Looking for A Guide to Nursing Home Billing? Here’s It!

Nursing homes are a crucial part of modern American society. They play an important role in the well-being of citizens, especially the infirm and elderly. Billing is an essential component in the complex world of nursing homes (e.g., Independent Living Facilities). The following two facilities follow state guidelines for the billing process:

• Skilled Nursing Facilities (SNFs)
• Assisted Living Centers

The guidelines might vary from state to state. In this article, we have discussed every aspect of nursing home billing for your better understanding. So, without further ado, let’s dive into the details of this specialty.

Introduction of Nursing Home Billing

Billing at nursing homes happens every month, where residents or their legal representatives are billed for the care they receive. Providers make bills and claims as per the patient’s contract with the payer. This bill covers basic charges and possibly extra services. The following variables affect the rates:

• the complexity of care,
• level of service,
• type of room,
• and additional amenities.

Billing starts according to contract terms. If a resident arrives mid-cycle, the bill is prorated for the admission month. Some bills include a notice for the next month. Certain states tax the total bill. Final owed amounts deduct Medicare, Medicaid, health insurance, and long-term care insurance payments.
Skilled nursing within a Continuing Care Retirement Community (CCRC) with a lifecare agreement. It may have different billing processes based on specific arrangements.

Fundamentals of Nursing Home Billing Codes and Procedures

The billing codes and procedures used in nursing homes are complex. Financial operations in healthcare for the elderly and infirm follow strict regulations. This includes coding systems for services, detailed billing procedures, and adherence to state rules. These ensure accurate reimbursement and clear financial transactions. Key aspects involve assessing care needs, understanding insurance coverage, and managing billing cycles. Coding systems, specific CPT codes, and modifiers play a crucial role in medical billing services.
Key Components:

• Assessment of Care Level
• Insurance Plans Coverage
• Billing Period Overview
• Coding Framework
• Specific CPT Codes in Use
• Modifiers Enhancing Specificity

Nursing Home Billing: Assessment of Care Level

Insurance reimbursement for nursing homes depends on determining the appropriate level of care. This involves understanding residents' needs and ensuring the facility meets those standards. There are different levels of care:

• Primary Care: Provided by general practitioners like doctors and nurse practitioners who offer a wide range of medical services.

• Secondary Care: Involves specialists such as pathologists and oncologists for specific medical conditions.

• Tertiary Care: Offers advanced specialty care in facilities like dialysis and neurosurgery centers for complex cases.

• Quaternary Care: Provides the most advanced treatments in select institutions, pushing healthcare boundaries.

There are several advantages to selecting the right level of care. These include ensuring specific services, accurate reimbursement, and optimized revenue cycle management.

Insurance Plans Coverage Criteria

Medicare Part A and Part B have specific guidelines for nursing home services. Under Part A, coverage includes up to 20 days in a nursing facility. After day 20, Medicare provides partial coverage with co-insurance.

Coverage depends on the benefits available. Once these benefits are used up, the nursing home will bill the resident for further services.

Medicare Part B covers long-term care services after Part A benefits are exhausted. This includes reimbursing services like physical, occupational, and speech therapy frequently used in long-term care.

Billing Period for Nursing Home

Nursing homes bill on a monthly basis using CMS-1450 (UB-04) forms. Claims are submitted when patients are no longer eligible for skilled care, discharged, or when benefits are exhausted. Accurate billing requires thorough documentation.
The billing cycle involves several steps for timely and precise billing:

1. The Medicare Administrative Contractor (MAC) returns a continuing stay bill until the prior bill's Remittance Advice (RA) is received.
2. Certain days, like discharge, death, or the start of Leave of Absence (LOA), aren't counted as billing days. Immediate discharges and returns before midnight aren't considered discharges for billing.
3. The HIPPS rate code on the claim must match the state-accepted assessment.
4. After verifying all details, the bill is submitted to the patient or insurer. Payment is processed, and a Remittance Advice (RA) shows the payment and any adjustments.
5. The billing cycle ends when payment is received, and records are updated. Policies, procedures, and service types can influence the billing cycle. Providers can maximize reimbursements by following these guidelines. But note that staying updated with CMS guidelines is crucial as they evolve.

Codes Used in Nursing Home Billing

There are several codes used in nursing home billing services. These codes are essential to describing the services rendered by the doctor. Below, we have given a brief description of these codes:

*- ICD-10 Codes: *

These codes are used in medical billing to indicate the diagnosis of the patient. Medical billers and coders use them to describe the services and procedures.

*HCPCS Codes: *

Coders use these codes to indicate specific supplies or services provided to patients. These codes are used to bill government payers like Medicaid and Medicare.

CPT Codes:

CPT Codes are used to indicate the specified services or procedures rendered to patients. These codes are used to bill private insurance payers.

CPT Codes Used in Nursing Home Billing

Note that guidelines for the usage of CPT keep changing by the regulatory bodies. So, it's important to stay up-to-date with the latest AMA guidelines.

Final Thoughts

Medical billing is a complex field that keeps evolving with the latest technology, laws, and regulations. Providers sometimes find themselves in a dilemma between handling billing and taking care of patients simultaneously. The best solution to cater to this problem is to outsource medical billing services to a reputable medical billing company. Such companies can streamline your billing process, optimize the revenue cycle, and maximize reimbursements.