A Medicare skilled nursing facility billing manual is a resource for nurses and long term care staff who provide care for Medicare beneficiaries. The manual provides guidance and information on how to bill for services in Skilled Nursing Facilities (SNFs).
An example of such a document is the nursing facility billing manual provided by the Colorado Department of Health Care, Policy, and Financing. This manual technically only applies to Colorado nursing facilities enrolled in the Medicare program, but it covers broader topics such as:
- Medicare crossover claims
- Eligibility requirements
- Documentation requirements
- Coverage of services
- Revenue coding
Here we will provide a more general Medicare skilled nursing facility billing manual that SNFs across the US can use by extracting information from the manual provided by the Department of Health and Human Services. In different sections throughout this article, we will touch on four main points:
- General information on the Medicare skilled nursing facility billing manual
- Medicare Part A coverage
- Medicare Part B coverage
- Coding and documentation
General information on the Medicare skilled nursing facility billing manual
In the United States, skilled nursing facilities are long term care facilities that provide 24-hour nursing care, rehabilitation services, and social activities for Medicare beneficiaries. They are regulated by both the Centers for Medicare and Medicaid Services (CMS) and the state where they are located. The CMS sets minimum standards that SNFs must meet in order to participate in the Medicare program. Meanwhile, each state’s Department of Health regulates the SNFs within its borders and may impose additional requirements on facilities.
Medicare is a government-funded insurance program that provides health care to senior citizens, people with disabilities, and people suffering from end-stage renal disease (such as permanent kidney failure requiring dialysis or a transplant).
Medicare Part A provides some financial assistance for non-custodial and short-term inpatient care in a hospital or skilled nursing facility. Medicare Part B, meanwhile, assists with outpatient care, including services provided in a skilled nursing facility. Most people who are covered by Medicare Part A will also be covered by Medicare Part B.
How Skilled Nursing Facility Billing Works
Skilled nursing facilities bill private insurers or Medicare for services they provide to residents. If a resident is covered by Medicare, there are two ways skilled nursing facility billing occurs: for Medicare Part A only or for Medicare Part A and Part B (Consolidated billing).
Medicare Part A only explained
Medicare Part A covers inpatient care in a skilled nursing facility. As stated in the Medicare skilled nursing facility billing manual from the HHS, for a stay in a SNF to be covered by Medicare Part A, a patient must first have had a qualifying hospital stay for a minimum of three days. And the patient must be admitted to a skilled nursing facility for care that can only be provided in an SNF within 30 days of being discharged from a hospital. This care is typically custodial or rehabilitation care.
Other requirements to qualify for Medicare Part A, as stated in the Medicare skilled nursing facility billing manual, include:
- Skilled nursing services must be performed or supervised by a professional or by technical personnel
- All skilled nursing services offered to patients must have been ordered by a physician
- Services must be provided for an ongoing disease for which the beneficiary received inpatient hospital care or for a new condition that developed during the SNF’s treatment of the ongoing condition
- Services can only be provided on an inpatient basis in a SNF
- The services provided are both appropriate and necessary for the treatment of the beneficiary’s inpatient sickness or injury, and they are also reasonable in terms of duration and quantity
Medicare Part A has a benefit period of 20 days, which covers semi-private rooms, meals, nursing care, and other services offered by the skilled nursing facility. From day 21 to 100, coinsurance kicks in, and from day 101 onwards, Medicare coverage fully expires.
It is worth noting that once Medicare coverage expires, patients are responsible for paying a deductible and coinsurance for Medicare Part A coverage if they do not have Medicare Supplement Insurance (Medigap) or a Medicare Advantage Plan.
Medicare Supplement Insurance, also known as Medigap, is a type of health insurance plan that helps people with Medicare coverage pay contributing costs that the original Medicare coverage (Original Medicare) did not include. This is offered by private companies and includes coinsurance, co-payments, and deductibles.
Medicare Advantage plans—also sometimes referred to as Medicare Part C or MA Plans—are offered by private insurance companies, and they must follow the rules set by the CMS. Not only are the benefits with these types of plans required to be equivalent to Original Medicare, but they can also surpass it by providing extra benefits, like prescription drug coverage.
One big difference between Medicare Advantage plans and Medigap is that Medigap policies only work with Original Medicare, while Medicare Advantage plans work with either Original Medicare or a Medicare Prescription Drug Plan (Part D).
Another difference is that Medigap policies do not have networks, while Medicare Advantage plans do. A Medicare provider network consists of doctors, other healthcare professionals (pathologists or occupational therapists), and hospitals that contract with the plan to provide care to the plan’s members.
Medicare Part A and Part B (Consolidated billing)
Medicare Part B is a federal-funded insurance program designed to provide coverage for some necessary medical and preventive healthcare services, such as lab tests, doctor’s visits, x-rays, and outpatient hospital procedures.
Unlike other types of healthcare coverage, such as Medicare Part A or private health insurance plans, Medicare Part B typically does not cover any costs associated with hospital stays or long term care. However, it does typically cover a range of treatment options deemed clinically necessary by a licensed provider.
Individuals who are enrolled in Part B should carefully review their plan details to understand the benefits for which they are eligible. Additionally, it is crucial that they stay up-to-date on any changes in their medical needs or those of their family members in order to ensure that they continue receiving appropriate coverage under Medicare Part B.
That leaves one part of our Medicare skilled nursing facility billing manual: consolidated billing, which is explained in great detail here. You may also be interested in understanding consolidated billing in the specific context of SNFs. Consolidated billing is a way for a provider to submit one bill that encompasses all the various services they have provided to a patient during a single stay. This can include everything from inpatient care (Medicare Part A) to outpatient rehabilitation services (Medicare Part B).
The goal of consolidated billing is to streamline the process of getting accurate reimbursements from Medicare and other insurers. It also simplifies things for patients, who only have to deal with a single bill instead of multiple bills from different providers.
Contact us here if you would like to optimize your consolidated billing process using our long term care EHR.
SNF Consolidated Billing Services
SNFs provide a range of services to patients, including skilled nursing care, rehabilitation therapies, and social services. It is worth noting that only some services provided to SNF patients are considered to be consolidated billing services covered by Medicaid.
The list of these services and additional resources is included in the HHS Medicare skilled nursing facility billing manual. Here we will list some of the services that are excluded in the SNF Billing guidelines for consolidated billing. Some excluded services are those provided by:
- Physician assistants under a physician’s supervision
- Certified nurse-midwives
- Clinical specialists and nurse practitioners working with a physician
- CRNAs (Certified registered nurse anesthetists)
Other excluded services are:
- Radioisotope services
- Covered ambulance transportation to obtain dialysis services and certain dialysis-related services
- Home care related to a terminal condition
- Erythropoietin for certain dialysis patients
- Certain ambulance services
- Certain chemotherapy administration services
- Certain chemotherapy drugs
- Customized prosthetic services
Skilled nursing facility billing Medicare codes, meanwhile, are used to track the type of services provided, the patient’s diagnosis, and other important information. A SNF consolidated billing process must use the correct code for each service provided for it to be accurately reimbursed by Medicare.
Fortunately, the CMS offers a complete resource of downloadable PDFs that lists all the up-to-date CPT/HCPCS Codes. Additionally, Experience Care offers PDPM training that reviews all five case-mix adjusted components under PDPM in depth.
Billing to Medicare using the consolidated billing system can be complex. Hence, it is important for SNFs to partner with a long term care software provider that understands how it works. A good EHR with billing software will help ensure that your facility is submitting accurate, timely invoices and will help you get reimbursed for the services you provide.
Medicare Skilled Nursing Facility Billing Manual: Tips for SNFs
As we conclude our Medicare skilled nursing facility billing manual, it is worth mentioning the most important SNF billing tips and facts for making the billing process easier:
- Generally, SNFs do not count the day of discharge, death, or a leave of absence (LOA) as a utilization day
- If a beneficiary is discharged and returns to the facility before midnight on the same day, Medicare does not consider this an official discharge
- The HIPPS rate code on the claim must match the assessment that was transmitted and accepted by the state in which the skilled nursing facility operates.
The Medicare Skilled Nursing Facility Billing Manual is a valuable resource for nurses and long term care staff who provide care to Medicare beneficiaries. It informs teams on how to bill for services rendered to skilled nursing facility patients by providing detailed information on coverage under Medicare Part A and Part B, as well as coding and documentation guidance. This Medicare skilled nursing facility billing manual is an essential tool for anyone who works in a skilled nursing facility or who provides care to Medicare beneficiaries.
To make the billing process easier, it is essential that SNFs partner with a SNF software provider that understands how Medicare works. An effective nursing home software with financial modules will help ensure that your facility is submitting accurate and timely claims and will help you get reimbursed for the services you provide.
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