Medicare Part A and Part B, Medicare Advantage, Medicaid and private pay billing for freestanding and hospital-based skilled nursing facilities, multi-facility operators and swing bed hospitals.
Skilled nursing revenue leaks one resident day at a time: a 5-day MDS set outside its window bills at the default rate, an outside lab invoice lands on the facility under consolidated billing, or a Medicare Advantage stay runs past its last authorized day. Eligibility and coverage errors caused 24% of denials in the Luxen claim audit. Luxen matches your census, MDS and authorizations to every claim so each covered day is paid once, at the right rate.
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SNF billing services manage Medicare Part A, Part B, Medicare Advantage, Medicaid and private pay claims for skilled nursing facilities, including PDPM HIPPS codes from the MDS, consolidated billing, no-pay claims and resident liability. In 2026, Medicare residents owe $217 a day in coinsurance for days 21 to 100 of a benefit period.
Each skilled nursing setting files differently.
Also billed: Part B therapy on 22X, outpatient services on 23X, Medicare Advantage and Medicaid per diems, coinsurance, patient liability and hospice room and board.
Most lost SNF revenue is a covered day billed at the wrong rate, a supplier charge nobody checked, or a day nobody authorized, so eligibility and prior authorization checks start before admission.
| Scenario | Codes | What goes wrong | $ at stake per claim | Luxen audit finding |
|---|---|---|---|---|
| Late 5-day assessment | Revenue code 0022, HIPPS ZZZZZ | ARD after day 8, so late days bill at the default rate | The case-mix per diem for each late day | The top three denial reasons accounted for 58% of denied dollars in the average practice |
| Coinsurance, days 21 to 100 | Type of bill 21X | Never billed to the resident, Medicaid or the secondary plan | $217 per day in 2026 | Practices lost 3.1% of collections to patient balances written off before a second statement |
| Supplier services during a Part A stay | Consolidated billing HCPCS exclusion files | Supplier bills Part B and is rejected, or the SNF pays for an excluded service | The full supplier charge | Duplicate claim denials made up 9% of denials |
| Part B therapy past the threshold | KX with GP, GO or GN | KX missing once 2026 spending passes $2,480 | Every therapy line past $2,480 | Coding and modifier errors caused 21% of denials |
| Medicare Advantage days past the authorization | Revenue code 0022 or plan level of care codes | No extension on file | Contracted per diem for each unauthorized day | Missing or invalid prior authorization caused 17% of denials |
Part A SNF claims go on the UB-04 (837I), one month at a time and in order. Our certified medical coding team checks each field against the MDS accepted in iQIES.
| Code | Meaning | When it is used |
|---|---|---|
| 21X | SNF inpatient, Part A | Covered days; frequency 1 for admit through discharge, 2 to 4 for interim claims |
| 210 | No-pay claim | Resident dropped to non-skilled care but stays in a Medicare-certified bed |
| 22X | SNF Part B for residents | Part B services, such as therapy, for residents of the certified SNF |
| 23X | SNF outpatient | Patients in the non-certified part of the building |
| 18X | Hospital swing bed | Swing bed stays |
| 0022 | SNF PPS revenue code | Carries the HIPPS code and covered days |
Level of care is certified at admission, recertified by day 14, then at least every 30 days (42 CFR 424.20). Days without a valid certification are not payable.
Since October 1, 2019, Medicare pays SNFs under the Patient Driven Payment Model (PDPM): five case-mix components from the 5-day PPS assessment plus a non-case-mix component, wage adjusted.
| Component | FY2026 urban | FY2027 urban | FY2027 rural |
|---|---|---|---|
| Physical therapy | $75.73 | $77.46 | $88.30 |
| Occupational therapy | $70.49 | $72.10 | $81.10 |
| Speech-language pathology | $28.28 | $28.93 | $36.44 |
| Nursing | $132.00 | $135.02 | $129.00 |
| Non-therapy ancillary (NTA) | $99.59 | $101.87 | $97.33 |
| Non-case-mix | $118.21 | $120.91 | $123.15 |
FY2027 rates apply from October 1, 2026, after a 2.4% update (CMS-1843-F).
Character 1 is the PT and OT group, 2 SLP, 3 nursing, 4 NTA, and 5 the assessment indicator: 1 for the 5-day assessment, 0 for an interim payment assessment. It must match the assessment in iQIES.
PT and OT pay at a 1.00 factor for days 1 to 20, then fall by 0.02 every 7 days, to 0.76 by day 98. NTA pays 3.0 for days 1 to 3, then 1.0. A readmission to the same SNF within 3 consecutive calendar days is an interrupted stay: both schedules continue.
A 5-day ARD set on day 11 bills days 1 to 3 at the default HIPPS code ZZZZZ. Missed SNF QRP reporting costs 2 percentage points of the annual update, and SNF VBP withholds 2% of Part A fee-for-service payments.
Under consolidated billing (Social Security Act 1862(a)(18) and 42 CFR 411.15(p)), the SNF bills Medicare for almost everything a Part A resident receives and pays outside suppliers itself. The supplier cannot bill Part B for the same service, so we check every outside invoice against the CMS annual HCPCS exclusion files before the facility pays.
| Category | Excluded services | Who bills |
|---|---|---|
| Practitioner services | Professional services of physicians, NPs, PAs and clinical nurse specialists; marriage and family therapists and mental health counselors since January 1, 2024 | The practitioner, on Part B |
| CMS Major Category I | CT, MRI, cardiac catheterization, radiation therapy, angiography, lymphatic and venous procedures, outpatient surgery and emergency services furnished by a hospital, plus related ambulance | The hospital or ambulance supplier |
| CMS Major Category II | Dialysis and ESRD services; hospice care for the terminal illness | The dialysis facility or hospice |
| CMS Major Category III | Certain chemotherapy and its administration, radioisotopes, customized prosthetic devices, blood clotting factors | The furnishing provider |
Outside a covered Part A stay, only therapy stays under consolidated billing. The SNF bills it on type of bill 22X with GP, GO or GN, and KX once 2026 spending passes $2,480 for PT and SLP combined or $2,480 for OT. Therapy assistant services carry CQ or CO and are paid at 85%.
They do not. The qualifying stay is 3 consecutive inpatient days, counting admission but not discharge day; observation and emergency room time do not count (Medicare Benefit Policy Manual, Chapter 8). Eligibility and coverage errors caused 24% of denials in the Luxen claim audit.
An ARD after day 8 bills the default HIPPS code ZZZZZ for every day out of compliance, and those days are not restored (CMS MDS 3.0 RAI Manual). The top three denial reasons accounted for 58% of denied dollars in the average practice (Luxen billing reviews).
A resident in a Medicare-certified bed after skilled care ends still needs no-pay claims, type of bill 210 with condition code 21, until discharge (First Coast Service Options, SNF no-payment claims). Secondary payers ask for them. Timely filing caused 6% of denials, and only 4% of those were recovered (Luxen claim audit).
Physician, NP, PA and clinical nurse specialist services are excluded from consolidated billing and billed to Part B by the practitioner (42 CFR 411.15(p)(2)). Absorbing them leaves the SNF with a cost it never owed. Coding and modifier errors caused 21% of denials (Luxen claim audit).
MA plans must apply Traditional Medicare SNF coverage criteria and may use internal criteria only where those are not fully established (42 CFR 422.101(b)). Appeals filed by Luxen were overturned 68% of the time (Luxen client data).
We run the revenue cycle from eligibility to zero balance inside the practice management system you already use. How full-service billing works.
Certified coders review charges against your documentation and payer rules before the claim goes out, so the denial is prevented rather than appealed. Medical coding.
Aged and denied claims are worked to resolution, then the upstream cause is fixed so the same claims stop coming back. Denials and AR recovery.
Benefits are verified and authorizations secured before the appointment, which is the cheapest place in the cycle to stop a denial. Eligibility and prior authorization.
Statements, balance questions and payment plans are handled by the same team that worked the claim. Patient billing.
Payer enrollment and re-credentialing are tracked through to approval, so a lapsed credential never quietly stops payment. Credentialing.
A HIPAA-trained front-office assistant working inside your EHR on calls, scheduling, intake and referrals, alongside the billing team. Medical virtual assistant.
We work inside the systems your facility already runs, with no migration.
We sign the BAA before access.
2 weeks
from a signed BAA to our team working your claims
About 3 weeks
to the first recovered payments on aged AR
20+ years
combined billing and coding experience
Luxen client data, 38 client practices, Jan 2024 to Jun 2026:
Admissions, transfers, leave days, and discharges were not consistently reflected in our billing census. Luxen built a daily reconciliation that reduced census-related claim corrections from 18% to 4% and released $96,300 in held revenue.
Chief Financial Officer, 120-bed skilled nursing facility
Part B claims were being returned because covered-stay dates and consolidated billing status were not checked first. Luxen added a coverage review, reduced those denials by 71%, and recovered $43,800 from affected claims.
Revenue Cycle Manager, multi-facility skilled nursing operator
Full engagements are written up in our dental practice case study and our ambulance billing case study.
Since January 1, 2024, MA plans must follow Traditional Medicare SNF coverage criteria, and an approved authorization stays valid while medically necessary. From January 1, 2026, plans must decide expedited prior authorization requests within 72 hours and standard requests within seven calendar days, with a specific denial reason. We keep each plan enrollment current through credentialing, and our denial and AR recovery team appeals denied days.
Medicaid reduces its payment by the resident's income after deductions, including a personal needs allowance of at least $30 a month (42 CFR 435.725), so the facility must collect that patient liability monthly. Our patient billing statements carry liability and coinsurance.
On January 1, 2026, South Carolina moved nursing facility residents into Medicaid managed care for medical services, while nursing facility services stay fee-for-service (South Carolina medical billing rules). Wisconsin allows 455 days to resubmit a claim denied for an incorrect nursing home level of care authorization or patient liability amount, if the original arrived within 365 days (Wisconsin medical billing).
3% to 6% of collections
Luxen's pricing generally falls between 3% and 6% of collections, depending on claim volume, specialty, payer mix, and how much of the revenue cycle your practice hands over.
Higher-volume practices usually land toward the lower end. Smaller or more complex practices land higher because there is more work per account. There is no setup fee and no exit fee, and the agreement runs month to month with 30 days notice.
A lower fee attached to weak billing is still expensive. The number that matters is what your collections do after you hire someone.
Luxen charges 3% to 6% of collections, depending on payer mix, census and authorization workload. No setup or exit fee.
| Service line | Monthly collections | Luxen at 3% | Luxen at 6% |
|---|---|---|---|
| Medicare Part A | $260,000 | $7,800 | $15,600 |
| Medicare Advantage | $140,000 | $4,200 | $8,400 |
| Medicaid nursing facility days | $300,000 | $9,000 | $18,000 |
| Part B, coinsurance and private pay | $100,000 | $3,000 | $6,000 |
| Total | $800,000 | $24,000 | $48,000 |
| Cost | In-house business office | Luxen |
|---|---|---|
| Cost basis | Payroll, benefits, billing software and training | $24,000 to $48,000 a month ($288,000 to $576,000 a year) in this example |
| When a biller leaves | Open biller roles took a median 67 days to fill | No gap in coverage |
| Denial follow-up | 42% of practice managers said nobody owns denial follow-up full time | A named owner for every denial |
| Terms | Employment commitments | Month to month, 30 days notice |
| Partner type | PDPM and MDS depth | Consolidated billing checks | Terms |
|---|---|---|---|
| In-house business office | One or two people | Often left to accounts payable | Payroll and turnover |
| Generalist billing company | Physician claim focus | Rarely included | Often annual |
| Specialty SNF billing company | PDPM and Medicaid experience | Sometimes included | Some charge setup fees |
| EHR vendor RCM | Vendor workflows | Limited | Bundled with software |
| Luxen | Certified coders for UB-04, HIPPS and Part B therapy | Included | Month to month, 30 days notice |
Compare medical billing companies on these points, or see what full-service medical billing covers.
A 30-minute look at your AR ageing, denial reasons and payer mix. You leave knowing what is recoverable, what we would work first and what it would cost.
We sign a business associate agreement before anyone touches your system. Your named team then works inside the practice management system and clearinghouse you already use. Nothing is migrated, and claims are being worked within two weeks of the signed BAA.
Aged and denied claims come first because that is revenue you have already earned. Most practices see the first recovered payments inside three weeks.
Once the backlog is moving, we take over the agreed part of the daily cycle: eligibility, coding review, submission, posting, denials and patient balances.
You know who owns your claims. The team works inside the practice management system and EHR you already run, with no migration.
Claims are coded by certified coders against your documentation and payer rules. Automation handles the repetitive checks so people spend their time on the claims that need judgment.
We sign a business associate agreement before accessing protected health information, and access is limited to the named people on your account.
We look at your AR ageing, volume, payer mix and denial profile first, then tell you what we believe is recoverable and what it would cost.
A billing company is a poor fit if you are not willing to share visibility into your billing, if the vendor uses a rotating pool of people who never learn your practice, or if it cannot explain why your claims are being denied. Be wary of anyone promising large collection increases before they have seen your AR ageing. The right partner makes your revenue cycle more visible, not less.
Medicare Part A SNF stays bill on type of bill 21X, with revenue code 0022 carrying the HIPPS code. Part B services for residents, such as therapy, bill on 22X, non-certified areas on 23X, and hospital swing beds on 18X. No-pay claims use 210 with condition code 21.
Luxen charges 3% to 6% of collections, depending on payer mix, census and authorization workload. For a facility collecting $800,000 a month, that is $24,000 to $48,000 a month. There is no setup or exit fee, and terms are month to month with 30 days notice.
About 2 weeks from signed BAA to working claims; across Luxen clients, median time from signed BAA to first claims worked was 9 business days. We start with open Part A months, pending Medicaid accounts and the oldest recoverable claims, so first recovered payments arrive in about 3 weeks.
Yes. We work inside PointClickCare, MatrixCare, Netsmart, Yardi EHR and other SNF systems, using the census, MDS and billing modules your team already uses. We sign a BAA before access.
Under PDPM, a readmission to the same SNF within 3 consecutive calendar days is an interrupted stay. The variable per diem and assessment schedules continue, with no new 5-day or PPS discharge assessment. A return after the window starts a new Part A stay and a new 5-day assessment.
Thirty minutes, no deck and no fee. We look at what is sitting past 90 days and where your denials cluster, and you leave knowing what is recoverable, what we would work first, and what it would cost.
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