Skilled Nursing Facility Revenue Cycle Management
Nursing home billing built for skilled nursing facilities
Medbilling RCM handles PDPM classification coding, MDS-to-claim alignment, consolidated billing compliance, and Medicare Advantage denial management for skilled nursing facilities across all 50 states. We run UB-04 institutional claims under one workflow, with PDPM component verification and Triple Check validation built into every submission. Book a free revenue assessment and we'll review 90 days of your SNF claims, denials, and AR aging before you sign anything.
5-day onboarding · All 50 states
Where nursing home billing breaks
Five revenue leaks hiding inside your SNF billing workflow
PDPM diagnosis driving wrong payment
The primary diagnosis on the MDS determines the PDPM clinical category for all five payment components. A misassigned ICD-10 code lowers the per diem rate on every Part A day the resident stays in the facility.
MDS sections undercoded on assessment
Nursing and NTA components are the most frequently undercoded on the MDS. ADL self-performance scores in Section G directly affect the Nursing payment rate, and missing comorbidities reduce the NTA per diem.
Ancillary billing outside the bundle
SNF consolidated billing requires that most Part A services are included in the per diem. When ancillary providers bill Medicare directly for covered services, the facility faces recoupment demands and compliance flags.
Coverage routing errors between parts
Covered SNF stays bill under Part A prospective payment, while non-covered days bill Part B for physician services. Wrong routing sends the claim to the wrong payment system and it rejects entirely.
MA authorization expired during stay
Medicare Advantage plans require concurrent authorization that expires on a set date. If the facility doesn't track the expiration and request an extension before coverage lapses, every subsequent day is denied retroactively.
The Nursing Home Billing Gap
Five-Phase Operating System
How the Revenue Control Framework runs for nursing homes
Nursing home billing breaks where PDPM classification meets consolidated billing rules. Wrong diagnosis category, wrong MDS section score, wrong ancillary routing. The Revenue Control Framework catches each one before the claim goes out.
Onboarding and payer setup
We pull your payer contracts, load the 2026 PDPM ICD-10 mapping file, and connect to your SNF system (PointClickCare, MatrixCare, or whichever you run) within 5 days. By day one, every PDPM component rule and consolidated billing exclusion is configured.
Eligibility and pre-auth prep
Before every Part A claim is released, we verify the qualifying hospital stay, confirm coverage status, and check authorization dates on every MA resident. We run the same clearance workflow that drives collections for our hospital billing partners.
Coding and charge capture
Certified coders assigned to your facility validate the PDPM primary diagnosis against the clinical record and verify ADL scores in MDS Section G. NTA comorbidity capture is confirmed before submission through our medical coding services.
Denial resolution and appeals
Denied claims get categorized by root cause within 48 hours. CO-50 medical necessity denials, CO-5 POS mismatch errors, and MA concurrent review rejections each follow a separate AR recovery path because batching SNF denials doesn't work.
Reporting and revenue tracking
Live dashboards track collections by payer, denial rates by CARC code, and PDPM case-mix accuracy per MDS assessment. You'll see which diagnosis categories underperform and which MA plans deny most frequently before the month closes.
nursing-home-billing-workflow.webp
560 × 500px · WebP
SNF billing specialist reviewing PDPM classification coding dashboard on dual monitors showing PointClickCare or MatrixCare interface with MDS assessment validation and Triple Check compliance queue. Professional billing office, warm lighting, no patient data. Documentary healthcare photography.
Nursing Home Coding Reference
Revenue and CPT codes we bill every resident
Every code here comes from skilled nursing encounters we bill weekly. We've verified each against AMA CPT 2026.
nursing-home-coding-dashboard.webp
1180 × 340px · WebP (wide)
Wide banner showing skilled nursing facility billing dashboard with PDPM case-mix accuracy tracker, HIPPS code validation queue, Part A vs Part B routing status, and Triple Check compliance dashboard. Professional SNF billing office, warm lighting. Wide landscape documentary style.
| Code | Description | Payer rule and documentation logic |
|---|---|---|
99304-99306 | Initial nursing facility visit by MDM | Bill on admission day. MDM level drives code selection, not time alone. |
99307-99310 | Subsequent nursing facility visit | 99310 reserved for unstable patients. Overuse triggers audit attention. |
0584 / 0585 | Revenue codes: Part A / Part B ancillary | Part A = per diem under PDPM. Part B = fee schedule for non-covered days. |
HIPPS codes | PDPM classification codes on Part A claims | Generated from MDS. Maps to 5 payment components. Drives the daily rate. |
96365-96368 | IV infusion therapy during covered stay | Included in consolidated billing unless on the exclusion list. Verify first. |
99217 | Observation discharge on day of discharge | Use when resident transitions from observation to SNF admission same day. |
G2211 | Complexity add-on for Part B office visits | Applies when physician serves as continuing focal point on non-covered days. |
97110-97542 | Therapy services (PT/OT/SLP) Part B days | Bill under Part B fee schedule on non-covered days. Part A bundles therapy. |
Nursing Home Denial Patterns
Four denial codes that cost nursing homes the most
These four denial codes, verified against the NCCI Policy Manual, drive the bulk of skilled nursing claim denials we see.
PDPM primary diagnosis doesn't support skilled level of care
Align ICD-10 to clinical record; verify against 2026 PDPM mapping file
POS code or modifier incompatible with billed service on claim
Verify POS 31 vs 32 assignment; check consolidated billing exclusion list
MA authorization expired or never obtained for the SNF stay
Track MA auth dates per resident; request extension before coverage lapses
Diagnosis on physician Part B claim doesn't match MDS primary
Match Part B diagnosis with MDS assessment; reconcile before claim release
Why does CO-50 hit nursing homes hardest? PDPM misclassification. The primary diagnosis on the MDS drives the clinical category that sets the daily rate across all five payment components. We onboarded a facility that wasn't validating PDPM diagnoses against the 2026 ICD-10 mapping file, generating clinical category misassignments that lowered the per diem on every Part A day per the X12 CARC code set. We loaded the updated mapping file and corrected the MDS coding in week one.
Division of Work
What your team handles versus what our team handles
We don't replace your clinical staff. We plug into your workflow and handle the billing side. Here's where the line sits.
System Compatibility
Works with the systems your nursing home runs
We don't ask you to switch platforms. Your SNF management system and clinical documentation software stay in place, and we build the billing workflow around them. Custom integrations get scoped during your revenue assessment.
Get a Free Revenue Assessmentnursing-home-pointclickcare.webp
600 × 520px · WebP
SNF administrator working in PointClickCare or MatrixCare showing PDPM classification dashboard, Part A vs Part B routing status, and MA authorization expiry tracker on dual monitors. Professional skilled nursing facility, warm lighting, no patient data. Documentary style.
Common Questions
What nursing homes ask before switching billing partners
Straight answers about PDPM coding, onboarding, pricing, and the compliance workflows that matter to your facility.
How do you validate PDPM classification accuracy?
We verify the primary diagnosis on every MDS against the 2026 CMS PDPM ICD-10 mapping file before the claim is released. If the diagnosis doesn't align with the clinical record, we correct the classification so the daily rate reflects the actual acuity of care. The Nursing and NTA components are checked separately because they're undercoded most often.
How do you handle consolidated billing compliance?
We maintain the current SNF consolidated billing exclusion list and verify every ancillary charge against it before submission. If a service is included in the Part A per diem, we flag it before an outside provider bills Medicare directly. That prevents recoupment demands and compliance violations.
How do you manage Medicare Advantage SNF denials?
We track authorization dates per resident and request extensions before coverage lapses. When a concurrent review denial comes in, we appeal with clinical documentation supporting skilled-level necessity. MA plans deny differently from Original Medicare, and the appeal process runs on their timelines, not CMS timelines.
How do you route claims between Part A and Part B?
Covered stays bill under Part A prospective payment through the PDPM classification. Non-covered days and post-benefit periods bill Part B for physician services under the fee schedule. We verify coverage status daily and route each claim to the correct payment system automatically.
What is the Triple Check and how do you run it?
The Triple Check validates clinical accuracy, financial accuracy, and compliance accuracy on every Part A claim before it's released. We don't treat it as a checkbox. Each exception gets clinical and billing review so the claim doesn't generate a first-pass denial that could've been caught.
How long does onboarding take for a nursing home?
Five days. We load the 2026 PDPM ICD-10 mapping file, configure the consolidated billing exclusion list, map Part A versus Part B routing rules, and connect to your SNF management system before we start processing claims.
Ready when you are
The free assessment is specific to your nursing home
We'll pull a sample of your SNF claims and show your top denial reasons by dollar, your PDPM case-mix accuracy per MDS assessment against classification benchmarks, and your aged AR by payer with filing window exposure. You keep the findings whether or not you work with us.
- PDPM diagnosis validation: primary ICD-10 against 2026 CMS mapping file per MDS
- MDS Section G ADL score audit: Nursing component payment support verification
- NTA comorbidity capture: billable comorbidity completeness per assessment
- Consolidated billing compliance: ancillary exclusion list verification
- MA authorization tracking: concurrent auth expiry and extension status
- No setup fees. No long-term contract.
Get a Free Revenue Assessment
Sources: CMS SNF PPS (FY 2026), AMA CPT (2026), X12 CARC (2026), NCCI Policy Manual (2026), RAI Manual, MGMA, BLS. All codes verified at publication.