Navigating Medicare billing in Skilled Nursing Facilities (SNFs) can be a bit confusing. As a result, understanding when to bill Medicare Part A or Part B is one of the most significant tasks of SNF providers and billers.This procedure, also identified as split billing, guarantees that healthcare providers receive the maximum reimbursements without errors in the bills or rejection of claims.

There are strict rules associated with Medicare.When SNFs incorrectly code services or charge for the incorrect part, there might be cases of audits, withholding payment, or non-compliance issues. In this blog, we’ll explore the essentials of SNF split billing and how to stay compliant.

We’ll also explain how Outsource SNF billing and coding services providers is helping SNFs handle these tasks more efficiently.

What is Split Billing in SNFs?

Split billing means dividing Medicare billing between Part A and Part B, depending on the services provided and the patient’s eligibility. SNFs must determine which Medicare part applies to each service. If the billing is incorrect, it may result in a denial or duplicate payments – both of which can negatively impact the facility’s revenue.

Split billing is especially important when a patient’s Part A benefits have ended or when they are in the SNF for outpatient services. Understanding the rules helps avoid claim delays and improves split billing compliance for skilled nursing with CMS policies.

Key Differences: Medicare Part A vs. Part B in SNFs

Understanding the distinctions between Medicare Part A and Part B is essential. Let’s explore:

1. Type of Services and Billing Approach

Medicare Part A provides bundled payment coverage for inpatient treatments in skilled nursing facilities. During a qualifying stay, this covers lodging, meals, nursing care, and in-facility therapies. On the other hand, Medicare Part B covers outpatient services. These include doctor visits, diagnostic tests, and treatments that are given after Part A expires. CPT/HCPCS codes are used to bill each service under Part B separately.

2. Patient Eligibility and Coverage Limits

Medicare Part A billing requires a three-day inpatient hospital stay (excluding the discharge day), admission to a Skilled Nursing Facility (SNF) within 30 days, and the need for daily skilled care.The coverage is subject to a 100-day limit per benefit period. On the other hand, Medicare Part B does not require hospitalization and provides ongoing coverage for medically necessary outpatient services. To qualify, the patient must be enrolled in Part B and be responsible for deductibles and coinsurance.

3. Compliance and Claim Submission Differences

Part A claims are submitted by the SNF using a UB-04 form for bundled payments. But Part B claims are submitted using the CMS-1500 form by individual providers or the SNF for separate services. It is important to understand the correct form and process for each Medicare part is essential to ensure accurate claim submission, avoid denials, and maintain compliance with Medicare billing regulations.

Medicare Part A in SNFs: When is it Applicable?

Medicare Part A applies when a patient is admitted into a skilled nursing facility (SNF) following a qualifying stay in the hospital.Based on the Part A requirements, the patient must visit the hospital consecutively for three days. Additionally, the patient must be admitted to the SNF within 30 days of discharge. In addition, the services have to be classified into skilled and medically necessary care.Medicare Part A may provide coverage of up to 100 days, but with complete coverage of the first 20 days and partial benefit coverage thereafter, for every benefit period.

The covered Part A stay is paid through a bundled reimbursement that covers room and board, nursing, therapy, and selects in-house diagnostics in SNFs. Nevertheless, it is essential to regularly track the number of benefit days and the level of care provided to the patient. Billing errors and rejected claims may be the result of mistakes in eligibility verification. To prevent billing errors and ensure compliance with Medicare guidelines, careful attention to eligibility and documentation is necessary.

Medicare Part B in SNFs: When is it Applicable?

Medicare Part B comes into effect when either a patient in an SNF is not qualified to receive Part A or has surpassed the 100-day limit.It also applies where services are deemed as outpatient or not incorporable under Part A consolidated billing.Part B allows SNFs and external providers to bill individually on certain services, including visits to physicians, some therapy services, diagnostic tests, and durable medical equipment. It also covers ambulance services, certain preventive services, and mental health care when medically necessary.

Every service under Part B should be correctly coded and justified by medical necessity and must be billed individually. Unlike Part A, which is managed under consolidated billing, Part B billing requires strict adherence to specific CPT/HCPCS codes and documentation standards to support medical necessity. In fact, proper understanding and application of these billing requirements are essential to ensure accurate Part B claims submission, reduces rejections, and maintains compliance with CMS regulations.

SNF Consolidated Billing and its Role in Split Billing

The consolidated billing rule requires SNFs to submit a single claim to Medicare for most services provided during a Part A stay. These involve numerous services provided by external providers.Nonetheless, not all services qualify under consolidated billing and can be separately billed by the provider under Part B. Understanding which services are included or excluded is key to successful split billing.

Included in Consolidated Billing (Part A):

• Nursing services
• Therapy services (in-house)
• Medical equipment provided by the SNF
• Routine laboratory tests and X-rays
• Medications and supplies during the covered SNF stay
• Enteral nutrition and parenteral nutrients, if administered in the facility

Excluded From Consolidated Billing (Billable under Part B):

• Physician services
• Advanced diagnostic tests (MRI, CT scans)
• Chemotherapy, certain radioisotope therapies, and specific high-cost drugs
• Ambulance services under specific conditions
• Dialysis for ESRD patients
• Certain prosthetics and orthotics not commonly furnished by the SNF

Included under Part B (if the patient is not under Part A or has exceeded 100 days):

• Outpatient physical, occupational, and speech therapy
• Physician office visits and consultations
• Diagnostic lab tests and imaging not bundled under Part A
• Durable Medical Equipment (DME) for home use
• Preventive services (e.g., flu and pneumonia vaccines)
• Mental health services (e.g., psychiatric evaluations, counseling)
• Ambulance transport when medically necessary and not covered by Part A

When a service falls outside the consolidated billing rules, it must be submitted as a Part B claim by the performing provider.

Conclusion

Split billing in SNFs goes beyond simply choosing between Medicare Part A or Part B. It requires careful eligibility verification, accurate coding, and a thorough understanding of consolidated billing rules. Any mistake during the process can result in financial losses, compliance issues, and even audits. To manage these complexities, the best approach includes proper training, accurate documentation, and reliable billing support. Many SNFs now trust offshore medical billing and coding services provider in India to manage their Medicare billing more efficiently and cost-effectively.

Info Hub Consultancy Services is your trusted partner as for many SNFs. We offer end-to-end solutions to ensure timely and accurate Medicare billing for your facility. Outsource your medical billing and coding with Info Hub Consultancy Services and experience seamless, compliant, and profitable operations.

FAQs

1. Can SNFs bill both Medicare Part A and Part B for the same patient on the same day?

SNFs cannot bill both Part A and Part B for the same service date; only one applies, based on the patient’s coverage status.

2. Does Medicare cover telehealth services in SNFs?

Under certain conditions, Medicare Part B may cover telehealth services provided in SNFs.

3. What happens if a patient switches from Medicare Advantage to Original Medicare mid-stay?

Billing must be adjusted accordingly, and SNFs need to verify eligibility before submitting claims.

4. Are therapy caps still applicable under Medicare Part B in SNFs?

Therapy caps have been eliminated, but medical necessity and proper documentation are still required for therapy claims.

5. Can SNFs bill Medicare for private room charges?

Medicare typically does not cover private rooms unless they are medically necessary and documented as such.

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