Denied claims and pending patient responsibilities are the two major reasons for high AR. We work on both problems, ensuring that you get paid for the services you provide. Our experts use different AR and denial management strategies to ensure maximum reimbursements.
Nursing home billing is how skilled nursing facilities get paid for their residents’ care. It involves submitting claims to Medicare, Medicaid, private insurance, and sometimes residents themselves. Getting billing right is crucial for nursing homes to stay in business and provide good care.
This guide simplifies complicated nursing home billing codes into easy-to-understand stages. We will discuss the basic rules, essential codes, common mistakes, and best practices. This will help your facility receive correct payments and avoid issues with insurance companies and regulators.
Nursing homes use billing to receive payment for the care they provide. They send bills (called claims) to insurance companies, government programs, and sometimes to residents or their families. These bills cover:
Good billing practices keep money flowing into the facility, which helps maintain quality care. Poor billing leads to rejected claims, late payments, rule violations, and possible legal problems.
Nursing Home Administrators oversee all billing operations. They make decisions about billing systems and staff while ensuring the facility follows all rules.
Medical Coders and Billing Specialists turn medical notes into billing codes, submit claims, track payments, and fix payment issues. Their knowledge of codes and insurance requirements helps maximize proper payment.
Insurance payers such as Medicare, Medicaid, Medicare Advantage plans, commercial insurance, and long-term care insurance. Each has different rules, documentation needs, and payment schedules.
Patients and family members know what their insurance covers and understand what they might have to pay. Often, they manage long nursing home stay costs when insurance stops paying.
Nursing homes usually bill monthly for services provided during the previous month. Medicare requires “consolidated billing,” meaning the nursing facility must submit all Medicare claims for covered services rather than letting outside providers bill separately.
Medicare Billing Periods
Medicaid Billing Periods
Private Insurance Billing
All claims must be filed within certain time limits—from 30 days to one year after service, depending on the payer. Missing these deadlines usually means no payment.
Good documentation is the foundation of proper billing. Essential records include:
This documentation must clearly show medical necessity, proving that services are needed to treat illness or injury. All providers must ensure that billed services follow accepted medical practices and deliver them at appropriate levels.
Federal rules require nursing facilities to have compliance programs, including:
Wrong Patient Information causes claim rejections and payment delays. Always check:
Coding Errors lead to payment problems and compliance risks:
Authorization Problems happen when services need pre-approval:
Non-covered services billed to insurance get denied:
Using claim-checking software, conducting regular internal reviews, and providing ongoing staff education can reduce these common errors significantly.
Category | Code | Description |
Initial Nursing Facility Care | 99304 | Simple decision-making, basic history, and exam |
99305 | Moderate decision-making, detailed history and exam | |
99306 | Complex decision-making, comprehensive history, and exam | |
Follow-up Nursing Facility Care | 99307 | Basic follow-up visit, simple decision-making |
99308 | Expanded follow-up visit, low complexity decision-making | |
99309 | Detailed follow-up visit, moderate complexity decision-making | |
99310 | Comprehensive follow-up visit, high complexity decision-making | |
Nursing Home Discharge | 99315 | Management of nursing home discharge days in 30 minutes or less |
99316 | Management of nursing facility discharge days that go longer than 30 minutes |
Note: Documentation must support the billed level of service, such as time spent, decision complexity, and care coordinating tasks.
Code | Description |
29125-29131 | Applying arm splints |
36415 | Drawing blood |
43760 | Changing feeding tubes |
93000 | EKG (heart test) |
94640 | Breathing treatments |
97597-97598 | Cleaning wounds |
11042-11047 | Removing dead tissue from wounds |
Note: Each procedure code requires specific documentation of medical necessity, technique, body location, and the resident’s response.
Category | Code | Description |
Physical Therapy Codes | 97161-97163 | PT evaluation (simple to complex) |
97110 | Exercise therapy | |
97112 | Nerve and muscle retraining | |
97116 | Walking training | |
97530 | Activity therapy | |
97535 | Self-care training | |
Occupational Therapy Codes | 97165-97167 | OT evaluation (simple to complex) |
97129-97130 | Thinking skills therapy | |
97532 | Cognitive skill improvement | |
97535 | Self-care training | |
97537 | Community/work reintegration | |
Speech Therapy Codes | 92521-92524 | Speech evaluation |
92507 | Treatment for speech, language, and voice problems | |
92526 | Swallowing treatment | |
92609 | Services for speech-generating devices |
Note: Each therapy session must document time spent (usually in 15-minute units), specific treatments provided, measurable progress, and plans for continued treatment.
Category | Code | Description |
Care Planning and Oversight | G0180 | Doctor certification for Medicare home health services |
G0181 | Doctor supervision of patient getting Medicare home health services | |
G0182 | Doctor supervision of patient under Medicare hospice care | |
Respite Care | S5150 | Basic respite care, per 15 minutes |
S5151 | Basic respite care per day | |
T1005 | Respite care services, 15 minutes | |
Medical Equipment (DME) | E0130-E0159 | Walkers |
E0185-E0199 | Pressure care equipment | |
E0250-E0373 | Hospital beds and accessories | |
E0424-E0486 | Oxygen and breathing equipment | |
E0910-E0948 | Support and traction equipment |
Category | Code | Description |
Common Revenue Codes | 0100-0179 | Room and board (semi-private, private duty nursing CPT codes, etc.) |
0183 | Leave of absence | |
0250-0259 | Pharmacy | |
0270-0279 | Medical supplies | |
0420-0429 | Physical therapy | |
0430-0439 | Occupational therapy | |
0440-0449 | Speech therapy | |
0550-0559 | Skilled nursing CPT codes | |
Value Codes | 23 | Monthly income (patient contribution) |
31 | Patient responsibility amount | |
66 | Medicare spend-down amount | |
80-83 | Covered days, non-covered days, co-insurance days |
Note: The correct revenue codes ensure proper payment processing and financial reporting service categorization.
Implementing nursing home billing codes requires attention to detail, an understanding of coding systems, and a commitment to following the rules. By investing in expert medical coding services nursing facilities can remain financially strong, allowing them to focus on their primary goal: providing quality care to residents.
Contact us today for a free billing assessment and discover how much revenue you could be recapturing.
The denial can be appealed within 120 days. First, review the denial reason, fix any errors in documentation or coding, and resubmit with supporting evidence.
You must submit Medicare claims within 12 months of service. Late submissions are typically rejected, resulting in lost revenue for your facility.
Medicare covers short-term skilled care (up to 100 days) after hospitalization. Medicaid covers long-term care for those with limited income and assets.
At Medi Billing, we provide comprehensive medical billing services that cover everything from coding and claims to payment recovery. We take the stress out of your revenue cycle across all specialties so you can dedicate your time to patient care.
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