Wednesday, June 27, 2018

SNF Billing Guide

Recently, we've noticed that there are a number of Skilled Nursing Facility claims/encounters rejected by CMS due to the following reasons:

  1. Skilled Nursing Facility Claims required Health Insurance Prospective Payment System (HIPPS) codes not present on the claim.
  2. HIPPS Codes and Revenue Codes conflict 
  3. Hospital to Skilled Nursing Facility within 24 hours.

All of these issues can be remedied, by following the Centers for Medicare and Medicaid Services guidelines for billing of Skilled Nursing Facility guidance, including the correct use of HIPPS codes.

Although CMS allows Medicare Advantage plans to provide services which may not meet the coverage criteria in Fee-for-service (FFS) Medicare, provision of services and submission of an encounter data are two distinct things.   So, while coverage may be extended in some cases when FFS guidelines are not met, encounter  data must meet FFS billing requirements in order to be processed.  And CMS does require that all services must be submitted as encounter data, whether or not CMS covers them.

In order to ensure your encounter data is processed correctly, you should follow the instructions contained in the CMS Skilled Nursing Facility (SNF) Billing Reference.  For complete instructions on HIPPS Codes, you should review the HIPPS code page on the CMS website as well.
Finally, in order to ensure that your claim/encounter for a SNF transfer within 24 hours, be sure to use Condition Code 40 on the encounter.

The importance of correct encounter data cannot be stressed enough. In order for CMS to have an accurate and complete picture of the services provided to our members, encounters must be processed to completion.  By and large, that means they must meet the requirements of FFS medicare when they are sent to health plans. This ensures that they will be correctly processed, and that CMS can more accurately assess the care provided to MA members.

If you have questions regarding CMS Encounter Data, contact Michelle Nguyen of our Encounter Data team at

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