Nursing homes and skilled nursing facilities (SNFs) play a critical role in providing long-term care, rehabilitation, and post-acute services for the elderly and chronically ill. While these facilities focus on enhancing the quality of life for their residents, managing the financial side — especially medical billing and reimbursement — can be overwhelmingly complex.

Nursing home billing involves multiple payers, including Medicare, Medicaid, commercial insurance, and private pay, along with frequent regulatory changes, therapy limits, and authorization requirements. Accurate and timely billing is vital to maintaining cash flow, avoiding compliance risks, and ensuring the continuity of resident care.

At Progressive RCM, we specialize in providing complete nursing home billing services, helping long-term care facilities reduce denials, meet compliance standards, and secure full reimbursement for every service delivered.

---

Unique Billing Challenges in Nursing Homes

1. Multiple Payer Sources

Residents may transition between Medicare Part A, Part B, Medicaid, and private insurance during their stay. Billing must reflect the correct payer and coverage phase, especially after a hospital discharge.

2. Medicare Part A Billing for Skilled Services

SNFs receive per diem payments for eligible residents under the Patient-Driven Payment Model (PDPM). Billing must align with:

• The correct assessment period

• Services provided (therapy, nursing, non-therapy ancillary)

• Compliance with the 3-day qualifying hospital stay

3. Medicare Part B Therapy Billing

When Part A benefits are exhausted or the resident is not eligible, services like physical, occupational, and speech therapy must be billed under Part B using CPT codes, timed units, and modifiers.

4. Medicaid Complexity

Each state’s Medicaid program has different rules for per diem payments, eligibility, authorization, and resident liability (patient pay amounts). Errors in eligibility tracking often result in payment delays or audits.

5. Managed Care and Medicare Advantage Plans

Managed care requires authorization for nearly all services. Each plan has its own portal, codes, and documentation needs — making billing a full-time job without expert help.

6. Room and Board vs. Ancillary Services

Facilities must differentiate between residential charges and billable medical services, especially when submitting claims to Medicaid or private insurance.

---

Common CPT, HCPCS, and ICD-10 Codes in Nursing Home Billing

✅ CPT Codes (Outpatient/Part B Services):

• 97110 – Therapeutic exercise

• 97530 – Therapeutic activities

• 99213 – Office/outpatient visit

• 97161–97163 – PT evaluations

• 97165–97167 – OT evaluations

• 92523 – Speech and language evaluation

• 99495 – Transitional care management

✅ HCPCS Codes:

• G0151–G0156 – Therapy services by licensed therapists

• E0100–E1399 – Durable medical equipment (DME)

• A4556–A4559 – Surgical dressings and supplies

• Q5001 – Nursing facility services

• G0299 – RN services, each 15 minutes

• G0300 – LPN services, each 15 minutes

✅ ICD-10 Codes (Examples):

• I10 – Hypertension

• F03.90 – Dementia, unspecified

• M62.81 – Muscle weakness

• R26.9 – Unspecified abnormalities of gait and mobility

• E11.9 – Type 2 diabetes without complications

• Z74.09 – Dependence on care due to functional limitations

---

Our Nursing Home Billing Services

At Progressive RCM, we offer complete medical billing support for long-term care providers, SNFs, and rehabilitation centers.

✅ Eligibility & Payer Verification

• Confirm Medicare/Medicaid coverage, commercial insurance, and residential status

• Track payer transitions throughout a resident’s stay

• Calculate patient responsibility (deductibles, co-pays, coinsurance)

✅ Medicare Part A & PDPM Billing

• Monitor admission assessments and interim payment assessments (IPAs)

• Submit UB-04 claims with accurate RUG or HIPPS codes

• Track benefit days and SNF stay qualifications

✅ Medicare Part B & Outpatient Billing

• Code and bill therapy, diagnostics, and provider visits

• Apply correct units, modifiers (GP, GO, KX)

• Monitor therapy caps and thresholds

✅ Medicaid Billing and Resident Liability Tracking

• Submit state-specific Medicaid claims

• Track and apply resident cost sharing or patient pay amounts

• Respond to Medicaid audits and recoupments

✅ Managed Care Billing

• Obtain authorizations for rehab, labs, imaging, and specialist care

• Submit claims per plan-specific portals and formats

• Follow up on denials or underpayments

✅ AR Management and Denial Resolution

• Reduce aging AR through proactive claim management

• Track denials by payer and reason

• File appeals with clinical documentation

✅ Revenue Cycle Reporting

• Daily, weekly, and monthly collection reports

• Aging reports by payer and facility

• PDPM utilization trends

• Denial and appeal success rates

---

Why Choose Progressive RCM for Nursing Home Billing?

✅ Long-Term Care Billing Experts
We have experience working with SNFs, assisted living, rehab centers, and post-acute providers, fully versed in PDPM, Part B, and Medicaid rules.

✅ State-by-State Medicaid Knowledge
Our billers stay current with state-specific Medicaid systems, whether you’re in Texas, Florida, New York, or beyond.

✅ Compliance-Focused Billing
We ensure claims meet CMS guidelines, HIPAA standards, and are ready for Medicare or Medicaid audits.

✅ Faster Reimbursements
With claim scrubbing, real-time follow-ups, and clean submissions, we help you get paid faster.

✅ Custom Billing for Multi-Facility Groups
Whether you run one location or twenty, we tailor workflows to suit your operational model, staffing, and systems.

---

KPIs We Monitor for Nursing Homes

• Average reimbursement per resident

• Days in AR

• Denial rate by payer

• Medicare Part A claim acceptance rate

• Medicaid patient-pay collection rate

• Part B revenue per therapy type

• Authorization turnaround time

---

SEO Keywords Used:

• nursing home medical billing services

• skilled nursing facility billing company

• PDPM billing support

• long-term care billing solutions

• Medicare SNF billing

• Medicaid billing for nursing homes

• therapy billing for SNFs

• managed care billing nursing home

• UB-04 claim submission

• RCM for nursing facilities

---

Final Thoughts

Nursing homes and skilled nursing facilities must balance quality resident care with revenue integrity — and that’s only possible with accurate, efficient billing. From navigating Medicare Part A/Part B and PDPM billing to managing state Medicaid complexities, there’s no room for error.

At Progressive RCM, we take the billing burden off your shoulders, improve claim accuracy, and deliver the financial clarity your team needs to keep doing what you do best — caring for others.