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As a professional in the long-term care industry, you understand how critical it is to provide high-quality care to your residents. However, another important aspect of your job is ensuring that your facility is reimbursed correctly for the services provided. And that’s where effective SNF billing comes into play. 

It is upon long-term care providers to understand the billing process and employ the use of effective accounts receivable billing and elder care software to ensure that residents receive the full range of services they need and that the SNF is reimbursed for the services provided. In short, SNF billing means: 

A nurse explaining the medicare SNF billing process to a SNF resident.
It is upon long-term care providers to ensure that residents receive the full range of services they need and that the SNF is reimbursed for the services provided.
  • Submitting claims to Medicare for reimbursement payments
  • Ensuring that all charges are accurately reflected on the billing statement
  • Charging for all services related to the resident’s stay, such as room and board, nursing care, rehabilitation services, and any medical supplies and equipment used

SNF consolidated billing, meanwhile, is a means of simplifying the billing process to ensure that all relevant services are accurately reflected in the SNF’s billing statement. Consolidated billing is a requirement of Medicare. However, one should note that Medicare Part A and Part B cannot be billed for the same dates. Part A goes on a consolidated bill for the resident’s skilled stay, while Part B is billed one line per service received.

So why consolidated billing? It helps to prevent errors and ensure that all services are correctly accounted for, which can lead to more accurate reimbursements and better resident care. But this can be challenging, which is why long-term care providers must fully know the requirements and procedures involved in SNF consolidated billing.

In this blog, our goal is to help you understand the basics of SNF billing, avoid common mistakes, streamline your billing process, maximize your reimbursements, and stay ahead of the curve as the SNF billing landscape evolves.

Medicare SNF Billing Codes and Claims Forms Requirements

A big part of accurate SNF billing is understanding SNF billing codes and claims forms requirements. To help with SNF billing, the CMS has created a Skilled Nursing Facility Billing Reference that is updated annually and provides detailed information on billing codes, payment policies, and coverage criteria for SNF services under Medicare Part A. For a full list of the HCPCS Codes, CMS provides a page with all the latest effective CPT/HCPCS codes.

Additionally, Chapter 25 of the Medicare Claims Processing Manual highlights the importance of focusing on specific areas of the CMS-1450 (also known as UB-04) claim form when submitting for SNF billing. These areas to focus on

A nurse filling in a form to be used in SNF billing
A big part of accurate SNF billing is understanding SNF billing codes and claims forms requirements.
  • Field 04: This field indicates the type of bill (TOB). For SNF inpatient services, enter 21X, while for hospital swing bed services, enter 18X.
  • Field 06 (Date of Service): The “from” date in this field is the first day of the monthly billing period. If billing for a continuous stay, enter the day after the “through” date from the previous bill. The “through” date is the last day of the billing period.
  • Fields 31-34: For each assessment period, report 50 with the Assessment Reference Date (ARD) and revenue code 0022 (in Field 42). Note: This is not necessary for the default Health Insurance Prospective Payment System (HIPPS) code.
  • Fields 35 and 36: To report the dates for the qualifying three consecutive days, indicate 70 with the from and through dates of the stay.
  • Field 42: To submit the claim under the SNF PPS, report revenue code 0022. Note: This code can be reported multiple times to account for various HIPPS rate codes and assessment periods.
  • Field 44: The HIPPS rate code must be reported in the order in which the patient received care. Certain HIPPS require additional ancillary revenue codes for rehabilitation therapy, which must be included in the claim. If excluded, the claim will be returned for resubmission.
  • Field 46: Units of service refer to the number of days covered for each HIPPS code.
  • Field 47 (Total Charges): If the billing revenue code is 0022, the charge will be zero.
  • Field 67: Ensure the primary ICD-10-CM diagnosis listed here is accurate and as specific as the documentation supports.
  • Fields 67A-67Q: These fields allow for the reporting of up to eight additional conditions.

Contact us here if you would like to demo our easy-to-use SNF billing software.

How To Navigate the Medicare SNF Billing Process

Having a streamlined SNF billing process is critical to ensuring that your facility is reimbursed correctly and efficiently. But for that to happen, one must first fully understand the medicare SNF billing process. Fortunately, there are guides that provide information to SNF financial staff, so they can better understand SNF billing. Some of the areas covered in these SNF billing guidelines include:

The billing cycle

A physician filling in a form with the relevant SNF billing codes.
Having a streamlined SNF billing process is critical for ensuring that your facility is reimbursed correctly and efficiently.

The billing process for SNFs is conducted on a monthly basis. To bill for Medicare Part A, skilled nursing facilities should submit their claims electronically using the 5010 file format. Meanwhile, the CMS-1450 form is used by MDS nurses to document the review of claims prior to submission. These monthly claims should be promptly submitted in the event of a resident’s:

  • Discharge
  • Reduction from skilled care in a skilled nursing facility 
  • Expiration of their coverage period

To ensure accurate tracking of a resident’s coverage period after their benefits have been exhausted, the claims processing system must comply with CMS guidelines. Also, it is important to be aware of the time frame for all billing services and the SNF billing codes for services provided to a resident. If a resident’s stay begins after the first day of the month, they will typically be charged on a daily basis for room and board, with the cost being calculated by multiplying the number of days since admission.

Types of insurance accepted

If a senior qualifies for Medicare Part A, they will receive full coverage for their first 20 days in a skilled nursing facility. However, from day 21 to day 100, a coinsurance rate of $200.00 a day is applied to the patient’s responsibility and deducted from the Medicare A reimbursement. If the benefits period is exhausted, the staff should still submit monthly claims of non-covered services to the resident so the claims system can accurately track the benefit period.

The services covered by Medicare Part A include: 

  • Short-term inpatient care (whether in a hospital or a skilled nursing facility) 
  • Hospice care
  • Home health care 

From day 101 onwards, the cost of care is transferred to the resident and any secondary coverage they may have.

Meanwhile, Medicare Part B begins after Medicare Part A’s coverage ends, and it only reimburses 80% of the HSPCS rate, with the resident being responsible for the remaining 20%. In long-term care facilities, Medicare Part B covers therapy services, including: 

  • Physical therapy 
  • Occupational therapy
  • Speech-language pathology 

In general, it can cover a wide range of services, such as clinical research, ambulance services, durable medical equipment, mental health services, and limited outpatient prescription drugs. These two (Medicare Part A and Part B) are worth fully understanding as they are a part of SNF consolidated billing.

Billing tips

Accurate billing is crucial for SNFs to avoid unnecessary penalties. Therefore, if SNFs want to improve their billing processes, they should follow the guidance set by the Department of Health and Human Services and keep these key points in mind:

  • Discharge dates, death dates, or the start of a Leave of Absence are not considered utilization days for billing purposes.
  • If a Medicare recipient is discharged and returns to the facility on the same day before midnight, it is not considered a discharge by Medicare.
  • The HIPPS rate code on a billing claim must align with the assessment approved by the state where the long-term care facility operates.

By following the above tips, SNF administrators can ensure they are meeting the required regulations to maximize their reimbursements for services rendered. 

The Future of SNF Billing

As the healthcare industry evolves, SNFs face new challenges, such as having to care for residents with higher acuity levels. This shift will impact SNF billing, and administrators and accounting staff must be prepared to ensure the billing process remains accurate.

These residents will require more intense medical attention, including additional treatments and procedures, which will lead to higher costs for the facility. This means that the billing process will need to be more precise and accurate to ensure that SNFs are properly reimbursed for the care they provide.

SNFs will also need to adapt to the new resident population by making changes to their staffing models. With higher acuity residents, SNFs will need more specialized staff and more hands-on care. This will increase the need for more nursing hours, which will, in turn, increase the cost of staffing.

To prepare for the changes ahead, SNFs must focus on updating their billing processes to ensure they are in line with current regulations and standards. One of the best ways to do so is to implement effective senior care software with financial features, staff training on billing processes, and review current policies and procedures to identify areas for improvement.

For more on recent trends in long-term care, read our blog and subscribe to the LTC Heroes podcast.