SNF RCM

SNF Billing: PDPM, MDS Integrity & Medicare Part A/B Coordination

From MDS 3.0 accuracy to consolidated billing exclusions and Part A exhaustion handoffs, our SNF-specialized team protects per-diem revenue while keeping compliance audit-ready.

99.0% MDS Accuracy Rate
20% Average Reimbursement Lift
19 Days Average Days in AR
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The Challenge

Why SNF Billing Requires Specialists

PDPM case-mix, MDS 3.0 coding, 3-day qualifying stays, Part A/B transitions, consolidated billing exclusions, and HIPPS generation all interact inside a single SNF stay. Generic billers miss the compounding.

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PDPM Case-Mix

Five components (PT, OT, SLP, Nursing, NTA) plus variable per-diem adjustments drive reimbursement. Every MDS field feeds the HIPPS code, we audit before lock.

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MDS 3.0 Integrity

Section GG functional scoring, Section I diagnosis coding, Section K nutrition, and Section O therapy minutes each cascade into case-mix placement. Our RAC-CT reviewers audit every scheduled MDS.

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3-Day Qualifying Stay

Medicare Part A SNF coverage requires a 3-midnight inpatient hospital stay. Observation status does not count. We verify every qualifying stay before billing.

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Part A/B Split Billing

When Part A exhausts at day 100 or benefit criteria end, billing shifts to Part B for therapy, drugs, and other services. We manage the transition day-exactly.

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Consolidated Billing

During Part A stays, SNFs bill for nearly all services, with a short excluded list (chemo, dialysis, certain drugs). We manage the exclusion list and outside-provider contracts.

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HIPPS Generation

5-character HIPPS codes must match MDS data and CMS grouper logic. We generate HIPPS and verify UB-04 placement before submission.

Our Approach

SNF-Certified Billing From Admission to Discharge

Our SNF RCM team includes RAC-CT certified MDS reviewers, CPC-certified coders specializing in long-term care, and compliance specialists who understand PDPM transmittals, CMS survey rules, and OIG focus areas.

  • Pre-lock MDS review for every 5-Day, IPA, and Discharge assessment
  • PDPM HIPPS audit with case-mix component verification
  • 3-day qualifying stay verification before Part A claim submission
  • Part A exhaustion tracking with automatic Part B transition
  • Consolidated billing exclusion management including outside-provider coordination
  • Triple-check process aligning MDS, clinical records, and UB-04 before billing
Skilled nursing facility staff caring for resident
20% Average Reimbursement Lift
99.0% MDS Accuracy
95% First-Pass Resolution
19 Days Average Days in AR
Compliance & Security

HIPAA-Compliant SNF Billing Operations

SNF data includes MDS assessments, clinical observations, and resident financial records. Our operations align with HIPAA, ISO 27001, and HITRUST CSF.

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HIPAA & SNF CoPs

All PHI lives inside encrypted, access-controlled systems with audit trails. Our team is trained on SNF Requirements of Participation and survey-readiness documentation standards.

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ISO 27001 & HITRUST

Information security management aligned with ISO/IEC 27001 and HITRUST CSF. Continuous monitoring, least-privilege access, and documented incident response protect SNF data.

FAQ

SNF Billing Questions Answered

Related Services

Billing & AR Medical Coding Denial Management Eligibility & VOB Prior Authorization
The Patient-Driven Payment Model (PDPM) replaced RUG-IV in 2019, paying SNFs based on five case-mix components, PT, OT, SLP, Nursing, and NTA (Non-Therapy Ancillary), plus variable per-diem adjustments that decrease over the stay. MDS 3.0 Section GG, diagnosis coding, and comorbidity capture directly drive HIPPS codes. We audit every MDS before lock to ensure accurate PDPM case-mix placement.
MDS 3.0 is the single largest determinant of PDPM reimbursement. Errors in Section GG functional scores, Section I diagnoses, Section O therapy minutes, or Section K nutritional approach cascade into the wrong HIPPS code and often tens of thousands in lost revenue per stay. Our RAC-CT certified reviewers audit every scheduled MDS (5-Day, IPA, Discharge) before lock.
Medicare Part A SNF coverage requires a qualifying inpatient hospital stay of at least 3 consecutive midnights (not counting the day of discharge) immediately preceding SNF admission. Observation status does not count. We verify admission records, UB-04 Type of Bill 111, and discharge documentation before billing. Invalid qualifying stays cause full-claim takebacks.
During a Part A stay, nearly all services (including therapy) are bundled into the per-diem. When Part A benefits exhaust (day 100) or the patient drops to skilled-but-not-Part-A status, billing shifts to Part B for therapy (97xxx codes), Part B drugs (J-codes), and other services. We manage the transition date-exactly, tracking benefit day counts and billing correctly on both sides.
Under consolidated billing, the SNF bills Medicare for nearly all services delivered during a Part A stay, including therapy, DME, imaging, and most drugs, even when those services are performed by outside providers. A short list of excluded services (chemotherapy, certain high-cost drugs, dialysis) can be billed directly by outside providers. We manage the excluded-service list and contract arrangements with outside providers.
SNF HIPPS codes under PDPM are five-character alphanumeric identifiers reflecting PT, OT, SLP, Nursing, and NTA case-mix groups. Our team generates HIPPS directly from locked MDS data and verifies placement against CMS grouper logic before UB-04 submission.
PDPM PT/OT case-mix weights decrease after day 20 (adjusted by 2% every 7 days), and NTA weights drop dramatically after day 3. We model expected reimbursement for the full length of stay and advise on care planning to optimize both patient outcomes and financial viability.
Yes. Medicare Advantage plans increasingly pay SNFs on contracted per-diem or case-rate terms rather than PDPM HIPPS. We manage MA authorization workflows, concurrent reviews, and discharge planning to prevent authorization gaps.
We integrate with PointClickCare, MatrixCare SNF, American HealthTech, SigmaCare, HealthMedx Vision, and NetSolutions. Our team configures MDS review workflows, HIPPS generation, and consolidated-billing exclusions inside your existing platform.
Related Specialties

Adjacent Post-Acute & Long-Term Care Specialties

Home Health ›

PDGM, OASIS, F2F, and NOA management for HHAs.

Hospice ›

Per-diem billing, levels of care, and NOE management.

Hospitals ›

Facility billing, DRG optimization, and transitions of care.

Physical Therapy ›

PT billing, 8-minute rule, and Medicare therapy threshold management.