#pdpm coding

If you've spent any time managing billing at a skilled nursing facility, you know the drill. A claim goes out, weeks pass, and then denial. Or worse, a partial payment with no clear explanation. You chase the payer, dig through documentation, resubmit, and wait again. Meanwhile, your facility's cash flow sits in limbo.

This isn't a rare problem. It's the norm for a lot of SNFs operating without a structured claims submission and management process. And the financial damage adds up faster than most administrators expect.

Let's talk about why this keeps happening and what a proper SNF claims management approach looks like when it's done right.

The Real Cost of Claim Denials in SNFs

Most SNF administrators are aware that denials are a problem, but few track just how much revenue is being left on the table. Industry data consistently shows that a significant percentage of denied claims are never resubmitted. They simply disappear into the backlog. Staff is stretched thin, follow-up falls through the cracks, and the revenue is written off.

Beyond lost payments, there's the hidden cost of rework. Every denied claim that needs to be corrected and resubmitted takes time - time that your billing team could be spending on new claims or patient-facing tasks. Multiply that across dozens or hundreds of claims per month, and the operational drag becomes very real.

The root causes are usually predictable: incorrect or incomplete ICD-10 coding, missing MDS documentation, PDPM component errors, or simply claims that don't meet a specific payer's submission format. None of these are mysterious. They're fixable but only with the right process in place.

Electronic Submission Isn't Just a Tech Upgrade - It’s a Compliance Issue

Many SNFs still rely on manual or semi-manual claims processes. While the intent is fine, the execution creates problems. Manual entries introduce errors. Paper-based workflows slow down turnaround. And certain payer requirements around EDI compliance simply can't be met without proper electronic claims infrastructure.

SNF electronic claims submission done through EDI-compliant channels isn't just faster. It's more accurate, more traceable, and less prone to the kind of data-entry mistakes that trigger automatic rejections. When claims go out clean the first time, payment turnaround improves measurably. It's one of those changes that looks small on paper but makes a significant difference in monthly cash flow.

That said, electronic submission alone doesn't solve everything. The claim still needs to be coded correctly. The documentation still needs to match. And someone still needs to follow up if the claim stalls in processing.

PDPM Coding: Where the Money Actually Comes From

Since Medicare shifted to the Patient-Driven Payment Model, accurate PDPM coding has become central to SNF reimbursement. The model is designed to reward clinical complexity but only if your claims reflect that complexity accurately.

This is where a lot of facilities underperform. Not because the care isn't being delivered, but because the coding doesn't capture it properly. PDPM components including physical therapy, occupational therapy, speech-language pathology, nursing, and non-therapy ancillary categories each need to be mapped to the right diagnosis codes for the claim to reflect full clinical picture.

Under coding means underpayment. And in a reimbursement environment where margins are already tight, that's a problem that compounds over time.

What a Full Claims Lifecycle Actually Looks Like

A well-run SNF claims process isn't just about submitting claims and hoping for the best. It involves active management at every stage:

It starts with documentation review pulling together the MDS assessments, medical records, and clinical notes needed before a claim ever gets coded. Gaps at this stage almost always result in denials later, so catching them early is critical.

From there, claims go through coding and preparation, with ICD-10 codes, PDPM components, and therapy codes assigned based on clinical data. Then electronic submission through the appropriate EDI channels.

But the process doesn't end there. Tracking is essential. Claims need to be monitored through payer systems, and if they stall or come back with issues, someone needs to engage directly with the payer to resolve it fast.

When denials do happen, the response needs to be systematic. That means root-cause analysis, not just resubmission. If a certain type of claim is being denied repeatedly, there's usually a pattern that can be corrected upstream.

Finally, payment reconciliation closes the loop making sure what was paid matches what was billed, and flagging discrepancies before they become aged AR issues.

The Case for Working with a Specialized SNF Billing Partner

Not every billing company understands the specific demands of skilled nursing. SNF billing sits at a complicated intersection of Medicare, Medicaid, PDPM, MDS, consolidated billing requirements, and payer-specific rules that change regularly. Generalist billing teams often struggle here.

That's why facilities that partner with specialists in SNF billing tend to see meaningfully better results fewer denials, faster payments, and cleaner AR. MCA Medical Billing Solutions, L.L.C. is one example of a company that has built its entire practice around SNF revenue cycle management. Their claims submission and management service covers the full lifecycle, from initial documentation review to payment reconciliation, with dedicated follow-up and denial management built into the process. For facilities looking to reduce administrative burden without sacrificing billing performance, that kind of specialized support can be genuinely valuable.

What to Look for If You're Evaluating Your Current Process

Here are a few honest checkpoints worth running through:

What's your first pass claim acceptance rate? If it's below 95%, that's worth investigating. Are denials being appealed consistently, or are some just being written off? Do you have visibility into claim status at any given moment, or is it a black box? How long does it typically take from service date to payment receipt?

If the answers to any of these are unclear or concerning, the issue usually isn't the billing staff it's the process. Billing in a high-complexity environment like SNF requires structure, the right tools, and people who know the specific rules well enough to catch problems before they become denials.

Final Thought

SNF billing isn't going to get simpler. Regulatory changes, payer rule updates, and increasing documentation demands are ongoing realities. But facilities that invest in a structured, managed claims process with accurate coding, electronic submission, proactive follow-up, and systematic denial management consistently outperform those that are still running on reactive, manual workflows.