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Skilled nursing facility billing under PDPM
Medicare Part A, Part B, Medicaid and managed care billing for SNFs, built on accurate MDS assessments, HIPPS codes and consolidated billing rules.
How skilled nursing billing works
Medicare Part A pays SNFs under the Patient Driven Payment Model (PDPM). Each stay’s payment comes from HIPPS codes generated by MDS assessments, so billing accuracy starts with assessment timing and coding, especially ICD-10-CM diagnoses that drive the PDPM components.
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Part A stays are billed on institutional claims (type of bill 21x), while Part B services for long-term residents use type of bill 22x.
Codes we bill every day
| Code | What it covers |
|---|---|
| TOB 21x | SNF inpatient (Medicare Part A) |
| TOB 22x | SNF inpatient Part B services |
| HIPPS | PDPM payment groups from the MDS 5-day and other assessments |
| Rev 0022 | SNF PPS revenue code with HIPPS |
| Occurrence span 70 | Qualifying inpatient stay dates |
Code descriptions are summarized. Payer coverage and documentation rules vary by plan and state.
Denials we prevent
- Missing or late MDS assessments that change the HIPPS code
- Qualifying 3-day inpatient stay not documented
- Consolidated billing items billed separately by outside suppliers
- Benefit days not tracked (coinsurance days 21–100)
- Medicare Advantage plans billed with Part A rules instead of plan rules
Payer rules to watch
Original Medicare covers up to 100 SNF days per benefit period, with daily coinsurance from day 21. Medicare Advantage plans set their own authorization and payment rules, and many pay per diem rates negotiated in your contract.
Questions about skilled nursing billing
Do you work with our MDS coordinator?
Yes. We review assessment dates and HIPPS codes with your MDS team before claims go out.
Do you bill Medicaid long-term care?
Yes, including state Medicaid room-and-board claims and patient liability.
Get a free skilled nursing billing audit
Send a few details and we will set up a short call to review your claims, denials and A/R. No cost and no commitment.
We sign a Business Associate Agreement before we handle any patient data.