Specialty
Skilled nursing billing services
Skilled nursing billing services keep two claim streams straight for one building.
See where claims are getting stuck. No patient data needed.
Under Part A, the facility bills a monthly 21X claim with revenue code 0022 and a PDPM HIPPS code that must match the assessment the state accepted, with the qualifying hospital stay and any interrupted stay coded the way the contractor expects. Under Part B, the same office bills therapy for residents not in a covered stay, because consolidated billing makes the facility the only one allowed to bill it. Remitwright gives SNF billing offices a dedicated biller who runs both streams by date, files the benefits exhaust and no-pay bills that keep the benefit period straight, and works denials to the cause.
Skilled nursing billing is one of Remitwright's specialty billing services, each set out with its own code families, denial reasons and payer rules.
Last reviewed by the Remitwright billing team. Editorial policy
- 0022
- 018
- 042
Denials
Why skilled nursing claims get denied
The reasons that come up most on skilled nursing remittances, with the usual cause and the fix. Code explanations are our own; the official list is maintained by X12.
| Code | Reason | Usual cause | The fix |
|---|---|---|---|
| CO-16 | Claim data missing or wrong | The HIPPS code on the 0022 line does not match the code on the state's Final Validation Report, or the claim went out before that report arrived; a continuing-stay claim sent before the prior month finalized is returned rather than paid | Claims released only after the validation report is in hand, with the report's code used when it differs from what was submitted, and a sequence check per resident before each month's run |
| CO-96 | Qualifying stay or 30-day window not met | Observation or emergency room time counted toward the three-day inpatient stay, or the resident arrived more than 30 days after hospital discharge without an exception | Inpatient admission and discharge dates confirmed with the hospital before admission and entered as occurrence span code 70, with the 30-day transfer window checked against the SNF admission date |
| CO-119 | Covered SNF days used up | Days billed as covered after the 100th day of the benefit period, or a benefits exhaust bill skipped so the common working file still shows days remaining when it should not | Benefit days tracked per resident from the eligibility response, benefits exhaust bills filed monthly, and Part B 22X claims held until the exhaust claim has processed |
| CO-97 | Bundled to the facility's Part A claim | An outside supplier, lab or therapy company billed Part B for a resident in a Part A stay, the contractor bundled the service to the facility, and the vendor is now billing the facility under the arrangement | Every vendor told which residents are in a Part A stay and when it ends, with services furnished under arrangements captured on the facility's claim |
| CO-18 | Duplicate or overlapping dates | Claim dates overlap a hospital inpatient claim because an interrupted stay was not reported with occurrence span code 74 and leave days, or a return within three days was billed as a new admission | Admission, discharge and return dates reconciled against the census before billing, with the interruption window applied the way the manual describes |
| CO-50 | Not medically necessary | The record does not show a skilled service needed and delivered on a daily basis, or the physician certification or recertification is missing or unsigned | Certification dates on the admission calendar, and therapy frequency checked against the daily requirement before the claim is released |
Codes
Common skilled nursing codes and modifiers
Code families by number with our own one-line explanations. CPT descriptors belong to the AMA and are not reproduced here.
| Codes | What the codes cover |
|---|---|
| Type of bill 21X with revenue code 0022 | The Part A inpatient claim, billed monthly and in sequence, with one 0022 line for each HIPPS code and assessment period that applies to the covered days. |
| Occurrence span code 70 and condition code 57 | The dates of the qualifying hospital stay, and the flag that the resident had Medicare-covered skilled care within the previous 30 days. |
| PDPM HIPPS code, five characters | Position one is the physical and occupational therapy group, two the speech-language pathology group, three the nursing group, four the non-therapy ancillary group, five the assessment indicator. ZZZZZ is the default code that pays the lowest per diem when the assessment is late. |
| Revenue code 018x with occurrence span code 74 | Leave of absence days and the from and through dates of an interrupted stay, reported as non-covered so a short absence is not turned into a new admission. |
| Revenue codes 042x, 043x, 044x | Physical, occupational and speech-language therapy. On the Part A claim the units are calendar days on which therapy was given, not minutes or visits. |
| Type of bill 22X and 23X | Inpatient Part B for residents who are not in a covered Part A stay, which is where therapy must be billed under consolidated billing, and outpatient Part B for people in a part of the building that is not Medicare-certified. |
Claim codes and fields that matter
- Occurrence span code 74
- Not a modifier but the way an interrupted stay is shown. Use it for any interruption of more than one day, with the day the resident left as the from date and the last day the resident was out at midnight as the through date, and report the leave days on revenue code 018x with no charge.
- Condition code 57
- When a resident is readmitted within 30 days of a discharge bill. The resident is deemed not to have been discharged, no new qualifying hospital stay is needed, and the claim carries the current admission date plus occurrence span code 70 for the original hospital stay.
- Occurrence code 21 or 22 with condition code 20
- A demand bill. The facility believes the covered level of care has ended, the resident believes the services are still covered, and the claim goes in with condition code 20 so the contractor makes the coverage decision.
Payers
Payer notes
- MedicareUnder consolidated billing the facility must submit all Medicare claims for all services its residents receive under Part A, apart from the excluded categories, and for all physical, occupational and speech-language pathology services residents receive under Part B. A resident's status for this purpose ends on admission to a hospital, on receiving home health under a plan of care, on receiving one of the exceptionally intensive outpatient services, or on discharge without returning to a SNF before the following midnight.1
- MedicareThe services outside the bundle include physician professional services, the services of physician assistants, nurse practitioners, clinical nurse specialists, certified nurse-midwives, qualified psychologists and nurse anesthetists, mental health counselors and marriage and family therapists from January 1, 2024, dialysis and related services, hospice for the terminal condition, the initial and final ambulance trips, cardiac catheterization, CT, MRI, emergency services, radiation therapy and angiography, specified chemotherapy and radioisotopes, customized prosthetics and certain clotting factors from October 1, 2021. The facility cannot unbundle anything else to an outside supplier; it furnishes or arranges the service, bills Medicare itself and pays the supplier.3
- MedicareFor a resident who is not in a Part A stay, only therapy is subject to consolidated billing; every other covered service can be billed separately by whoever furnished it.2
- MedicareThe Patient Driven Payment Model has been the case-mix classification model for the SNF prospective payment system since October 1, 2019, with fact sheets on the variable per diem adjustment, the concurrent and group therapy limit and the administrative level of care presumption.4
- MedicareThe variable per diem adjustment applies only to the therapy and non-therapy ancillary components. The physical and occupational therapy factor is 1.00 for days 1 through 20 and then falls by 0.02 every seven days to 0.76 for days 98 through 100; the non-therapy ancillary factor is 3.0 for days 1 through 3 and 1.0 from day 4.5
- MedicareA resident in a covered stay who leaves and returns to the same facility no later than 11:59 pm on the third consecutive calendar day is in the same stay: no new assessments are required and the variable per diem does not reset. A return after that window, or to a different facility, is a new stay with a new five-day assessment and a reset schedule.1
- MedicareRepetitive Part B services are billed on one monthly claim, and Part B rehabilitation services are billed by the facility for Part A inpatients, for Part B residents and for outpatients, paid under the physician fee schedule.6
- MedicareCoverage requires a medically necessary inpatient hospital stay of at least three consecutive calendar days, with observation and emergency room time not counting, transfer to the facility within 30 days of hospital discharge, and skilled services needed on a daily basis; therapy at least five days a week meets the daily test.7
- MedicareThe FY 2027 final rule raised SNF payment rates by 2.4 percent, a 3.3 percent market basket less a 0.9 percentage point productivity adjustment, an estimated 882.74 million dollars in aggregate, and extended the MDS data submission requirement to all residents regardless of payer.8
Authorizations
Original Medicare has no prior authorization for a skilled nursing stay. Its gates are the qualifying hospital stay, the 30-day transfer window, a skilled need on a daily basis, the physician certification and recertification, and an assessment schedule under PDPM of one five-day assessment per stay plus an optional interim payment assessment when the resident's condition changes. Medicare Advantage plans authorize the admission and then the continued stay in blocks of days, and Medicaid long-term care after the Medicare days end follows the state's level-of-care determination and its own forms. Your biller keeps the Medicare gates and the plan authorizations on one calendar per resident, with the next date that needs action at the top.
Documentation traps
- Hospital observation days counted toward the three-day stay because the facility only saw the hospital's dates, not the inpatient order
- The Final Validation Report never pulled, so the facility bills the HIPPS code it submitted rather than the one the state calculated and accepted
- Therapy minutes documented carefully while the Part A claim carries the wrong number of calendar days on revenue codes 042x through 044x
- A short hospital stay recorded as a discharge and a new admission, which resets the assessment schedule and the variable per diem when the manual says it should not
- Physician certification and recertification signatures missing or dated after the claim, which leaves the covered days undefended on review
- Benefits exhaust and no-pay bills skipped after day 100 or after skilled care ends, so the common working file shows the wrong benefit period at the next admission
What a specialist checks
Specialist or generalist for skilled nursing billing?
A generalist biller can enter a skilled nursing claim. Whether it pays turns on three things specific to skilled nursing billing, and a specialty-aware biller checks each one.
Billing codes
Each code reported with what the record has to show for it.
- Type of bill 21X with revenue code 0022
- Occurrence span code 70 and condition code 57
- PDPM HIPPS code, five characters
Claim codes and fields
Each one reported only where the record supports it.
- Occurrence span code 74
- Condition code 57
- Occurrence code 21 or 22 with condition code 20
If you are moving from another billing company or an in-house biller, switching billing companies follows a plan: the old and new processes run side by side until the new one is proven, and every login and every skilled nursing claim stays in your name.
What we handle
What we handle for skilled nursing facilities
- Eligibility verificationCoverage and benefits checked before visits
- Claim submissionScrubbed, submitted and tracked to acceptance
- Payment postingERAs and EOBs posted, variances flagged
- Secondary claims billingSecondary and tertiary claims, tracked
- Denial managementEvery denial read, worked and appealed
- A/R follow-upUnpaid claims chased before filing limits
A dedicated biller with named cover, working inside your system and reporting to you on one written page. How it works sets out the five stages.
Software
Systems skilled nursing facilities usually run
- PointClickCare
- MatrixCare
- Netsmart
Your biller works inside your system as a user you create. All the systems we work in.
Questions
Questions about skilled nursing billing
Do you provide SNF billing services for the facility or for the physicians who round there?
For the facility's billing office. Physician professional services are excluded from consolidated billing and are billed by the practitioner to the Part B contractor; the facility bills the technical component of any test it arranges. Your biller works the Part A and Part B streams, the benefits exhaust and no-pay bills, and the Medicaid and coinsurance claims that follow. Your biller does not complete the MDS or write any clinical documentation; that stays with your nurse assessment coordinator and clinicians.
What does consolidated billing mean for a skilled nursing facility?
During a Part A stay the facility is the only entity that may bill Medicare for the resident's care, apart from a list of excluded services such as physician visits, dialysis, hospice and the most intensive hospital outpatient services. Anything else an outside vendor provides is furnished under an arrangement with you, you bill it, and you pay the vendor. Therapy stays bundled to the facility even when the resident is not in a Part A stay, billed on a 22X claim.
What is the interrupted stay rule?
If a resident in a covered stay leaves Part A coverage and returns to the same facility by 11:59 pm on the third consecutive calendar day, the stay continues: no new assessment, no reset of the variable per diem, and the absence is reported with occurrence span code 74 and leave-of-absence days. Return on day four or later, or to a different facility, and it is a new stay with a new five-day assessment.
Why does the daily rate fall as the stay goes on?
Because of the variable per diem adjustment. The physical and occupational therapy components pay at a factor of 1.00 for the first 20 days and then step down by 0.02 every seven days, reaching 0.76 for days 98 to 100. The non-therapy ancillary component pays at three times its rate for the first three days and at its base rate from day four. Nursing and speech-language pathology do not change.
What do we bill after day 100?
A benefits exhaust bill every month for as long as the resident continues to receive skilled care, and again when the level of care changes, regardless of who is paying next. Once skilled care ends for a resident still in the certified area, monthly no-pay bills take over. Part B 22X claims for therapy go in only after the benefits exhaust claim has processed.
Which hospital days count toward the three-day stay?
Medically necessary inpatient days, counted from the calendar day of the inpatient admission, across one or more hospitals. Time in observation or the emergency room before or instead of an inpatient admission does not count. The resident must also arrive at the facility within 30 days of hospital discharge, with limited exceptions, and need care for a condition treated in the hospital.
How is therapy billed for a resident who is not in a Part A stay?
By the facility, on a type of bill 22X claim, under the physician fee schedule, with repetitive services grouped on one monthly claim. An outside therapy company cannot bill Medicare for it while the resident lives in the certified part of the building. If the resident moves to a non-certified area, the therapy provider may bill directly or the facility bills on a 23X claim.
What access does your biller need inside a skilled nursing facility?
A user account in your facility software, access to the contractor's direct data entry system and eligibility tool, and the state validation reports for MDS submissions, all under a signed BAA and worked remotely. From there your biller builds the per-resident calendar: qualifying stay dates, benefit days used, assessment status, certification dates and the next claim due.
Next step
See where your skilled nursing claims are getting stuck.
Three quick questions. No patient data. A billing specialist reads every request and replies in writing.
- Three questions, about two minutes
- No patient data, no software to buy
- A written reply from a biller, not a sales deck
You answer three questions
A billing specialist reads them
A written reply by email
Prefer email? sales@remitwright.com
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- A billing specialist reads your answers and replies by email.
- If a look at real claims makes sense, we agree read-only access under a BAA first.
- You get a written summary of what is worth working and what it would take. No commitment.
While you wait: see the sample weekly report or read how switching works. You can also download the sample weekly report (PDF).