Qualifying stay or benefit days
Claims deny when the three-day inpatient stay is missing, was observation only, or benefit days are exhausted. We verify the hospital stay type and remaining days at admission and track benefits exhaust dates.
Home / Specialties / Skilled Nursing Facility
Skilled nursing facility billing services
Skilled nursing billing pays a per-diem rate set by the MDS assessment under PDPM, so a late or inaccurate assessment changes revenue before the claim exists. Whether a claim pays depends on the qualifying hospital stay, the benefit days remaining, consolidated billing compliance and matching the HIPPS code to the assessment on file.
What makes skilled nursing billing different
Facility billing under PDPM is driven by assessments, benefit periods and bundling rules that physician billers rarely encounter.
- Part A stays bill on type of bill 21X with a five-character HIPPS code from the 5-day MDS, and an Interim Payment Assessment can change the code mid-stay; a missed assessment window forces the default code.
- Medicare requires a three-day qualifying inpatient hospital stay reported with occurrence span code 70, admission within thirty days of discharge and daily skilled need, with coinsurance beginning on day twenty-one of the benefit period.
- Consolidated billing means most services during a Part A stay, including therapy, drugs and many outpatient procedures, are bundled into the SNF payment, and outside providers must bill the facility rather than Medicare.
- Part B therapy for residents not in a covered stay bills on 22X with GP, GO or GN modifiers, the KX modifier once the annual threshold is passed, and units reported under the 8-minute rule for timed codes.
Denials we see most in skilled nursing
Every denial gets a root cause, a fix and a feedback loop, so the same denial stops coming back.
HIPPS does not match MDS
A HIPPS code that differs from the accepted assessment, or an assessment submitted late, returns or pays at the default rate. We reconcile every claim to the MDS before billing and monitor assessment deadlines.
Medicare Advantage authorization lapses
MA plans authorize skilled stays in short blocks and deny days delivered after the authorization ends. We track authorization end dates, submit continued stay requests early and appeal with the therapy and nursing record.
How Core MB bills for skilled nursing
Core MB bills skilled nursing as a census-driven process: admission verification, MDS reconciliation, triple-check before Part A claims release, consolidated billing review and Part B therapy tracking run monthly. Credentialing for medical directors, physicians and nurse practitioners runs in the same client portal. Credentialing for new providers runs in the same system, tracked live in your client portal.
- Monthly triple-check of HIPPS codes, assessment dates, occurrence codes and therapy minutes before each Part A claim.
- Consolidated billing review of outside invoices so bundled services are paid to vendors and excluded services are billed correctly.
- Medicare Advantage authorization calendars with continued stay requests and NOMNC timing tracked per resident.
Everything in the service
Facilities get the complete revenue cycle from Core MB, from admission verification and Part A and Part B claims through consolidated billing, denials, resident statements and reporting by payer.
- Insurance verification and eligibility checks
- Charge entry and specialty-specific coding review
- Claim scrubbing and electronic submission
- Payer follow-up on every open claim
- Denial management and appeals
- Payment posting and reconciliation
- Accounts receivable recovery
- Patient statements and balance support
- Monthly reporting you can read in five minutes
- Provider credentialing and payer enrollment
Skilled nursing billing questions
What happens when the 5-day MDS is submitted late?
When the assessment is late or missing, the days it should have covered are billed with the default HIPPS code at the lowest rate until a valid assessment is in place. We monitor assessment reference dates with the MDS team and hold affected claims until the assessment is accepted so revenue is not written down unnecessarily.
Why do outside providers keep billing Medicare directly for our residents?
Under consolidated billing, services for a Part A resident are the facility's responsibility and Medicare rejects direct claims from the outside provider for bundled services. We maintain a list of excluded services, communicate stay status to vendors and pay or reject their invoices against the bundling rules.
How is an interrupted stay billed?
When a resident leaves and returns to the same facility within three days, the stay continues on the original assessment schedule and variable per diem counts rather than starting over. A longer absence creates a new stay with a new 5-day MDS. We apply the interrupted stay rules to the claim dates and assessment schedule for each readmission.
How do we get started with Core MB for skilled nursing billing?
Send us your bed count, average Medicare and Medicare Advantage census and current billing setup through the quote form and we will reply with a written proposal. Transitions run alongside your current billing so no claim cycle is missed, and credentialing for facility physicians and nurse practitioners can start at the same time.
More in facilities and ancillary care
Per-diem claims that match the assessment every month
Tell us about your census and payer mix and we will show how Core MB runs triple-check, consolidated billing and authorization tracking for your facility.