Specialty billing / Skilled Nursing Facility
Skilled nursing billing depends on eligibility conditions established before the resident arrives and on assessments completed after admission. A qualifying hospital stay, available benefit days, an accurate MDS, and consolidated billing rules that make the facility responsible for services it did not order all shape whether a stay is paid correctly.
0
Years in revenue cycle
48h
Claim filing window
30d
Target days to payment
HIPAA
Compliant by design
Where it breaks
Medicare Part A skilled coverage generally requires a preceding qualifying inpatient hospital stay. Residents admitted after time spent in observation status do not qualify, and facilities frequently learn this only after providing weeks of skilled care.
Coverage runs for a limited number of days per benefit period with a coinsurance tier partway through. Without day-by-day tracking and timely notice to the resident, facilities deliver care that has already moved beyond the covered period.
Most services furnished to a Part A resident must be billed by the facility, including many therapies and supplies provided by outside vendors. Outside claims are denied, the vendor bills the facility, and the cost was never captured in the rate.
Payment classification is driven by the MDS. Late assessments, missed assessment windows, or documentation that does not support the clinical categories coded change the payment group and create liability under review.
Frequently billed
Representative codes only. Actual coding follows current CPT/HCPCS guidance and payer policy.
Denials we prevent
FAQ
Medicare Part A skilled nursing coverage generally requires a medically necessary inpatient hospital stay of at least three consecutive days, not counting the discharge day. Time spent under observation status does not count toward that requirement, even when the patient occupied a hospital bed. Confirm inpatient status, not just the length of the hospitalization.
A benefit period begins with an inpatient admission and ends after the beneficiary has been out of a hospital or skilled facility for 60 consecutive days. Coverage within the period is limited, with full coverage for an initial span and daily coinsurance after. Tracking day counts per resident prevents billing beyond the covered period.
Under Part A, the facility receives a bundled payment and must bill for most services furnished to the resident, including many provided by outside suppliers and therapists. Those vendors cannot bill Medicare directly. When a vendor's claim is denied, the cost returns to the facility, so vendor arrangements must be identified at admission.
The assessment classifies the resident into a payment group based on clinical characteristics and care needs. Assessments completed late, outside the required window, or with categories the clinical record does not support change the payment and create exposure on review. Assessment accuracy is a revenue function, not only a clinical one.
Yes, and their rules differ substantially from traditional Medicare. Many require authorization before admission, apply their own level of care criteria, and conduct concurrent review with the ability to end coverage mid-stay. We manage those authorizations and reviews so coverage decisions are known before the days are delivered.
Other specialties
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