | Whooping cough, unspecified species with pneumonia | |
| Cholera | A00.0 | Cholera due to Vibrio cholerae 01, biovar cholerae |
| A00.1 | Cholera due to Vibrio cholerae 01, biovar eltor | |
| A00.9 | Cholera, unspecified | |
| Clostridium difficile (C. Diff) | A04.71 | Enterocolitis due to Clostridium difficile, recurrent |
| A04.72 | Enterocolitis due to Clostridium difficile, not specified as recurrent | |
| COVID-19 | B97.29 | Coronavirus (other) as cause of diseases classified elsewhere |
| J12.82 | Pneumonia due to coronavirus disease | |
| U07.1 | COVID-19 | |
| Cowpox and vacina not from vaccine | B08.010 | Cowpox |
| B08.011 | Vaccinia not from vaccine | |
| B08.02 | Orf virus disease | |
| B08.03 | Pseudocowpox [milker's node] | |
| B08.04 | Paravaccinia, unspecified | |
| Diphtheria | A36.0 | Pharyngeal diphtheria |
| A36.1 | Nasopharyngeal diphtheria | |
| A36.2 | Laryngeal diphtheria | |
| A36.9 | Diphtheria, unspecified | |
| Extended Spectrum Beat Lactamase (ESBL) | Z16.10 | Resistance to beta lactam antibiotics |
| Influenza | J09.X1 | Influenza due to identified novel influenza A virus with pneumonia |
| J09.X2 | Influenza due to identified novel influenza A virus with other respiratory manifestations | |
| J09.X3 | Influenza due to identified novel influenza A virus with gastrointestinal manifestations | |
| J09.X9 | Influenza due to identified novel influenza A virus with other manifestations | |
| Influenza due to other identified influenza virus | J10.00 | Influenza due to other identified influenza virus with unspecified type of pneumonia |
| J10.01 | Influenza due to other identified influenza virus with the same other identified influenza virus pneumonia | |
| J10.08 | Influenza due to other identified influenza virus with other specified pneumonia | |
| J10.1 | Influenza due to other identified influenza virus with other respiratory manifestations | |
| J10.2 | Influenza due to other identified influenza virus with gastrointestinal manifestations | |
| J10.81 | Influenza due to other identified influenza virus with encephalopathy | |
| J10.82 | Influenza due to other identified influenza virus with myocarditis | |
| J10.83 | Influenza due to other identified influenza virus with otitis media | |
| J10.89 | Influenza due to other identified influenza virus with other manifestations | |
| J11.00 | Influenza due to unidentified influenza virus with unspecified type of pneumonia | |
| J11.08 | Influenza due to unidentified influenza virus with specified pneumonia | |
| J11.1 | Influenza due to unidentified influenza virus with other respiratory manifestations | |
| J11.2 | Influenza due to unidentified influenza virus with gastrointestinal manifestations | |
| J11.81 | Influenza due to unidentified influenza virus with encephalopathy | |
| J11.82 | Influenza due to unidentified influenza virus with myocarditis | |
| J11.83 | Influenza due to unidentified influenza virus with otitis media | |
| J11.89 | Influenza due to unidentified influenza virus with other manifestations | |
| J12.9 | Viral pneumonia, unspecified | |
| Measles | B05.0 | Measles complicated by encephalitis |
| B05.1 | Measles complicated by meningitis | |
| B05.2 | Measles complicated by pneumonia | |
| B05.3 | Measles complicated by otitis media | |
| B05.4 | Measles with intestinal complications | |
| B05.81 | Measles keratitis and keratoconjunctivitis | |
| B05.89 | Other measles complications | |
| B05.9 | Measles without complication | |
| Meningococcal Infection | A39.0 | Meningococcal meningitis |
| A39.1 | Waterhouse-Friderichsen syndrome | |
| A39.2 | Acute meningococcemia | |
| A39.3 | Chronic meningococcemia | |
| A39.4 | Meningococcemia, unspecified | |
| A39.50 | Meningococcal carditis, unspecified | |
| A39.51 | Meningococcal endocarditis | |
| A39.52 | Meningococcal myocarditis | |
| A39.53 | Meningococcal pericarditis | |
| A39.81 | Meningococcal encephalitis | |
| A39.82 | Meningococcal retrobulbar neuritis | |
| A39.83 | Meningococcal arthritis | |
| A39.84 | Postmeningococcal arthritis | |
| A39.89 | Other meningococcal infections | |
| A39.9 | Meningococcal infection, unspecified | |
| MRSA - Streptococcus, Staphylococcus, Enterococcus | B95.0 | Streptococcus, group A, as the cause of diseases classified elsewhere |
| B95.1 | Streptococcus, group B, as the cause of diseases classified elsewhere | |
| B95.2 | Enterococcus as the cause of diseases classified elsewhere | |
| B95.3 | Streptococcus pneumoniae as the cause of diseases classified elsewhere | |
| B95.4 | Other streptococcus as the cause of diseases classified elsewhere | |
| B95.5 | Unspecified streptococcus as the cause of diseases classified elsewhere | |
| B95.61 | Methicillin susceptible Staphylococcus aureus infection as the cause of diseases classified elsewhere | |
| B95.62 | Methicillin resistant Staphylococcus aureus infection as the cause of diseases classified elsewhere | |
| B95.7 | Other staphylococcus as the cause of diseases classified elsewhere | |
| B95.8 | Unspecified staphylococcus as the cause of diseases classified elsewhere | |
| Mumps | B26.0 | Mumps orchitis |
| B26.1 | Mumps meningitis | |
| B26.2 | Mumps encephalitis | |
| B26.3 | Mumps pancreatitis | |
| B26.81 | Mumps hepatitis | |
| B26.82 | Mumps myocarditis | |
| B26.83 | Mumps nephritis | |
| B26.84 | Mumps polyneuropathy | |
| B26.85 | Mumps arthritis | |
| B26.89 | Other mumps complications | |
| B26.9 | Mumps without complication | |
| Norovirus and other - Acute gastroenteropathy due to Norwalk agent and other small round viruses and Other viral enteritis | A08.11 | Acute gastroenteropathy due to Norwalk agent |
| A08.19 | Acute gastroenteropathy due to other small round viruses | |
| A08.31 | Calicivirus enteritis | |
| Organ or tissue transplant | Z94.0 | Kidney transplant status |
| Z94.1 | Heart transplant status | |
| Z94.2 | Lung transplant status | |
| Z94.3 | Heart and lungs transplant status | |
| Z94.4 | Liver transplant status | |
| Z94.5 | Autogenous skin transplant status | |
| Z94.6 | Bone transplant status | |
| Z94.7 | Corneal transplant status | |
| Z94.81 | Bone marrow transplant status | |
| Z94.82 | Intestine transplant status | |
| Z94.83 | Pancreas transplant status | |
| Z94.84 | Stem cells transplant status | |
| Parvovirus | B34.3 | Parvovirus infection, unspecified |
| Pneumonic plague | A20.2 | Pneumonic plague |
| Respiratory syncytial virus (RSV) | J12.1 | Respiratory syncytial virus pneumonia |
| Rubella (German measles) | B06.00 | Rubella with neurological complication, unspecified |
| B06.01 | Rubella encephalitis | |
| B06.02 | Rubella meningitis | |
| B06.09 | Other neurological complications of rubella | |
| B06.81 | Rubella pneumonia | |
| B06.82 | Rubella arthritis | |
| B06.89 | Other rubella complications | |
| B06.9 | Rubella without complication | |
| Scabies | B86 | Scabies |
| Severe acute respiratory syndrome (SARS) | J12.81 | Pneumonia due to SARS-associated coronavirus |
| Smallpox | B03 | Smallpox |
| Tuberculosis (Respiratory tuberculosis) | A15.0 | Tuberculosis of lung |
| A15.4 | Tuberculosis of intrathoracic lymph nodes | |
| A15.5 | Tuberculosis of larynx, trachea and bronchus | |
| A15.6 | Tuberculous pleurisy | |
| A15.7 | Primary respiratory tuberculosis | |
| A15.8 | Other respiratory tuberculosis | |
| A15.9 | Respiratory tuberculosis unspecified | |
| Typhoid and paratyphoid Fevers | A01.00 | Typhoid fever, unspecified |
| A01.01 | Typhoid meningitis | |
| A01.02 | Typhoid fever with heart involvement | |
| A01.03 | Typhoid pneumonia | |
| A01.04 | Typhoid arthritis | |
| A01.05 | Typhoid osteomyelitis | |
| A01.09 | Typhoid fever with other complications | |
| A01.1 | Paratyphoid fever A | |
| A01.2 | Paratyphoid fever B | |
| A01.3 | Paratyphoid fever C | |
| A01.4 | Paratyphoid fever, unspecified | |
| Varicella (chicken pox) | B01.0 | Varicella meningitis |
| B01.11 | Varicella encephalitis and encephalomyelitis | |
| B01.12 | Varicella myelitis | |
| B01.2 | Varicella pneumonia | |
| B01.81 | Varicella keratitis | |
| B01.89 | Other varicella complications | |
| B01.9 | Varicella without complication | |
| Vancomycin-resistant enterococci (VRE) | Z16.21 | Resistance to vancomycin |
| Z16.22 | Resistance to vancomycin related antibiotics | |
| Viral hemorrhagic fevers | A98.0 | Crimean-Congo hemorrhagic fever |
| A98.1 | Omsk hemorrhagic fever | |
| A98.2 | Kyasanur Forest disease | |
| A98.3 | Marburg virus disease | |
| A98.4 | Ebola virus disease | |
| A98.8 | Other specified viral hemorrhagic fevers | |
| A99 | Unspecified viral hemorrhagic fever | |
| Yellow Fever | A95.0 | Sylvatic yellow fever |
| A95.1 | Urban yellow fever | |
| A95.9 | Yellow fever, unspecified | |
| Zoster (herpes zoster) | B02.0 | Zoster encephalitis |
| B02.1 | Zoster meningitis | |
| B02.21 | Postherpetic geniculate ganglionitis | |
| B02.22 | Postherpetic trigeminal neuralgia | |
| B02.23 | Postherpetic polyneuropathy | |
| B02.24 | Postherpetic myelitis | |
| B02.29 | Other postherpetic nervous system involvement | |
| B02.30 | Zoster ocular disease, unspecified | |
| B02.31 | Zoster conjunctivitis | |
| B02.32 | Zoster iridocyclitis | |
| B02.33 | Zoster keratitis | |
| B02.34 | Zoster scleritis | |
| B02.39 | Other herpes zoster eye disease | |
| B02.7 | Disseminated zoster | |
| B02.8 | Zoster with other complications | |
| B02.9 | Zoster without complications |
Procedures for which a private room is considered medically appropriate
| ICD-10-CM Procedure Codes | Description |
|---|---|
| 02YA0Z0 | Transplantation of Heart, Allogeneic, Open Approach |
| 30230G0 | Transfusion of Autologous Bone Marrow into Peripheral Vein, Open Approach |
| 30230G4 | Transfusion of Allogeneic Unspecified Bone Marrow into Perpheral Vain, Open Approach |
| 30230AZ | Transfusion of Embryonic Stem Cells into Peripheral Vein, Open Approach |
| 30230Y4 | Transfusion of Allogeneic Unspecified Hematopoietic Stem Cells into Peripheral Vein, Open Approach |
| 0FY00Z0 | Transplantation of Liver, Allogeneic, Open Approach |
| 0FYG0Z0 | Transplantation of Pancreas, Allogeneic, Open Approach |
| 0FYG0Z2 | Transplantation of Pancreas, Zooplastic, Open Approach |
| 0TS00ZZ | Reposition Right Kidney, Open Approach |
| 0TS10ZZ | Reposition Left Kidney, Open Approach |
| 0TY00Z0 | Transplantation of Right Kidney, Allogeneic, Open Approach |
| 0TY10Z0 | Transplantation of Left Kidney, Allogeneic, Open Approach |
Revision History
| Date | Nature of Revision |
|---|---|
| 08/03/2026 | Migrated to new platform |