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Skilled Nursing Facility Billing Services
When the MDS and the Claim Don't Agree, the SNF Pays for It: PDPM Errors, Missed Consolidated Billing and MA Auth Gaps
What Is SNF Billing, and What Does It Require?
SNF billing is the process of turning each MDS assessment into a HIPPS code under the Patient Driven Payment Model (PDPM), billing the Medicare Part A per diem with its variable adjustments, and keeping outside providers' services under consolidated billing. It also covers Part B therapy for long-term residents, Medicare Advantage stays and Medicaid per diem claims. Qualigenix does this for skilled nursing facilities with coders at 98.9% coding accuracy and an over- and undercoding rate under 2%. Book a free billing audit at 786-259-0231.
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PDPM Diagnosis & NTA Coding
PDPM assigns each stay a clinical category from the primary diagnosis on the MDS, and the non-therapy ancillary (NTA) component pays for comorbidities and services the MDS captures. A primary diagnosis the record doesn't support, or a comorbidity that isn't coded, changes the HIPPS code and the per diem.
How Qualigenix Aligns the MDS, the Chart & the Claim
Qualigenix checks each SNF claim against the MDS, the medical record and the payer's authorization before release. Each fix below answers one of the gaps above, in the same order.
PDPM Diagnosis Coding and NTA Capture
Coders confirm the primary diagnosis maps to the right PDPM clinical category and that each NTA comorbidity on the MDS is supported in the record. Qualigenix holds 98.9% coding accuracy with over- and undercoding under 2%.
CASE STUDY 01
How a 3-provider podiatry group cleared $214K in aged A/R
THE SITUATION
A 3-provider podiatry group with roughly 60% Medicare payer mix carried $412,000 in A/R, 38% of it past 120 days. Routine foot care claims (11720, 11721, 11055–11057) had stalled on inconsistent Q7/Q8/Q9 modifiers and class-finding documentation, so payers held or partially paid and nobody worked the remainder. Medicare crossover to secondaries was not being posted, and small patient balances were written off.
WHAT QUALIGENIX DID
We ran a full A/R aging segmentation, worked claims by payer and denial reason rather than by date, rebilled the stalled routine-care claims with corrected modifiers, and reactivated secondary and crossover billing.
Key Outcomes & Turnaround
38% to 14%A/R past 120 days
$214,000recovered from aged A/R
90 daysto turn it around
~60%Medicare payer mix
Audited Practice Results
How a solo podiatrist lifted first-pass acceptance to 96%
THE SITUATION
A solo podiatrist coding 320 encounters a month was stuck at 82% first-pass acceptance. Routine foot care went out without the systemic-condition diagnosis pairing and class findings Medicare requires, so it read as non-covered. Wound debridement was coded to the wrong depth (11042 for skin and subcutaneous where the note supported 11043 for muscle and fascia). Same-day E/M with a procedure went out without modifier 25 and got bundled.
WHAT QUALIGENIX DID
We rebuilt the coding workflow: diagnosis-to-CPT pairing rules for at-risk foot care, correct Q-modifier logic, depth-based debridement coding tied to the operative note, and disciplined use of modifiers 25 and 59/XS.
Key Outcomes & Turnaround
82% to 96%first-pass acceptance
+11%per-encounter reimbursement
60 daysto turn it around
320/moencounters coded
Audited Practice Results
How a 2-location podiatry practice cut its denial rate by two-thirds
THE SITUATION
A 2-location podiatry practice sat at a 19% denial rate, mostly Medicare routine-foot-care and nail-debridement rejections. The denials clustered in three buckets: medical-necessity rejections on routine foot care (missing qualifying diagnosis and class findings), frequency-edit denials on nail debridement billed inside the 60-day window, and missing Q modifiers that flagged services as non-covered.
WHAT QUALIGENIX DID
We built a front-end denial-prevention layer, checking eligibility and coverage against payer LCDs before claims went out, plus a structured appeal workflow with documentation templates mapped to each denial reason.
Key Outcomes & Turnaround
19% to 6%denial rate
$68,000recovered on appealed claims
4 monthsto turn it around
2 locationspractice size
Audited Practice Results
SNF Billing Codes and Claim Types We Handle
Qualigenix bills every claim type a skilled nursing facility sends to Medicare, Medicare Advantage and Medicaid.
Part A PDPM Stays
Part A inpatient claims on type of bill 021x, with each HIPPS code on revenue code 0022 and day counts that follow the variable per diem schedule.
How We Keep SNF Billing Compliant
Qualigenix keeps SNF billing compliant by billing each stay from an MDS the medical record supports and applying Medicare's SNF rules as written. Every claim is checked for a qualifying stay, remaining benefit days, signed orders and certifications, and a HIPPS code that matches the assessment. Outside services during a Part A stay stay under consolidated billing, and a monthly triple check compares the MDS, the record and the claim before release. Underbilling costs the facility revenue it earned, and overbilling invites audits and repayment demands. Qualigenix holds a 98.6% compliance and audit pass rate with an over- and undercoding rate under 2%, and all patient data is handled under HIPAA-compliant security controls.
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Audit Pass Rate
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Variance Threshold
Why Skilled Nursing Facilities Choose Qualigenix
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Improper Payment Rate
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From Doc Gaps
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From Coding Errors
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Paid in Errors
QUESTIONS BUYERS ASK
Qualigenix quotes SNF billing after reviewing your census, payer mix between Medicare, Medicare Advantage and Medicaid, and current A/R, so the fee reflects the work your facility needs. Most facilities start with a free billing audit, and the quote follows from it.
Coders match the HIPPS code on every claim to the assessment that set it, confirm the primary diagnosis and NTA comorbidities in the record, and hold claims with a mismatch until the MDS team resolves it.
Medicare auditors check that the HIPPS code matches documentation supporting the MDS, that physician orders and certifications are present, and that the stay had a qualifying hospital stay and remaining benefit days. In CMS's 2025 data, HIPPS levels changed on review and missing orders were among the most frequent root causes.
Yes. Qualigenix works existing Medicare, Medicare Advantage and Medicaid A/R by age and payer, starting with claims closest to timely filing limits. Across Qualigenix clients, days in A/R dropped from 54 to 36.
Qualigenix confirms the pre-admission authorization, tracks approved days and level of care for each stay, and sends concurrent review updates before the last approved date so covered days don't lapse.
During a covered Part A stay, the SNF bills Medicare for most services the resident receives, including many from outside providers, and pays those providers. Qualigenix reconciles vendor invoices against Part A days so each service is billed once.
Qualigenix works across 133 EMR/EHR platforms, including the systems skilled nursing facilities commonly use. We confirm your setup on the first call.
Qualigenix onboarding averages 6 days for a facility, covering platform access, EDI setup and a first MDS-to-claim review. Multi-site groups can onboard facility by facility. Call 786-259-0231 to schedule a free billing audit and start.