Here are 6 key SNF billing compliance updates you must know:

• 8% Increase in SNF PPS Payment Rates
• PDPM Parity Adjustment Still in Focus
• New QRP Quality Measures (Effective October 2025)
• Expanded Value-Based Purchasing (VBP) Program
• ICD-10 Code Mapping Updates for PDPM
• Increased Staffing Data Scrutiny via PBJ Reporting

In April 2025, CMS released the FY 2025 Skilled Nursing Facility (SNF) PPS Final Rule, highlighting several critical regulatory changes for post-acute providers. These updates emphasize accurate coding, performance-based payment models, and enhanced data transparency, which are essential for SNF billing compliance.

As a Leading SNF billing service provider, Medical Billers and Coders is here to guide your facility through the most significant compliance updates of 2025.

1. 2.8% Increase in SNF PPS Payment Rates

CMS approved a 2.8% net rate increase for SNFs in FY 2025, amounting to an estimated $1.5 billion in additional funding. While this offers a revenue opportunity, CMS will monitor billing accuracy more closely.

Compliance Tip:

Ensure proper MDS coding and documentation. A reliable SNF billing service provider can help reflect rate updates correctly while avoiding billing discrepancies.

2. PDPM Parity Adjustment Under Review

The existing 4.6% PDPM parity reduction remains unchanged, but CMS has continuously evaluated the payment model. Expect continued oversight on clinical category coding and utilization.

Compliance Tip:

Audit PDPM coding regularly and align care documentation with billing. Partnering with an experienced SNF billing company helps reduce errors and withstand audits.

3. New SNF QRP Measures Begin October 2025

Three new quality measures will be tracked starting in October:

• Discharge Function Score
• HAIs requiring hospitalization
• Falls with major injury

These will impact Medicare payments in FY 2027.

Compliance Tip:

Begin collecting accurate QRP data now. SNFs failing to report face a 2% payment cut. Medical Billers and Coders can help align your reporting systems with CMS requirements.

4. Expanded Value-Based Purchasing (VBP) Program

CMS is expanding VBP metrics, including:

• Discharge to the community
• Medicare spending per beneficiary
• Staffing data, like turnover and weekend coverage

Compliance Tip:

These metrics will influence future payment incentives. A knowledgeable SNF billing service provider can help integrate quality data into your billing and compliance workflows.

5. ICD-10 Code Mapping Changes for PDPM

Revised ICD-10 mappings affect PDPM classification, particularly neurological, respiratory, and orthopedic conditions.

Compliance Tip:

Update coding protocols and train staff accordingly. Incorrect mapping can trigger audits or denials. Let Medical Billers and Coders review your claims for compliance accuracy.

6. Staffing Data Scrutiny via PBJ Reporting

CMS will increase reliance on Payroll-Based Journal (PBJ) data to evaluate staffing levels and turnover. This data now impacts both reimbursement and star ratings. (Ref No. 1)

Compliance Tip:

Ensure PBJ submissions are accurate and timely. Collaborate with an SNF billing service provider to integrate staffing data into your compliance checks and billing audits.

Why SNF Billing Compliance Matters More Than Ever?

SNF billing compliance is no longer just about submitting clean claims—it’s about aligning operations, documentation, and staffing with CMS’s growing expectations. Non-compliance can result in denied claims, penalties, and reduced payments.

How Medical Billers and Coders Can Help?

As an expert SNF billing company, we offer:

• PDPM compliance audits
• ICD-10 and CPT coding support
• QRP and VBP data tracking
• Denial management and appeal services
• PBJ and staffing compliance integration

We help skilled nursing facilities avoid penalties, maintain billing accuracy, and stay compliant.

Medical Billers and Coders — Your Partner in SNF Billing Compliance.

Source URL:

Ref No. 1  Payroll Based Journal Daily Nurse Staffing: https://data.cms.gov/quality-of-care/payroll-based-journal-daily-nurse-staffing

Ref No. 2 PDPM Calculation Worksheet for SNFs: https://www.cms.gov/medicare/medicare-fee-for-service-payment/snfpps/downloads/mds_manual_ch_6_pdpm_508.pdf

FAQ:

The post 6 Key SNF Billing Compliance Updates appeared first on Medical Billing and RCM Blogs.

Okay, so here’s the deal: Medicare has this rule called the 3-Day Qualifying Hospital Stay Rule, and it’s super important if you’re dealing with SNF coverage in 2025. If a Medicare patient needs to go to a Skilled Nursing Facility (SNF) after a hospital stay, they have to spend at least three full days in the hospital first. No exceptions—well, almost no exceptions. But in 2025, CMS (the folks who run Medicare) are tweaking the rules a bit, and everyone—hospitals, SNFs, and even billing pros—needs to stay on top of these changes to avoid getting claims denied.

What’s Changing in 2025? Here’s the Scoop

1. CMS is Loosening the Rules (a Little)

   • Telehealth Might Count: In some cases, CMS says, “Hey, maybe telehealth visits can count toward those three days.” That’s a big deal, especially for patients who can’t quickly get to the hospital.
   • Waivers for Special Situations: If there’s a public health emergency (like, say, another pandemic), CMS might let patients skip the 3-day rule altogether.

2. What This Means for SNFs and Hospitals

   • Documentation is Key: If you don’t have the paperwork to prove those three days, you’re out of luck. SNFs and hospitals need to double-check everything to ensure accuracy.
   • Watch Out for Denials: Mess up the admission or discharge details, and CMS might reject your claim. And nobody wants that.

3. Value-Based Care Is Shaking Things Up

   • CMS is starting to care more about patient outcomes. If your SNF isn’t helping patients recover, it could hurt your reimbursements.
   • They’re also rolling out bundled payments, which means SNFs might get paid differently depending on the type of care they provide.

How SNFs Can Stay Ahead of the Game

If you’re running an SNF or working in one, here’s how to make sure you’re ready for 2025:

• Keep Everything on File: Document every detail of the hospital stay. CMS loves paperwork.
• Track Inpatient Stays Like a Hawk: Make sure those three days in the hospital meet all the rules.
• Use Tech to Your Advantage: Tools like Electronic Health Records (EHRs) can help you keep track of everything without losing your mind.
• Stay in the Loop: CMS updates its rules frequently, so make sure you’re keeping up with the latest changes.

Why Medical Billers and Coders Are Your Best Friends

Let’s be real—billing and coding can be a nightmare. That’s where medical billers and coders come in. They’re like the superheroes of the healthcare world, especially when it comes to SNF billing and coding services, and here’s why:

• They Make Sure Claims Get Paid: They know all the tricks to avoid denials and approve your claims.
• They Keep You Compliant: They stay on top of CMS updates so you don’t have to.
• They Find Money You Didn’t Even Know You Were Missing: They’ll spot errors or missed opportunities and fix them to boost your revenue.
• They Fight for You: If a claim gets denied, they’ll handle the appeals process to make sure you get paid.

FAQs

The Takeaway

The 3-Day Qualifying Hospital Stay Rule is a big deal for SNF coverage, and with CMS making changes in 2025, it’s more important than ever to stay on top of the rules. Accurate billing, solid documentation, and staying compliant are the keys to getting reimbursed. And if you’re feeling overwhelmed, don’t sweat it—that’s what medical billers and coders are for. They’ll help you navigate the system and keep your SNF running smoothly.

The post Understanding the 3-Day Qualifying Hospital Stay Rule for SNF Coverage in 2025 appeared first on Medical Billing and RCM Blogs.

Key CMS Updates Affecting SNF Billing in 2025

1. Changes to the Patient-Driven Payment Model (PDPM)

   CMS has fine-tuned the PDPM to better match reimbursements with the actual care needs of patients. SNFs will need to focus on accurate Minimum Data Set (MDS) reporting and coding to ensure they receive the right payments.

2. Tighter Documentation and Compliance Rules

   To combat fraud and improve transparency, CMS is introducing stricter documentation requirements. SNFs will need to maintain thorough and detailed patient records to back up their billing claims.

3. Updates to Medicare Part A Reimbursements

   Medicare Part A reimbursement rates for SNFs are being adjusted to prioritize value-based care and quality outcomes rather than just the volume of services provided.

4. More Opportunities for Telehealth Services

   Telehealth is becoming a bigger part of senior care, and CMS is now offering reimbursements for certain remote patient monitoring and virtual consultations in SNFs.

5. A Stronger Focus on Value-Based Purchasing (VBP)

   CMS is doubling down on its Value-Based Purchasing Program, tying reimbursements to performance metrics like hospital readmission rates and patient satisfaction scores. This shift encourages SNFs to focus on delivering high-quality care.

How These Updates Impact SNF Reimbursements

• Higher Payments for Quality Care

  SNFs that meet or exceed CMS performance benchmarks can expect to see higher reimbursements, making compliance with the new guidelines more important than ever.

• Risks of Payment Cuts for Non-Compliance

  Failing to meet the updated documentation, coding, or quality reporting standards could lead to penalties or even denied claims, which can strain a facility’s finances.

• Easier Billing with Technology

  SNFs that use electronic health records (EHRs) and automated billing systems will have an easier time meeting CMS’s new requirements and keeping their revenue cycles running smoothly.

How Medical Billers and Coders Can Help

Medical Billers and Coders play a critical role in helping SNFs navigate CMS’s Updates Impact SNF Billing. Their expertise ensures:

• Accurate Billing and Coding

  Professional billers ensure that claims are coded correctly and submitted on time, reducing errors and the risk of denials.

• Staying Compliant with CMS Rules

  Billing specialists keep up with the latest CMS updates, helping SNFs stay on top of ever-changing regulations.

• Better Revenue Cycle Management

  By streamlining billing and coding processes, medical billing professionals help SNFs maintain a steady cash flow.

• Handling Prior Authorizations

  Billing teams can take the burden off healthcare providers by managing prior authorizations for SNF services.

• Support for Value-Based Purchasing

  Billing experts help SNFs meet the performance metrics needed to maximize reimbursements under CMS’s value-based programs.

• Telehealth Billing Assistance

  With telehealth services expanding, professional billers ensure SNFs properly document and bill for virtual care.

Conclusion

The CMS updates set to take effect in 2025 will bring significant changes to Skilled Nursing Facility Billing practices, from new reimbursement models to stricter documentation rules and expanded telehealth policies. To stay compliant and financially stable, SNFs should consider partnering with expert billing and coding services. By staying informed and adopting best practices, SNFs can navigate these changes effectively, ensuring they continue to provide high-quality care for seniors while maintaining their financial health.

FAQs

1. How do the 2025 CMS updates affect SNF billing?

   The updates refine reimbursement models, increase documentation requirements, and expand telehealth coverage.

2. What are the biggest challenges SNFs face with the new billing policies?

   SNFs may struggle with stricter documentation rules, adapting to value-based reimbursement models, and avoiding claim denials.

3. How can SNFs ensure compliance with CMS billing regulations?

   By keeping accurate records, staying informed about policy changes, and working with experienced billing professionals.

4. Will telehealth services be reimbursed for SNFs?

   Yes, CMS now allows SNFs to bill for remote patient monitoring and virtual consultations.

5. How can outsourcing billing services help SNFs?

   Outsourcing ensures accurate claims submissions, compliance with CMS regulations, and more efficient revenue cycle management.

The post Senior Care Costs: How CMS’s Updates Impact SNF Billing Practices appeared first on Medical Billing and RCM Blogs.

Overview of SNF Billing

SNFs provide specialized care for individuals requiring rehabilitation or skilled nursing services post-hospitalization. Billing for these services is primarily governed by Medicare, particularly Part A, which covers inpatient hospital stays, care in SNFs, hospice care, and some home health care.

Medicare Coverage for SNF Services

Medicare Part A covers up to 100 days of SNF care per benefit period under specific conditions:

• Qualifying Hospital Stay: A prior inpatient hospital stay of at least three days.

• Admission Timing: Admission to the SNF within a short period (generally 30 days) after leaving the hospital.

• Medical Necessity: The need for skilled care, such as physical therapy or intravenous injections, as prescribed by a doctor.

For the first 20 days, Medicare covers the full cost of care. From days 21 to 100, beneficiaries are responsible for a daily coinsurance amount, which may change annually based on CMS updates.

Consolidated Billing in SNFs

CMS mandates consolidated billing for SNFs, meaning the facility is responsible for billing almost all services provided to a resident under Medicare Part A. This includes services like:

• Therapies (physical, occupational, speech)

• Medications

• Lab tests

• Medical equipment

Certain services are excluded from consolidated billing, such as physician services and specific high-cost treatments. Residents should consult with their SNF to understand which services are included and which are billed separately.

Recent CMS Updates Impacting Resident Costs

In the Fiscal Year 2025 final rule, CMS announced a net increase of 4.2% in Medicare Part A payments to SNFs. This adjustment reflects a 3.0% market basket increase, a 1.7 percentage point forecast error adjustment, and a 0.5 percentage point productivity adjustment.

Additionally, CMS is rebasing and revising the SNF market basket to a 2022 base year to improve payment accuracy. The agency is also updating the SNF Prospective Payment System (PPS) wage index using new Core-Based Statistical Areas (CBSAs) to better reflect geographic variations in labor costs.

Quality Reporting and Value-Based Purchasing Programs

CMS continues to enhance the SNF Quality Reporting Program (QRP) and the SNF Value-Based Purchasing (VBP) Program to improve care quality and incentivize high performance.

For FY 2025, CMS is adding new measures to the SNF QRP, including assessments related to social determinants of health, such as living situation, food security, and utility needs. SNFs failing to meet reporting requirements may face a 2% reduction in their Annual Payment Update.

In the SNF VBP Program, CMS is adopting new quality measures, including the Nursing Staff Turnover Measure to assess staffing stability and the Discharge Function Score Measure to evaluate residents’ functional status at discharge. These measures aim to promote better care outcomes and encourage SNFs to maintain consistent and qualified staffing.

Impact on Residents

These updates may influence the cost of care for residents. While increased payments to SNFs could enhance service quality, residents might experience changes in out-of-pocket expenses, especially if facilities adjust their fee structures in response to CMS payment updates.

It’s essential for residents and families to stay informed about these changes and engage in open communication with their SNF providers to understand potential financial implications.

How Medical Billers and Coders (MBC) Can Help?

Navigating Skilled Nursing Facilities Billing complexities requires expertise in Medicare guidelines, coding accuracy, and claims management. Medical Billers and Coders (MBC) specialize in streamlining SNF billing processes to minimize errors and maximize reimbursement. Here’s how MBC can help:

• Accurate Coding: Ensuring correct CPT, HCPCS, and ICD-10 codes for SNF services, reducing the risk of claim denials.
• Claims Submission & Follow-up: Managing timely claims submissions and handling denials or rejections efficiently.
• Medicare Compliance: Keeping up-to-date with CMS guidelines to ensure compliance and avoid penalties.
• Consolidated Billing Assistance: Helping SNFs navigate bundled billing requirements to ensure proper reimbursement.
• Revenue Cycle Optimization: Identifying revenue leakages and improving cash flow by reducing delays in reimbursements.

By partnering with MBC, SNFs can focus on providing quality patient care while ensuring smooth and efficient billing operations.

FAQs

The post SNF Billing Basics: Understanding Resident Costs in Light of CMS’s Recent Guidelines appeared first on Medical Billing and RCM Blogs.

What if your facility could reclaim much of that revenue before year-end? Industry data shows that nearly 30% of uncollected SNF revenue is trapped in old AR––leading to financial strain during the final quarter. Can your facility afford to lose this potential income? More importantly, are your current billing practices actively contributing to this problem?

Why Precise SNF Billing is Essential for Last-Quarter AR Recovery

SNF billing plays a pivotal role in ensuring a facility’s financial health. However, claims can be delayed, denied, or left unaddressed without optimized billing practices–leading to increasing AR. As your AR ages beyond 90 to 120 days, the chances of successful recovery dwindle significantly. Studies show that recovery chances drop significantly when AR extends past 120 days––with only around 10-20% of the amount typically being collected.​ This makes the last quarter a critical period for revenue recovery, where every claim counts. Facilities that optimize their billing workflows can see up to a 15% increase in collections by the year’s end.

Days in AR: The Key to Efficient Old AR Recovery in SNF Billing

Days in Accounts Receivable (Days in AR) is one of the most critical KPIs for any facility focused on AR recovery. This metric tells you how quickly your SNF is collecting payments, giving insight into the efficiency of your billing process. The goal is to keep your Days in AR below 50 to ensure timely collections and prevent AR from aging beyond the point of recovery.

• Formula: Total AR ÷ Average daily charges = Days in AR.

By tracking this KPI and regularly analyzing it, your SNF can pinpoint problem areas, such as delayed claims, and take immediate action to resolve them. In the case of old AR recovery, improving days in AR can be the difference between a successful year-end and leaving money on the table.

Optimizing SNF Billing Services for Last-Quarter AR Recovery:

To maximize old AR recovery in the final quarter, your SNF Billing Services must focus on efficiency and precision.

Here are 4 tips to enhance your billing process:

1. Audit Your Billing Codes: Incorrect coding can lead to rejected claims, extending the time to collect payments.
2. Automate Billing Processes: Advanced billing software can help speed up claim submissions, reduce errors, and manage denial follow-ups.
3. Focus on Denial Management: Address denied claims promptly and resubmit them with correct information to avoid further payment delays.
4. Leverage Data Insights: Regularly track your Days in AR to spot bottlenecks and improve your billing cycle.

Outsource SNF Billing to MBC for Stress-Free Old AR Recovery:

For many Skilled Nursing Facilities (SNFs), internally managing billing and old AR becomes increasingly challenging–especially in the year’s final quarter. The complexity of navigating claim submissions, denials, and evolving regulations often leads to delayed payments and lost revenue. This is where Medical Billers and Coders (MBC) can make a significant impact. By outsourcing your SNF billing services to MBC, you gain access to a team of experts specializing in efficient, accurate billing and AR recovery.

Here’s how MBC can benefit your facility:

• Accuracy & Collections: MBC ensures precise billing to maximize collections and minimize errors.
• Data-Driven Insights: Leverage analytics to benchmark performance and improve your financial outcomes.
• Streamlined Documentation & SOPs: Consistent, well-structured processes produce measurable, efficient results.
• Dedicated Account Manager: Benefit from transparent communication with regular progress updates.
• Value-Added Solutions: Custom dashboards and forecasts offer actionable insights for future growth.

Ready to Recover Your Aged Accounts Receivable And Streamline Your SNF Billing Process?

Contact MBC today to explore how our SNF billing services can help maximize your revenue recovery in the final quarter.

FAQs:

Q: What is old AR recovery in SNF billing?

A: Old AR recovery in SNF billing refers to collecting overdue payments on accounts receivable that have aged beyond 90 or 120 days. It involves denial management, resubmitting claims, and optimizing billing processes to recover long-unpaid revenue.

Q: What are Days in Accounts Receivable, and why is it important?

A: Days in AR measures how long it takes your SNF to collect payments after services are provided. Lowering this metric improves cash flow and helps recover old AR faster.

Q: How can SNFs improve their old AR recovery?

A: Focusing on KPIs like Days in AR, addressing denied claims promptly, and optimizing billing processes through automation can significantly improve old AR recovery.

Q: What is the CPT code for SNF discharge?

A: The CPT codes for Skilled Nursing Facility (SNF) discharge services are CPT 99315 and CPT 99316. CPT 99315 is used for the discharge day management of a patient from an SNF with a stay of less than 30 minutes, and CPT 99316 is used when the discharge day management takes 30 minutes or more.

Q: What should I refer to for SNF billing guidelines and compliance?

A: For SNF billing guidelines and compliance, refer to the Centers for Medicare & Medicaid Services (CMS), the Medicare Learning Network (MLN) for educational resources, and state-specific Medicaid guidelines for local regulations.

The post SNF Billing Revamp: Last Quarter Old AR Recovery appeared first on Medical Billing and RCM Blogs.

Efficient and timely revenue collection is critical to any medical facility’s financial success, particularly skilled nursing homes. However, due to the complexities of medical billing and collection, this will be difficult to do. Several issues, including erroneous patient information, numerous claim denials, and poor follow-up on unpaid balances, can all result in lost healthcare earnings and a negative impact on the bottom line. As a result, SNFs should watch for signals of possible growth in medical billing collections and the healthcare revenue cycle.

Effective Strategies for SNF Billing Revenue Enhancement:

Proactive Documentation Practices:

Proactive documentation is the muse of a successful SNF billing sales enhancement. Correct and unique documentation of patient care services, including assessments, treatments, and interventions, is vital for ensuring proper compensation. SNFs must implement standardized documentation protocols and offer complete training to staff participants to promote consistency and accuracy in documentation practices.

Compliance with Regulatory Standards:

Compliance with regulatory standards is paramount for SNF billing revenue enhancement. SNFs need to stay current on federal and state guidelines governing billing practices, including the Medicare situations of Participation and the patient-driven payment model (PDPM). By way of adhering to regulatory necessities and preserving meticulous records, SNFs can limit the chance of billing mistakes and capability audit penalties.

Utilization of Technology:

Revenue enhancement efforts for SNF billing can be greatly enhanced by leveraging technology. Systems that combine electronic health records with billing software simplify documentation, minimize administration burden, and increase billing accuracy. Skilled nursing facilities can also employ advanced analytics tools to detect trends and patterns in reimbursement data, allowing them to maximize sales capture and identify growth opportunities.

Perform Regular Audit:

Periodically evaluate billing procedures, paperwork, and coding techniques to identify potential areas for improvement or compliance issues. Address any concerns swiftly to prevent revenue leakage and ensure compliance with legislation.

Collaboration of a Multidisciplinary Team:

For higher billing revenue, skilled care facilities should staff several medical professionals, including therapists, doctors, nurses, and billing specialists. All caregivers should collaborate and communicate well to meet billing goals and accurately record billable services. It is vital to facilitate knowledge sharing and promote a culture of accountability for sales optimization through regular interdisciplinary conferences and training sessions.

Case Study: Implementation of Strategies for SNF Billing Revenue Enhancement

Conclusion:

Skilled nursing facilities (SNFs) use effective strategies to boost billing sales to maintain their economic viability. SNFs can optimize reimbursement while simultaneously offering high-quality care to residents by utilizing proactive documentation techniques, guaranteeing regulatory compliance, employing technology, and promoting interdisciplinary teamwork.

Medical Billers and Coders play vital roles in making accurate, compliant, and revenue-generating SNF billing. They oversee claim denials, check documentation, and stay current on coding policies, decreasing errors and increasing sales.

Contact us today at: 888-357-3226 or email us at: info@medicalbillersandcoders.com to learn how our services can benefit your SNF.

FAQs:

1. What role does proactive documentation have in increasing SNF billing revenue?

Ensuring a comprehensive and all-inclusive patient care record by proactive documentation lowers claim denial rates and raises compensation.

2. How does compliance with regulatory standards contribute to SNF billing revenue enhancement?

Compliance with regulations minimizes billing errors and audit penalties, ensuring financial stability for SNFs.

3. What benefits does the utilization of technology bring to SNF billing revenue enhancement?

Technology streamlines the billing process reduces administrative burden, and improves accuracy, leading to faster claim submission and decreased AR days.

4. Why is interdisciplinary team collaboration crucial for increasing SNF billing revenue?

Collaboration among healthcare professionals ensures accurate capture of billable services and effective communication, ultimately optimizing revenue generation.

5. How can regular compliance audits help in SNF billing revenue enhancement?

Regular audits identify and rectify billing errors, ensuring compliance with regulatory requirements and reducing penalties and fines.

The post Strategies for SNF Billing Revenue Enhancement appeared first on Medical Billing and RCM Blogs.

Regulatory Changes Affecting SNF Billing in 2024

1. Introduction of new reimbursement models

The reimbursement environment in skilled nursing facilities (SNFs) is changing dramatically as new models emerge that promise to improve service quality while handling expenses. Those strategies include cost-based payment arrangements and bundled payments that encourage improved consequences and performance in SNF offers.

2. Impact of COVID-19-associated regulations on SNF billing

The COVID-19 pandemic has caused the implementation of specific guidelines affecting SNF billing in 2024. These guidelines aim to address the particular occasions and challenges confronted with the aid of those centers at some point in the public health crisis. The rules cover telehealth reimbursement, infection control measures, and waivers for billing requirements to facilitate pandemic response.

3. Changes in coding and documentation necessities

Skilled Nursing Facility Billing involves updated coding and documentation requirements mandated by regulatory bodies like the Centers for Medicare and Medicaid Services (CMS). These modifications regularly entail revisions to diagnosis coding structures, ICD-10, and heightened documentation standards to represent patient care and services provided accurately.

4. Updates to Medicare regulations and guidelines

Medicare is revising SNF reimbursement rules and policies to meet evolving healthcare priorities. Those updates encompass various elements, such as payment rates, coverage criteria, and excellent reporting necessities, which impact SNF billing practices appreciably.

5. Different regulatory changes specific to SNF billing practices

SNF billing is encountering several other regulatory updates tailored to their billing practices. Those may additionally consist of updates to therapy billing rules, revisions to payment methodologies for unique services, and necessities related to compliance with federal and state regulations governing healthcare billing.

Case Studies and Examples:

Outsource SNF Billing

Maximizing and refining the Skilled Nursing Facility Billing method in 2024 will permit nursing houses to generate more money. Nursing facility administrators want to learn and observe their SNF billing requirements properly so that their facilities do not lose money on unpaid bills.

Medical Billers and Coders can handle complicated and time-consuming obligations that require an understanding of SNF billing policies and rules, insurance policies, and payment strategies. They can deal with those troubles by outsourcing SNF billing.

FAQs

• What are the main regulatory changes affecting SNF billing in 2024?

New reimbursement models, COVID-19-related rules, changes in coding and documentation requirements, and modifications in Medicare regulation affect SNF billing.

• How can SNFs adapt to the introduction of new billing codes?

SNFs can adapt by promptly updating billing systems, training staff on the new codes, and ensuring accurate documentation to avoid denials and increase revenue.

• What challenges did an SNF in California face with revised reimbursement guidelines?

The SNF faced delayed payments and revenue loss but regained control by analyzing regulations, revamping billing practices, and training staff.

• Why should SNFs consider outsourcing their billing processes?

Outsourcing SNF billing tasks allows facilities to remain compliant with regulations, optimize payments, and free up staff to focus on patient care.

• What benefits do medical billers and coders bring to SNF billing?

They handle complex tasks requiring knowledge of billing rules, insurance policies, and payment procedures, ensuring accurate and timely billing processes.

The post The Impact of Regulatory Changes on SNF Billing in 2024 appeared first on Medical Billing and RCM Blogs.

Medicare SNF Billing Coverage

Medicare Part A Coverage

The SNF Prospective Payment System (PPS) pays for all SNF Part A inpatient services.

Medicare Part A covers Medicare-certified SNF skilled care. Skilled care is nursing or other rehabilitative services, provided according to physician orders, that:

• Require skills of qualified technical or professional health personnel, like registered nurses, licensed practical (vocational) nurses, physical therapists, occupational therapists, and speech-language pathologists or audiologists
• Are provided directly by, or under general skilled nursing or skilled rehabilitation personnel supervision, to assure patient safety and medically desired results
• General supervision requires initial direction and periodic inspection of the actual activity; the supervisor isn’t always physically present or at the location when the assistant performs services

Medicare considers a service skilled if its inherent complexity can only be performed safely and or effectively by, or under the general supervision of, skilled nursing or skilled rehabilitation personnel. Under the consolidated billing provision, SNF Part A inpatient services include all Medicare Part A services considered within the scope or capability of SNFs. In some cases, the SNF must obtain some services it does not provide directly. For these services, the SNF must make arrangements to pay for the services and must not bill Medicare separately for those services.

Medicare Part B Coverage

Medicare Part B may pay for some services provided to beneficiaries residing in an SNF whose benefit period exhausted or who are not otherwise entitled to payment under Part A; outpatient services rendered to beneficiaries who are not inpatients of an SNF, and services excluded from SNF PPS and SNF consolidated billing. Bill repetitive services monthly or when treatment stops. Bill one-time services when you complete the service. You can refer Medicare Claims Processing Manual, Chapter 7 for detailed information.

Original Medicare Coverage

Original Medicare enrollees must meet these conditions to qualify for Part A-covered SNF Billing services:

• The patient was a hospital inpatient for a medically necessary stay of at least 3 consecutive calendar days
  • Time spent in observation or in an emergency room doesn’t count toward a medically necessary 3-day qualifying inpatient hospital stay
  • A Medicare Advantage (MA) plan, 1876 Cost plan, or Program of All-inclusive Care for the Elderly (PACE) plan may waive the 3-day stay for enrollees
• Patient transferred to Medicare-certified SNF within 30 days after hospital discharge, unless both are true:
• The patient’s condition makes it medically inappropriate to begin active treatment in an SNF immediately after discharge
  • It’s medically predictable at patient’s hospital discharge that they’ll need covered SNF care within a predetermined time period (generally no more than 30 days), and they meet that prediction
  • The patient needs daily skilled nursing or rehabilitation services

Daily skilled services can happen only in an SNF Billing on an inpatient basis if:

• They aren’t available on an outpatient basis in the patient’s location
• When compared to an inpatient setting, transportation to a facility is:
  • Excessive physical hardship
  • Less economical
  • Less efficient or effective
• Services are reasonable and necessary for diagnosing or treating a patient’s qualifying condition and of reasonable duration and quantity

Medicare Advantage Coverage

Medicare Advantage (MA) plans, 1876 Cost plans, or PACE plans typically waive the 3-day hospitalization requirement. MA plans must cover the same number of SNF days Original Medicare covers, but they may cover more. Note that For MA plan patients, check with the MA plan for information on eligibility, coverage, and payment. Each plan can have different patient out-of-pocket costs and specific rules for getting and billing for services. You must follow the plan’s terms and conditions for payment.

• MA plans may offer different benefit periods
• Each MA plan’s Evidence of Coverage (EOC) describes all its benefits, including SNF coverage
• Most MA plans offer SNF coverage through network providers paid according to their contracts
• Non-network SNFs should confirm MA coverage with the enrollee’s MA plan
• MA plans that cover SNF services provided by non-network SNFs pay the Original Medicare payment rate

3-Day Prior Hospitalization

A patient meets the 3-consecutive-day stay requirement by staying 3 consecutive days in 1 or more hospital(s). Only the admission day, not the discharge day, counts as a hospital inpatient day. Time spent in observation or in the emergency room before admission doesn’t count toward the 3-day qualifying inpatient hospital stay.

3-Day Stay Waiver

Certain SNFs that have a relationship with Shared Savings Program (SSP) Accountable Care Organizations (ACOs) may waive the SNF 3-day rule. Occasionally, during a Public Health Emergency, we may issue a temporary waiver. Most MA plans to waive the 3-day hospitalization requirement.

We hope that this Medicare SNF billing coverage for the year 2022 would be helpful in accurately billing Medicare for SNF services. In case of any assistance needed in Skilled Nursing Facility (SNF) billing, contact Medical Billers and Coders (MBC) at info@medicalbillersandcoders.com or call us at 888-357-3226.

FAQs

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While billing for Skilled Nursing Facilities (SNF) or for hospital billing, billers always make the mistake of considering the wrong Medicare drug coverage. For example, Medicare Part A and Part B generally do not cover outpatient prescription drugs, most of which are covered under Part D.

In this article, we shared an excerpt from a CMS document, which will act as a basic tool to assist you in understanding Medicare drug coverage determinations under Part A, Part B and Part D of Medicare, and to clarify coverage for specific Part D products/drugs/categories. 

We also shared billing scenarios, which will help you to determine which part of Medicare covers a drug in a particular situation, assuming all other requirements are met, e.g., a drug must still be medically necessary to be covered. This information is applicable to people in the Original Medicare Plan.

People who have a Medicare Advantage HMO or PPO Plan with prescription drug coverage get all their Medicare-covered health care from the plan, including prescription drugs.

Part A Hospital Insurance

People with Medicare who are inpatients of hospitals or skilled nursing facilities (SNF) during covered stays may receive drugs as part of their treatment. Medicare Part A payments made to hospitals and skilled nursing facilities generally cover all drugs provided during a stay.

Under the Medicare hospice benefit, people receive drugs that are medically necessary for symptom control or pain relief. Part B can pay hospitals and SNFs for most categories of Part B-covered drugs if a person does not have Part A coverage, if Part A coverage for the stay has run out, or if a stay is not covered.

Part B Medical Insurance 

Medicare Part B covers a limited set of drugs. Medicare Part B covers injectable and infusible drugs that are not usually self-administered and that are furnished and administered as part of physician service. If the injection is usually self-administered (e.g., Imitrex) or is not furnished and administered as part of a physician’s service, it may not be covered by Part B. Medicare Part B also covers a limited number of other types of drugs as shown in the attached chart.1 (Regional differences in Part B drug coverage policies can occur in the absence of a national coverage decision.

Part D Prescription Drug Insurance

Part D-covered drugs are defined as drugs available only by prescription, used and sold in the United States, and used for a medically accepted indication; biological products; insulin; and vaccines. The definition also includes medical supplies associated with the injection of insulin (syringes, needles, alcohol swabs, and gauze).

Certain drugs or classes of drugs, or their medical uses, are excluded by law from Part D coverage. While these drugs or uses are excluded from basic Part D coverage, drug plans may choose to include them as part of supplemental benefits, not covered by Medicare.

Medicare Drug Coverage Scenarios

Here below we shared billing scenarios, which would help you to determine which part of Medicare covers a drug in a particular situation (assuming all other requirements are met, e.g., a drug must still be medically necessary to be covered): 

• If Medicare is covering beneficiary’s stay in a hospital or skilled nursing facility, their drugs will be paid for under Medicare Part A. Part A will stop paying for the drugs when patients leave the hospital or skilled nursing facility or when their benefit runs out, whichever comes first. 
• If a beneficiary is in a Medicare-approved hospice program, Medicare Part A will pay for drugs for symptom control or pain relief. However, Medicare is not permitted to pay for prescriptions intended to treat the terminal illness. If the beneficiary joins a Medicare prescription drug plan (Part D), drugs unrelated to the terminal illness would be covered by that plan. For instance, if they need medicine to treat an infection unrelated to the terminal illness, it would be covered by the beneficiary’s Medicare prescription drug plan (Part D). 
• If the drugs are currently covered by Part B, they will continue to be covered by Part B. Beneficiary might join a Medicare drug plan (Part D) to help pay for other drugs that which beneficiary might be taking that are not currently covered by Part B. 
• If a beneficiary is living in a long-term care facility, any medications they receive under the DME benefit such as nebulizer drugs for lung disease will no longer be covered since that benefit by law is only for services delivered in the home. If they have Medicare prescription drug coverage (Part D), their plan may cover those prescriptions. For this purpose, long-term care facilities include skilled nursing facilities (after Part A coverage is exhausted or for stays not covered by Medicare), nursing homes that give skilled care, and institutions that give skilled care.
• Please note that if Part A or Part B would cover the prescription drug as it is prescribed and dispensed or administered, that drug will not be paid for by the Medicare drug plan (Part D). 

Medical Billers and Coders (MBC) is a leading revenue cycle company providing complete medical billing services. We shared applicable billing information on drug coverage for original Medicare for provider education purposes.

To know more about ‘Medicare Drug Coverage Under Part A, Part B, and Part D’ you can refer to the CMS document. For any assistance required for Medicare billing, contact us at info@medicalbillersandcoders.com / 888-357-3226

FAQs

1. Which Medicare Parts cover prescription drugs?

Medicare Part A and Part B cover certain drugs in specific situations (e.g., during inpatient stays), while Medicare Part D covers outpatient prescription drugs.

2. What drugs are covered under Medicare Part A?

Part A covers drugs provided during inpatient hospital stays, skilled nursing facility care, or under the hospice benefit for symptom control or pain relief.

3. What types of drugs are covered by Medicare Part B?

Medicare Part B covers injectable and infusible drugs administered by a physician, as well as a limited set of other medically necessary drugs.

4. What is covered by Medicare Part D?

Part D covers prescription drugs, including insulin, vaccines, biological products, and medically necessary supplies for drug administration, but excludes certain drugs by law.

5. How do billing scenarios determine Medicare drug coverage?

Depending on the patient’s situation, such as being in a hospital or hospice care, different Medicare parts (A, B, or D) may cover the prescribed drugs, with coverage based on medical necessity and the setting of care.

The post Determining Drug Coverage for Original Medicare appeared first on Medical Billing and RCM Blogs.

Medicare requires SNFs to issue the SNF Advanced Beneficiary Notice of Non-coverage to Original Medicare, also called fee-for-service (FFS), beneficiaries prior to providing care that Medicare usually covers, but may not pay for in this instance because the care is not medically reasonable and necessary; or considered custodial.

The SNFABN provides information to the beneficiary so that s/he can decide whether or not to get the care that may not be paid for by Medicare and assume financial responsibility. SNFs must use the SNFABN when applicable for SNF Prospective Payment System services (Medicare Part A).

SNFs will continue to use the ABN Form CMS-R-131 when applicable for Medicare Part B items and services.

Form Filling Instructions for SNF Advanced Beneficiary Notice

The SNFABN has 5 sections for completion i.e., header, body, option boxes, additional information, and signature & date.  Failure to use this notice or significant alterations of the SNFABN could result in the notice being invalidated and/or the SNF being held liable for the care in question.

Header

The header of SNFABN includes SNF information, patient name, and identification number. 

• The SNF must include the SNF’s name, address, and phone number, at a minimum. A TTY number should be included when necessary to meet a beneficiary’s needs. Adding the SNF’s email address, additional contact information, and/or corporate logo is optional. 
• SNFs must enter the first and last name of the beneficiary receiving the notice, and a middle initial should be entered if there is one on the beneficiary’s Medicare card. The SNFABN will still be valid if there’s a misspelling or missing initial, as long as the beneficiary or their authorized representative recognizes the name listed on the notice. 
• Entering an identification number is optional, and the SNFABN is valid if this space is left blank.  SNFs may insert an internal filing number (such as a medical record number) that might help link the notice with a related claim. Medicare numbers (i.e., Health Insurance Claim Numbers) or Social Security numbers must not be listed on the notice.

Body

• In the blank that follows “Beginning on…,” the SNF enters the date on which the beneficiary may be responsible for paying for care that Medicare isn’t expected to cover.
• In the ‘Care’ section, the SNF lists the care that it believes may not or won’t be covered by Medicare. The description must be written in plain language that the beneficiary can understand. The care can be listed as “inpatient stay at this facility,” for example.
• The SNF must give the applicable Medicare coverage guideline(s) and a brief explanation of why the beneficiary’s medical needs or condition do not meet Medicare coverage guidelines. The reason must be sufficient and specific enough to enable the beneficiary to understand why Medicare may deny payment.
  • Example: Beneficiary no longer requires skilled care but wants to continue residing in the SNF. The reason Medicare May Not Pay: You need only assistive or supportive care. You don’t require daily skilled care by a professional nurse or therapist. Medicare won’t pay for your stay at this facility unless you require daily skilled care.
• In the “Estimated Cost” section, the SNF enters the estimated cost of the corresponding care that may not be covered by Medicare. The SNF should enter an estimated total cost or a daily, per item, or per service cost estimate. SNFs must make a good-faith effort to insert a reasonable cost estimate for the care. The lack of a cost estimate entry on the SNFABN or an amount that is different than the final actual cost charged to the beneficiary does not invalidate the SNFABN. 

Option Boxes

There are 3 options listed on the SNFABN with corresponding checkboxes. The beneficiary must check only one option box. If the beneficiary is physically unable to make a selection, the SNF may enter the beneficiary’s selection at his/her request and indicate on the notice that this was done for the beneficiary.  Otherwise, SNFs are not permitted to select or pre-select an option for the beneficiary as this invalidates the notice. 

Additional Information

SNFs may use this space to clarify and/or provide any additional information they think might be helpful to the beneficiary.  For example, SNFs may use this space to include:

• information on other insurance coverage, such as a Medigap policy, if applicable;
• an additional dated witness signature; or
• other necessary notes.

Information in this section will be assumed to have been made on the same date the SNFABN is issued.  If the notes are made on different dates, include those dates in the notes. 

Signature and Date

The beneficiary or their authorized representative must sign the signature box to acknowledge that they read and understood the notice. The SNF may fill in the date if the beneficiary needs help. This date should reflect the date that the SNF gave the notice to the beneficiary in person, or when appropriate, the date contact was made with the beneficiary’s authorized representative by phone. If an authorized representative signs for the beneficiary, write “(rep)” or “(representative)” next to the signature. 

MedicalBillersandCoders (MBC) is a leading revenue cycle company providing complete medical billing services. We can assist you in receiving accurate reimbursement for your skilled nursing facility (SNF) from Medicare, Medicaid, and even private payers also. To know more about our medical billing services for SNFs, contact us at info@medicalbillersandcoders.com/ 888-357-3226.

FAQs:

1. What is the purpose of the SNFABN?

The SNFABN informs beneficiaries that Medicare may not cover certain services, allowing them to decide if they want to proceed and accept financial responsibility.

2. When should the SNFABN be issued?

The SNFABN must be issued before providing care that Medicare usually covers but might not pay for in specific cases, such as when care is deemed custodial.

3. What should be included in the header of the SNFABN?

The header must include the SNF’s name, address, phone number, and the beneficiary’s name. An optional identification number can be included.

4. What should be detailed in the ‘Body’ section of the SNFABN?

This section should describe the care that may not be covered, provide Medicare coverage guidelines, and offer a brief explanation of why Medicare may deny payment.

5. How should the ‘Signature and Date’ section be completed?

The beneficiary or their representative must sign to acknowledge receipt and understanding of the notice. The date should reflect when the notice was given or communicated.

The post Instructions for SNF Advanced Beneficiary Notice of Non-coverage (SNFABN) appeared first on Medical Billing and RCM Blogs.