Effective billing and coding practices are essential for generating revenue in your skilled nursing facility. It ensures operational efficiency and financial stability. As a provider, you must understand the SNF billing and coding guidelines to ensure accurate reimbursements for the services rendered. 

Take a closer look at the guidelines to ensure indisputable revenue cycle management within your facility. 

SNF Medicare Coverage Requirements

The Centers for Medicare & Medicaid Services (CMS) state that for Part A coverage of SNF services to be available to traditional Medicare participants, they need to meet three requirements. 

1. The beneficiary must stay at the facility for three consecutive days. However, the time spent in observation, or an emergency room will not be counted in these necessary three-day stay requirements.
   
   
2. The patient is transferred within 30 days of post-hospital discharge to a skilled nursing facility certified by Medicare. Within 30 days of being released from the hospital, the patient is moved to an SNF that has Medicare certification. If the patient's condition makes it medically unsuitable to begin active treatment, if SNF care is anticipated at the time of release within a set time frame, and if the patient is admitted for care within the projected time, then this rule might not be enforced.
   
   
3. If outpatient care is not available, there is a problem with transportation, or it is required for diagnosis and treatment, daily inpatient SNF may result. 

Swing Beds Rule

The Social Security Act permits certain small, rural facilities to incorporate a small swing bed agreement, under which the facilities can use these as beds, as needed, to provide care. 

According to the regulations, a swing bed hospital is any hospital or critical access hospital (CAH) that accepts Medicare and satisfies specific conditions to be approved by CMS to offer post-hospital SNF treatment. Post-hospital extended care services provided in a swing bed hospital are covered by Medicare Part A, the hospital insurance program. 

SNF Services Billing

Medicare Part A pays for services rendered in licensed nursing facilities and non-CAH swing bed facilities per diem through the SNF Prospective Payment System (PPS). Reimbursement for CAH swing bed services is calculated at 101 percent of reasonable cost. 

All physical, occupational, and speech therapy services received during a non-covered stay, as well as the whole package of care during a covered Part A stay, are billed consolidated to the SNF. If Part A covers the patient's stay, the following services are not included in the consolidated billing arrangement and must be billed separately:

• Physician professional services
• Certain dialysis-related services
• Certain ambulance services
• Certain chemotherapy drug and administration services
• Radioisotope services
• Customized prosthetic devices 

Medicare patients in a non-covered stay are only liable to aggregated billing for treatment services. You may bill each covered SNF service separately. 

When a visit is not covered by Part A for any reason, Medicare Part B is invoiced (consolidated billing rules are not applied). Part B pays for certain services given to patients receiving treatment in an SNF when Part A coverage has run out or they are otherwise not eligible for Part A payment. It also covers outpatient hospital services to non-SNF patients, services excluded from SNF PPS, and consolidated billing. 

Requirements of Claim Forms in SNF Billing

The list of Healthcare Common Procedure Coding System (HCPCS) codes that can be independently billed to Medicare Part B and are not covered by SNF Medicare Part A consolidated billing (CB) rules have been updated, according to the Centers for Medicare and Medicaid Services (CMS). It is recommended that provider billers evaluate the revisions, which take effect on October 1, 2024. 

The CB exclusions were expanded to include seven codes falling within the main categories of blood clotting factors, specialized prosthetic devices, and chemotherapy. During an SNF Part A stay, one code under the chemotherapy major category will no longer be reimbursed separately because it was removed from the exclusion list. 

HCPCS Codes for Consolidated Billing Enforcement in Skilled Nursing Facilities

The quarterly update of HCPCS codes should be followed by SNFs, and other providers billing Medicare Administrative Contractors for services they provide to Medicare patients.

Providers must make sure their staff knows about

• Updated HCPCS codes subject to the CB provision of SNF
• Chemotherapy, specially made prosthetics and blood clotting agents added or removed from Medicare Part A and Part B SNF files

Conclusion

Understanding and implementing accurate coding guidelines can significantly improve your SNF billing services. This can help ensure proper reimbursement and reduce the risk of audits or denials. It is important to stay updated on any changes to coding regulations to maintain compliance and maximize revenue for your facility. Thus, it will ensure you accurate reimbursements for rendered services. A strategic approach toward your facility’s operation can boost the organizational performance, credibility, and integrity of your services. By following coding guidelines, you can also minimize the risk of audits and potential financial penalties. This will ultimately lead to a more efficient and profitable SNF billing process.