Direct Answer
Long-term care billing operates on two parallel billing tracks that must not be confused: (1) professional billing — the physician or NP's personal services billed on CMS-1500 using nursing facility E&M codes (99304-99318); and (2) facility billing — the nursing home's per-diem Medicare Part A payment under the Prospective Payment System (PPS), billed on the UB-04. The physician's professional services are always billed separately from the facility's room and board/therapy charges. The most critical concept in LTC billing is Medicare Part A consolidated billing, which bundles almost all ancillary services (therapy, labs, radiology, most drugs) into the SNF's per-diem PPS rate — meaning the SNF must furnish or arrange and pay for these services, and separate billing by outside providers during a Medicare Part A stay is generally not permitted.
Table of Contents
Nursing Facility E&M Codes
Physicians and NPPs providing services in skilled nursing facilities, nursing facilities, and intermediate care facilities bill using nursing facility E&M codes: Initial nursing facility care: 99304 — Initial nursing facility care, low complexity MDM; 99305 — Moderate complexity MDM; 99306 — High complexity MDM; these codes are used for the initial comprehensive assessment when a patient is admitted to a nursing facility or when a physician assumes care of a patient already in a nursing facility; Subsequent nursing facility care: 99307 — Subsequent nursing facility care, straightforward MDM; 99308 — Low complexity MDM; 99309 — Moderate complexity MDM; 99310 — High complexity MDM; Nursing facility annual assessment: 99318 — Evaluation and management of a patient involving an annual nursing facility assessment; this is a distinct code for the annual comprehensive assessment required by state and federal regulations for nursing facility residents; Discharge: 99315 — Nursing facility discharge day management, 30 minutes or less; 99316 — More than 30 minutes; Documentation requirements for NF E&M: the MDM framework (2021 E&M guidelines) applies to nursing facility E&M codes; the mental and physical examination must be documented; for initial NF care (99304-99306), a comprehensive assessment is expected; for subsequent visits (99307-99310), the interval visit note should document changes in condition, medication management, and updated plan; Nursing facility visits and billing frequency: there is no specific Medicare requirement for how often a physician must visit a nursing facility patient; Medicare pays for medically necessary visits; the 30-day rule (physician or NPP must visit within 30 days of admission and then at least every 30 days for the first 90 days, then every 60 days) is a certification and recertification requirement for Medicare Part A coverage, not a billing limit; beyond certification requirements, Medicare pays for medically necessary visits at whatever frequency the patient's condition warrants.
SNF Medicare Part A PPS and PDPM
The SNF's Medicare Part A payment uses the Prospective Payment System (PPS) with the Patient-Driven Payment Model (PDPM) since October 2019: What PDPM replaced: PDPM replaced the Resource Utilization Group (RUG-IV) system; under RUG-IV, SNF payment was primarily driven by the volume of therapy minutes; under PDPM, payment is driven by the patient's clinical characteristics, diagnoses, and functional status; PDPM payment components: PDPM calculates a per-diem payment that includes five case-mix adjusted components: PT (physical therapy) component; OT (occupational therapy) component; SLP (speech-language pathology) component; nursing component; non-therapy ancillary (NTA) component; each component uses different patient characteristics to assign a case-mix group that determines the component rate; The MDS (Minimum Data Set) drives PDPM: the Resident Assessment Instrument (RAI) / Minimum Data Set (MDS 3.0) is the clinical assessment tool that captures the patient characteristics that determine PDPM payment; MDS assessment schedule under PDPM: admission assessment (5-day): must be completed by day 8 of the Medicare Part A stay; sets the initial PDPM case mix groups; 30-day assessment: completed between days 21-35 of the stay; optional interim payment assessment (IPA): used when the patient's clinical status changes significantly enough to justify re-classifying the case mix; end-of-therapy OMRA: if therapy is discontinued, an OMRA (Other Medicare Required Assessment) triggers a recalculation without the therapy components; SNF Level of Care criteria for Medicare Part A: Medicare Part A covers SNF care when: the patient had a qualifying inpatient hospital stay of at least 3 consecutive days; the SNF admission occurs within 30 days of hospital discharge; the patient requires skilled care (skilled nursing or skilled therapy) that can only be safely and effectively performed by or under the supervision of professional or technical personnel; documentation of skilled care need is critical — custodial care (assistance with ADLs) is not covered under Medicare Part A.
Consolidated Billing Rules
Medicare Part A consolidated billing is one of the most important and misunderstood rules in SNF billing: What consolidated billing means: during a Medicare Part A SNF stay, the SNF receives a single bundled per-diem payment that is intended to cover nearly all the services the patient receives; the SNF is responsible for ensuring those services are provided — either by its own employees or by contracting with outside providers; outside providers who furnish services to Medicare Part A SNF residents generally cannot bill Medicare separately — the SNF must pay them out of the PPS rate; Services bundled into the SNF PPS rate (cannot be billed separately to Medicare during Part A stay): physical therapy, occupational therapy, and speech-language pathology services; physician-ordered diagnostic services (lab, radiology) performed by outside providers during the Part A stay; most prescription drugs; ambulance services (with some exceptions); most other services not listed as excluded; Services EXCLUDED from consolidated billing (can be billed separately to Medicare B): physician and NPP professional services (99304-99318); certain dialysis services; certain ambulance services; certain very high-cost drugs not available in a SNF formulary; Practical implication for outside providers: a physical therapy group, lab company, or radiology group that provides services to a Medicare Part A SNF patient should NOT bill Medicare directly — they must bill the SNF; the SNF pays them from its PPS rate; billing Medicare directly for consolidated billing services results in: improper payment that must be repaid; potential False Claims Act liability; SNF Part B billing during Part A stay: some physician services remain billable to Medicare Part B even during a Part A stay — specifically the physician's professional E&M services and certain procedures not listed in the consolidated billing exclusions.
NP and PA Billing in LTC
Nurse practitioners (NPs) and physician assistants (PAs) are heavily utilized in long-term care settings and have specific billing rules: NP and PA scope in LTC: NPs and PAs can perform and bill for nursing facility E&M services (99304-99318) within their scope of practice; NPs in many states have full practice authority and can be the attending provider of record in a nursing facility; Incident-to billing does NOT apply in NFs: incident-to billing (which allows NPPs to bill under the physician's NPI at 100% of the physician fee schedule) applies only in outpatient office settings; in nursing facilities, NPs and PAs always bill under their own NPI at the NPP rate (85% of the physician Medicare fee schedule); there is no exception — even if the physician is routinely reviewing and co-signing the NP's notes; Split-shared visits in LTC: split-shared visit rules allow the physician to bill a service when both the physician and NPP contribute to the same visit; the component that determines the billing provider (physician vs. NPP) is the provider who performs the substantive portion of the MDM or the majority of the total time; if the physician performs the substantive MDM portion, the physician bills at 100% of the physician fee schedule; if the NPP performs the substantive portion, the NPP bills at 85%; Physician certification and recertification: Medicare Part A requires physician (or NPP) certification that the patient requires skilled care and that a plan of care has been established; initial certification (within 14 days of admission) and recertification (every 30 days for the first 90 days, then every 60 days) are required for Medicare Part A payment to continue; certification is a separate function from the billable E&M visit; attending physician vs. consulting physician billing: the attending physician of record manages the overall care plan; consulting physicians (e.g., cardiologist, pulmonologist) bill their LTC consultation using standard E&M codes for their specialty focus.
Long-Term Care RCM
Long-term care revenue cycle management involves both the facility billing and the professional billing dimensions: Facility billing RCM (SNF/NF perspective): MDS accuracy and timeliness: the MDS drives PDPM payment — MDS errors directly reduce reimbursement; MDS coordinators must ensure: accurate coding of primary diagnoses and comorbidities; accurate capture of the SLP component factors (presence of swallowing disorder, cognitive impairment, mechanically altered diet, parenteral or enteral nutrition); accurate functional status coding (Section GG scores drive PT and OT components); accurate capture of the nursing component factors (infectious disease, skin conditions, behavioral symptoms, treatments); Medicare triple-check process: before billing the Medicare Part A claim, a "triple check" review should occur — a cross-functional review by billing, nursing, and therapy to verify: all services billed were documented as provided; therapy minutes documented match therapy minutes billed; diagnoses on the MDS match the clinical record; the MDS assessment type and reference dates are correct; Professional billing RCM (physician/NP practice perspective): census reconciliation: physicians and NP practices managing a nursing home census must reconcile their patient list against billing records; patients discharge, transfer, and are admitted without always notifying the billing office; a weekly census reconciliation prevents charge lag; Documentation timeliness: nursing facility notes are often documented at the time of the visit — the physician or NP practice must ensure notes are signed and available for billing within the payer's timely filing window; Co-management billing: when multiple providers share the care of LTC patients (attending physician + NP for routine care + specialist consultations), each provider bills their own services; coordination documentation prevents duplicate billing claims.
FAQ
What is the difference between Medicare Part A and Medicare Part B billing for SNF patients, and when does each apply?
The Medicare Part A vs. Part B distinction in SNF settings confuses many providers and is one of the most common sources of billing errors in long-term care. Medicare Part A SNF coverage: applies when the patient has had a qualifying 3-day inpatient hospital stay, is admitted to the SNF within 30 days of discharge, and requires skilled care; Part A covers up to 100 days per benefit period (days 1-20 at no cost-sharing; days 21-100 with a daily coinsurance); Part A covers the "room and board" plus all bundled services in the consolidated billing package; the SNF bills the facility fee (per diem PPS rate) on the UB-04 under Part A; Physician professional services during Part A stay: physician and NPP professional services (99304-99318 and other non-bundled services) are billed to Medicare PART B even during a Part A stay; Part B pays the physician/NPP directly for their professional visits; this is one of the key exclusions from consolidated billing; Medicare Part B SNF coverage (non-Part A stays): when a patient is in a SNF but does NOT have an active Medicare Part A SNF benefit (benefit period exhausted, no qualifying hospital stay, custodial-only care), Medicare Part B covers outpatient-type services; physician visits (99304-99318) are billed to Part B regardless of whether Part A is active; certain therapy services may be covered under Part B outpatient therapy benefit (Medicare B therapy benefit) when Part A is exhausted; transition from Part A to Part B: when a patient's Part A days are exhausted or the patient no longer meets skilled care criteria, the Part A benefit ends; the SNF must notify the patient of Part A termination (NOMNC — Notice of Medicare Non-Coverage); after Part A ends, the patient enters the custodial care track; professional services continue to be billed to Part B; the SNF is now paid by Medicaid (if the patient is dual-eligible), long-term care insurance, or private pay; Dual-eligible patients: patients with both Medicare and Medicaid ("dual eligibles") have Medicare as primary and Medicaid as secondary; for SNF professional services during Part A stays, Medicare Part B pays first; Medicaid may cover the Part B cost-sharing for full-benefit dual eligibles.
What are the most common PDPM coding and MDS errors that reduce SNF reimbursement, and how can they be prevented?
PDPM payment accuracy depends entirely on the MDS accurately capturing the patient's clinical characteristics. The most costly MDS coding errors that reduce reimbursement: Error 1 — Inaccurate or incomplete principal diagnosis coding: PDPM's nursing component and NTA component are heavily driven by the ICD-10 principal diagnosis; under-coded or vague diagnoses (e.g., "weakness" instead of the underlying condition causing the weakness) result in a lower case-mix group and lower payment; best practice: the MDS coordinator should review the hospital discharge summary, the admission H&P, and the attending physician's assessment to identify the most accurate and specific ICD-10 principal diagnosis; Error 2 — Incomplete NTA component coding: the NTA (non-therapy ancillary) component is driven by the presence of specific conditions and treatments, including active diagnoses from a defined list; infections, skin wounds, respiratory conditions, parenteral nutrition, IV medications, and tracheostomy/ventilator status drive high NTA scores; missing any of these from the MDS results in lower NTA payment; conduct a structured review of the clinical record, medication administration record (MAR), and treatment administration record (TAR) to identify all NTA-qualifying conditions; Error 3 — SLP component undercoding: the SLP component requires accurate coding of: swallowing disorder (dysphagia); cognitive impairment; mechanically altered diet or therapeutic diet; parenteral or enteral nutrition; presence of an SLP speech-language pathology planned or ongoing; missing any of these factors reduces the SLP component; Error 4 — Section GG functional status undercoding: Section GG (functional abilities and goals) determines the PT and OT components; underrating the patient's functional limitation (i.e., documenting the patient as more independent than they actually are at admission) reduces the PT/OT case-mix score and the resulting payment; the admission Section GG should reflect the patient's actual performance during the assessment period, not their anticipated discharge status; Error 5 — Late 5-day MDS: the PDPM 5-day assessment must be completed by day 8; late submission results in a payment gap during the uncovered days; establish a workflow that initiates MDS documentation on the day of admission and tracks completion against the day-8 deadline.
Long-Term Care Billing Specialists for SNF E&M, PDPM, Consolidated Billing, and LTC RCM
Valiant Lifecare's long-term care billing specialists handle nursing facility E&M codes 99304-99318, SNF Medicare Part A PDPM payment optimization through accurate MDS coding, consolidated billing compliance for Medicare Part A stays, NP and PA billing at 85% NPP rates in LTC settings, Medicare triple-check processes, census reconciliation, and long-term care revenue cycle management for physician LTC practices, NP-managed SNF programs, and skilled nursing facility operators.
Optimize Your Long-Term Care Billing