Billing a Skilled Nursing Facility (SNF) in the United States includes the associated costs of a patient who needs skilled nursing or rehabilitation services after they have stayed in an acute care hospital. The patient must have had a minimally three days of hospitalization to bill for these services.
The SNF billing must also follow strict guidelines and necessary documentation to account for the room, nursing, rehabilitation, or any other medically indicated treatment performed during the patient’s stay.
The clinical coding must be done to accurately identify the services being ordered, along with meeting the standards of documentation, to comply with Medicare/Medicaid and any third-party payer. Patient-Driven Payment Model (PDPM) now relies on the needs and clinical characteristics of patients rather than therapy minutes for reimbursement. Quality and outcomes are prioritized over quantity, which puts great importance on assessment and documentation standards. Effective billing supports both financial health and high-quality patient care.
Services Covered in SNF Billing
1) Physical Therapy (PT):
Helps residents regain strength and balance and begin walking or moving after an illness or surgery. PTs carry out evaluations and develop care plans with the purpose of improving residents’ walking and movement.
2) Occupational Therapy (OT):
Daily tasks like dressing, eating, and bathing are covered in this therapy. OTs take expert knowledge and teach residents new ways of remaining independent utilizing adaptive tools or equipment. Billing is based on evaluations and treatment sessions being utilized for improving performance in daily function.
3) Wound Care:
The main function of wound care is to promote healing, and to prevent infection in the skin or deeper tissue. Wound care would typically involve nurses cleaning, dressing, and assessing wounds – examples of wound care are ulcers or postoperative wounds.
4) Intravenous (IV) Therapy:
IV therapy is when a medication or IV fluids are infused straight into that patient’s bloodstream. IV antibiotics, IV hydration, or IV for pain are few examples. Billing for the service is determined on the basis of set up, observation, and safely administering effective IV therapy.
5) Long-Term Rehabilitation:
If a patient has recovery needs over a long period of rehabilitation it is a service that can be provided. All would include physical therapy, occupational therapy, and speech therapy, and regardless of the therapy one goal would be the same, which is independence over time. Long-term care billing includes therapy sessions and ongoing care plans that are working towards a goal of independence.
6) Medication Management:
Medication management refers to the processes wherein patients can take their prescribed medications in a safe and effective manner. Nurses administer, ensure at the time of administration that a patient has no adverse reactions. Billing reflects all aspects of managing residents’ prescribed medications.
Skilled nursing care involves providing medical care that includes licensed nurses and 24-hour nursing support, including monitoring vital signs, administering injections, and post-operative care. The services provided are billed as medically necessary treatment and supervision.
Billing for SNF services is complicated. Payer regulations are frequently changing, and changes in the coding requirements make nursing home billing challenging. Coding errors, denied claims, and claims that are not submitted leads to lost revenue, cash flow issues, and increase in accounts receivable (A/R).
7) Maximizing reimbursement:
SNFs can receive reimbursements if coding is accurate coding along with proper documentation, and timely billing. To create efficiency in the revenue cycle, skilled nursing facilities need to embrace revised code and billing modifications. It will provide more time to spend with patients and less time on documentation.
8) Ensuring Compliance With Regulations
Compliance is vital. Errors can lead to fraud inquiries, penalties, audits, and denials of reimbursement claims. The skilled billing staffs will keep track of the most recent updates.
9) Proper Documentation
Documentation must explain why the assessment, treatment, and outcome of the treatment were necessary for the patient.
Examples of documents include:
- Patient’s medical history and physical examination reports
- Physician’s orders and assessments
- Evidence of medical need
- Discharge summaries and therapy progress notes
- Documentation that supports each billing code
Payers assess all documentation to verify the need and would support accurate coding. Providing standardized documentation reduces errors associated with coding and ultimately reduces denials of claims.
Importance of Prior Authorization
Prior authorization helps secure timely payment and full payment. The staffs will take into consideration the medical needs of the patient, input supporting documentation, and obtain authorization from the payer before the patient receives treatment.
If authorization is not secured it can lead to denial of claim for service and gaps in cash flow. Securing prior authorization early in the discharge process will improve the provider’s revenue cycle.
Benefits of SNF Billing Outsourcing
Outsourcing SNF billing cuts down on overhead expenses by relieving the in-house billing staff. With expert billing staffs, there is less room for error in claim submission and quicker returns on revenue. It leads to more time spent on patient care and drives efficiency, minimizes cost, and promotes steady growth. By outsourcing, the billing cost can be reduced by up to 80% with hourly rates starting as low as $7/hour.
