Before we begin, let me remind you that the safe harbor provisions of the Private Securities Litigation Reform Act of 1995 apply to this conference call.
The net effect of the pandemic and the government's actions was to allow VITAS to report an increase in adjusted net income of 25.7% in 2020.
But VITAS had a patient base and its median length of stay fell to 11 days.
Residential revenue totaled $144 million in the first quarter of 2021, an increase of 32% when compared to the prior year quarter and a 7.2% sequential growth when compared to the fourth quarter of 2020.
Commercial revenue totaled $46.9 million in the quarter, an 8.4% decline when compared with the first quarter of 2020.
Although our Commercial demand has not yet normalized to pre-pandemic levels, this decline has shown significant improvement when compared to the Commercial unit-for-unit revenue declines of 29.1%, 11.6% and 9.8% in the second, third and fourth quarters of 2020, respectively.
Aggregate Roto-Rooter activity, which includes branch operations, independent contractors, as well as franchise fees and product sales, Roto-Rooter generated consolidated first quarter 2020 revenue of $212 million, an increase of 18.9%.
VITAS' net revenue was $316 million in the first quarter of 2021, which is a decline of 6.5% when compared to the prior year period.
This revenue decline is comprised primarily of a 7.1% decline in days of care.
Our days of care was negatively impacted 111 basis points by the 2020 leap year.
Our first quarter 2021 revenue included a geographically weighted average Medicare reimbursement rate increase, including the suspension of sequestration on May 1, 2020, of approximately 2.8%, offset by acuity mix shift, which reduced revenue by approximately $9.1 million or 2.7% in the quarter when compared to the prior year revenue and level of care mix.
In addition, the combination of a lower Medicare cap and other counter-revenue changes offset a portion of the revenue decline by approximately 50 basis points.
Our average revenue per patient per day in the first quarter of 2021 was $198.95, which, including acuity mix shift, is basically equal to the prior year period.
Reimbursement for routine home care and high acuity care averaged $170.14 and $991.77, respectively.
During the quarter, high acuity days of care were 3.5% of our total days of care, 71 basis points less than the prior year quarter.
In the first quarter of 2021, VITAS accrued $1.5 million in Medicare Cap billing limitations.
This compares to a $2.5 million Medicare Cap billing limitation we recorded in the first quarter of 2020.
Of VITAS' 30 Medicare provider numbers, 27 of these provider numbers currently have a Medicare Cap cushion of 10% or greater.
One provider number has a cap cushion between 5% and 10%.
One provider number has a cap cushion between 0% and 5%.
VITAS' first quarter 2021 adjusted EBITDA, excluding Medicare Cap, totaled $58.3 million in the quarter, which is a decrease of 3.3%.
Adjusted EBITDA margin in the quarter, excluding Medicare Cap, was 18.4%, which is a 66 basis point improvement when we compare it to the prior year period.
Roto-Rooter generated quarterly revenue of $212 million in the first quarter of 2021, an increase of $33.7 million or 18.9% over the prior year quarter.
As Kevin noted earlier, total Roto-Rooter branch commercial revenue totaled $46.9 million in the quarter, a decrease of 8.4% over the prior year.
This aggregate commercial revenue decline consisted of drain cleaning revenue, declining 5.8%, plumbing revenue, declining 5%, and excavation, declining 19.5%.
Water restoration for commercial increased 8.8%.
Our total Roto-Rooter branch residential revenue in the quarter totaled $144 million, an increase of 32% over the prior year period.
This aggregate residential revenue growth consisted of drain cleaning, increasing 29.5%, plumbing expanding 34.9%, excavation increasing 35.8% and water restoration increasing 28.7%.
In the first quarter, our average daily census was 18,050 patients, a decline of 6.1% over the prior year.
In the first quarter of 2021, total admissions were 18,135.
This is a 2.5% decline when compared to the first quarter of 2020.
However, These 18,135 admissions in the first quarter of 2021 compared favorably to the sequential admissions of 16,822, 17,973 and 17,960 in the second, third and fourth quarters of 2020.
In the first quarter, our home-based preadmit admissions decreased 1.5%.
Hospital directed admissions expanded 2.4%.
Nursing home admits declined 26.2%.
And assisted living facility admissions declined 13.1% when compared to the prior year quarter.
Our average length of stay in the quarter was 94.4 days.
This compares to 90.7 days in the first quarter of 2020 and 97.2 days in the fourth quarter of 2020.
Our median length of stay was 12 days in the quarter, which is two days less than the 14-day median in both the first quarter of 2020 and the fourth quarter of 2020.

Summary:
The net effect of the pandemic and the government's actions was to allow VITAS to report an increase in adjusted net income of 25.7% in 2020.