TL;DR
Chapter 6 of the Medicare Claims Processing Manual explains how skilled nursing facilities bill Part A stays and how consolidated billing works. It covers which services the SNF must bill even when an outside supplier furnishes them and which are excluded, how stays are billed with HIPPS rate codes under the Patient Driven Payment Model, the interrupted stay policy, utilization days and benefit exhaustion, payment bans, and billing by hospital swing beds.
Chapter 6 at a glance
- Current revision
- Rev. 13089
- Issued February 21, 2025
- Effective
- May 22, 2025
- Implemented May 22, 2025
- Sections
- 107
- 12 top-level sections
- Transmittals in history
- 81
- Listed at the end of the chapter
- Monthly searches
- 40
- Google Ads, US, October 2026
What chapter 6 governs for billing
Consolidated billing is the heart of the chapter. Under section 10, the SNF itself must bill Medicare for almost all services its Part A residents receive, including services furnished by outside suppliers under arrangement, and the supplier looks to the SNF for payment. Section 20 lists what stays outside: services beyond the scope of the SNF benefit, services excluded because of the beneficiary's characteristics or elections such as hospice and certain ESRD services, high-cost categories such as certain chemotherapy, radioisotope services and customized prosthetics, and most physician professional services (20.1 to 20.4). Therapy is the important exception: physical, occupational and speech-language therapy is bundled for Part A stays and must also be billed by the SNF for residents in a noncovered stay (20.5).
Sections 30 and 120 explain billing under the Patient Driven Payment Model. Each covered stay is billed with HIPPS rate codes derived from the resident's Minimum Data Set assessments (30.1), and the pricer applies the case-mix components and the variable per diem adjustment that lowers certain components as the stay lengthens (120.3). Under the interrupted stay policy, a resident who leaves Part A coverage and returns to the same SNF by 11:59 pm on the third consecutive calendar day continues the same stay, with no new assessment and no reset of the variable per diem schedule (120.2). Default billing applies when an assessment is missing (120.6).
Section 40 holds the inpatient billing rules: bills in sequence, admission and discharge dates, utilization days, ending a benefit period and billing when benefits are exhausted or no payment is due (40.8). Section 50 covers payment bans on new admissions, section 80 physician services, section 100 swing beds, and section 110 how Part B claims for SNF residents are edited, including the place of service codes for physicians: 31 for patients in a Part A stay and 32 for a noncovered stay.
Sections billing teams use most
Section numbers and headings are CMS's; the notes are ours. Each section number opens the official chapter 6 PDF at the page where that section starts.
| Section | CMS heading | Why it matters |
|---|---|---|
| 10.1 | Consolidated Billing Requirement for SNFs | The consolidated billing requirement and who must bill for services to SNF residents. |
| 20.2 | Services Excluded from Part A PPS Payment and the Consolidated Billing Requirement on the Basis of Beneficiary Characteristics and Election | Services excluded from consolidated billing because of the beneficiary's characteristics or elections. |
| 20.5 | Therapy Services | Therapy services: bundled into the SNF payment and billed by the SNF for Part A and Part B residents. |
| 30.1 | Health Insurance Prospective Payment System (HIPPS) Rate Code | HIPPS rate codes from MDS assessments on the SNF claim. |
| 40.8 | Billing in Benefits Exhaust and No-Payment Situations | Billing when benefits are exhausted and no-payment situations. |
| 110.1 | Correct Place of Service (POS) Code for SNF Claims | Place of service 31 or 32 on physician claims for SNF residents. |
| 120.2 | Interrupted Stay Policy | The PDPM interrupted stay policy and its three-day window. |
How chapter 6 shows up on claims and denials
Consolidated billing produces denials for everyone except the SNF. When an outside supplier, laboratory or practitioner bills Medicare Part B directly for a service that is included in a resident's covered Part A stay, the common working file edits reject the claim because the SNF's payment already covers it. For one of these edits chapter 6 tells contractors to deny with group code CO, reason code 96 and remark N121, which says Part B does not pay for the service during a covered SNF stay. The fix is an arrangement with the SNF, not an appeal.
SNF claims themselves are denied for missing qualifying stays, assessment timing problems and sequence errors. Bills must be submitted in sequence for the same stay, a missing assessment drives default billing, and the benefit-day and qualifying-stay rules come from the Medicare Benefit Policy Manual, chapter 8. Physician claims for residents should use place of service 31 or 32, which the edits compare with the resident's status.
Codes you are likely to see on the remittance when a claim runs into this chapter's rules. The code pages explain each code's meaning, root causes and the usual fix.
| Code | Type | When it appears |
|---|---|---|
| 96 | Claim adjustment reason code | Non-covered charge; chapter 6 pairs it with remark N121 for Part B services during a covered SNF stay. |
| 50 | Claim adjustment reason code | Skilled care not reasonable and necessary for the days billed. |
| 16 | Claim adjustment reason code | Missing or invalid HIPPS code, dates or assessment information. |
Current revision and recent transmittals
The chapter PDF posted on cms.gov is current through Rev. 13089, issued February 21, 2025, effective May 22, 2025, implemented May 22, 2025 (change request 13955). That revision changed section 30.4 (SNF PPS Pricer Software). Its subject line reads: “Manual Updates Regarding Home Health Adjustments and Skilled Nursing Facility, Home Health and Hospice Pricer Information”.
The newest rows of the transmittal history printed at the end of the chapter (81 revisions in all). Rows whose subject could not be read reliably from the PDF table are left out; the PDF has the complete list.
| Revision | Issued | Subject | CR |
|---|---|---|---|
| R13089CP | February 21, 2025 | Manual Updates Regarding Home Health Adjustments and Skilled Nursing Facility, Home Health and Hospice Pricer Information | 13955 |
| R12283CP | October 5, 2023 | Internet Only Manual Updates to Pub. 100-02 and 100-04 to Implement Consolidated Appropriations Act 2023 Changes for Skilled Nursing Facility (SNF) | 13271 |
| R11109CP | November 4, 2021 | Skilled Nursing Facility (SNF) Claims Processing Updates | 12344 |
| R10880CP | June 8, 2021 | Internet Only Manual Updates to Pub. 100-01, 100-02, and 100-04 to Implement Consolidated Appropriations Act Changes and Correct Errors and Omissions (SNF) | 12009 |
| R10569CP | January 14, 2021 | Updates to Skilled Nursing Facility (SNF) Patient Driven Payment Model (PDPM) Claims | 11992 |
| R10236CP | July 31, 2020 | Update to the IOM Publication (Pub) 100-04, Medicare Claims Processing Manual, Chapters 1, 6, 8, 17, 20, 22, 24, and 31 Referencing the Active Universal Resource Locators (URLs) for the Washington Publishing Company (WPC) and the ASC X12 Organizations, and Updates to the HIPAA Eligibility Transaction | 11857 |
Sections ordered by the date in the revision note printed under each heading.
| Section | Heading | Revision |
|---|---|---|
| 30.4 | SNF PPS Pricer Software | Rev. 13089, February 21, 2025; effective May 22, 2025 |
| 20.1.1 | Physician's Services and Other Professional Services Excluded From Part A PPS Payment and the Consolidated Billing Requirement | Rev. 12283, October 5, 2023; effective January 8, 2024 |
| 10.4.1 | "Under Arrangements" Relationships | Rev. 10880, August 6, 2021; effective November 8, 2021 |
| 20.3 | Other Services Excluded from SNF PPS and Consolidated Billing | Rev. 10880, August 6, 2021; effective November 8, 2021 |
| 20.3.1 | Ambulance Services | Rev. 10880, August 6, 2021; effective November 8, 2021 |
| 30 | Billing SNF PPS Services | Rev. 10880, August 6, 2021; effective November 8, 2021 |
| 30.1 | Health Insurance Prospective Payment System (HIPPS) Rate Code | Rev. 10880, August 6, 2021; effective November 8, 2021 |
| 30.5 | Annual Updates to the SNF Pricer | Rev. 10880, August 6, 2021; effective November 8, 2021 |
Section index
Every section in the chapter's table of contents, grouped under its top-level heading, with the PDF page where it starts. Open a heading to see its subsections.
10 Skilled Nursing Facility (SNF) Prospective Payment System (PPS) and Consolidated Billing Overview · p. 5 · 6 subsections
- Open section 10 in the PDF
- 10.1 Consolidated Billing Requirement for SNFs · p. 6
- 10.2 Types of Facilities Subject to the Consolidated Billing Requirement for SNFs · p. 9
- 10.3 Types of Services Subject to the Consolidated Billing Requirement for SNFs · p. 10
- 10.4 Furnishing Services that are Subject to SNF Consolidated Billing Under an "Arrangement" with an Outside Entity · p. 11
- 10.4.1 "Under Arrangements" Relationships · p. 13
- 10.4.2 SNF and Supplier Responsibilities · p. 14
20 Services Included in Part A PPS Payment Not Billable Separately by the SNF · p. 15 · 17 subsections
- Open section 20 in the PDF
- 20.1 Services Beyond the Scope of the Part A SNF Benefit · p. 16
- 20.1.1 Physician's Services and Other Professional Services Excluded From Part A PPS Payment and the Consolidated Billing Requirement · p. 16
- 20.1.1.1 Correct Place of Service (POS) Code for SNF Claims
- 20.1.1.2 Hospital's "Facility Charge" in Connection with Clinic Services of a Physician · p. 19
- 20.1.2 Other Excluded Services Beyond the Scope of a SNF Part A Benefit · p. 20
- 20.1.2.1 Outpatient Surgery and Related Procedures-Inclusion · p. 21
- 20.1.2.2 Emergency Services · p. 22
- 20.2 Services Excluded from Part A PPS Payment and the Consolidated Billing Requirement on the Basis of Beneficiary Characteristics and Election · p. 22
- 20.2.1 Dialysis and Dialysis Related Services to a Beneficiary With ESRD · p. 23
- 20.2.1.1 ESRD Services · p. 24
- 20.2.1.2 Coding Applicable to Dialysis Services Provided in a Renal Dialysis Facility (RDF) or Home) · p. 24
- 20.2.2 Hospice Care for a Beneficiary's Terminal Illness · p. 24
- 20.3 Other Services Excluded from SNF PPS and Consolidated Billing · p. 25
- 20.3.1 Ambulance Services · p. 26
- 20.4 Screening and Preventive Services · p. 29
- 20.5 Therapy Services · p. 31
- 20.6 SNF CB Annual Update Proces for A/B MACs (A) · p. 32
30 Billing SNF PPS Services · p. 33 · 5 subsections
- Open section 30 in the PDF
- 30.1 Health Insurance Prospective Payment System (HIPPS) Rate Code · p. 34
- 30.2 Coding PPS Bills for Ancillary Services · p. 35
- 30.3 Adjustment Request · p. 36
- 30.4 SNF PPS Pricer Software · p. 36
- 30.5 Annual Updates to the SNF Pricer · p. 37
40 Special Inpatient Billing Instructions · p. 38 · 23 subsections
- Open section 40 in the PDF
- 40.1 Submit Bills in Sequence · p. 38
- 40.2 Reprocessing Inpatient Bills in Sequence · p. 39
- 40.3 Determining Part A Admission Date, Discharge Date, and Utilization Days · p. 39
- 40.3.1 Date of Admission · p. 39
- 40.3.2 Patient Readmitted Within 30 Days After Discharge · p. 39
- 40.3.3 Same Day Transfer · p. 40
- 40.3.4 Situations that Require a Discharge or Leave of Absence · p. 41
- 40.3.5 Determine Utilization on Day of Discharge, Death, or Day Beginning a Leave of Absence · p. 42
- 40.3.5.1 Day of Discharge or Death Is the Day Following the Close of the Accounting Year · p. 43
- 40.3.5.2 Leave of Absence · p. 43
- 40.4 Accommodation Charges Incurred in Different Accounting Years · p. 43
- 40.5 Billing Procedures for Periodic Interim Payment (PIP) Method of Payment · p. 44
- 40.6 Total and Noncovered Charges · p. 44
- 40.6.1 Services in Excess of Covered Services
- 40.6.2 Showing Discounted Charges · p. 45
- 40.6.3 Reporting Accommodations on the Claim · p. 45
- 40.6.4 Bills with Covered and Noncovered Days
- 40.6.5 Notification of Limitation on Liability Decision · p. 47
- 40.7 Ending a Benefit Period · p. 48
- 40.8 Billing in Benefits Exhaust and No-Payment Situations · p. 48
- 40.8.1 SNF Spell of Illness Quick Reference Chart · p. 53
- 40.8.2 Billing When Qualifying Stay or Transfer Criteria are Not Met · p. 55
- 40.9 Other Billing Situations · p. 55
50 SNF Payment Bans, or Denial of Payment for New Admissions (DPNA) · p. 56 · 13 subsections
- Open section 50 in the PDF
- 50.1 Effect on Utilization Days and Benefit Period · p. 56
- 50.2 Billing When Ban on Payment Is In Effect
- 50.2.1 Effect of an Appeal to a DPNA on Billing Requirements During the Period a SNF is Subject to a DPNA · p. 57
- 50.2.2 Provider Liability Billing Instructions · p. 57
- 50.2.3 Beneficiary Liability Billing Instructions · p. 58
- 50.2.4 Part B Billing · p. 58
- 50.3 Sanctions Lifted: Procedures for Beneficiaries Admitted During the Sanction Period · p. 58
- 50.3.1 Tracking the Benefit Period · p. 58
- 50.3.2 Determining Whether Transfer Requirements Have Been Met · p. 59
- 50.4 Conducting Resident Assessments · p. 59
- 50.5 Physician Certification · p. 61
- 50.6 A/B MAC (A) Responsibilities · p. 61
- 50.7 Retroactive Removal of Sanctions · p. 62
60 Billing Procedures for a Composite SNF or a Change in Provider Number · p. 62
70 Billing for Services After Termination of Provider Agreement, or After Payment is Denied for New Admissions · p. 62 · 3 subsections
- Open section 70 in the PDF
- 70.1 General Rules · p. 62
- 70.2 Billing for Covered Services · p. 63
- 70.3 Part B Billing · p. 64
80 Billing Related to Physician's Services · p. 64 · 7 subsections
- Open section 80 in the PDF
- 80.1 Reassignment Limitations · p. 64
- 80.2 Payment to Employer of Physician · p. 65
- 80.3 Information Necessary to Permit Payment to a Facility · p. 66
- 80.4 Services Furnished Within the SNF · p. 66
- 80.5 Billing Under Arrangements · p. 66
- 80.6 Indirect Contractual Arrangement · p. 67
- 80.7 Establishing That a SNF Qualifies to Receive Part B Payment on the Basis of Reassignment · p. 68
90 Medicare Advantage (MA) Beneficiaries · p. 68 · 2 subsections
- Open section 90 in the PDF
- 90.1 Beneficiary Disenrolled from MA Plans · p. 68
- 90.2 Medicare Billing Requirements for Beneficiaries Enrolled in MA Plans · p. 69
100 Part A SNF PPS for Hospital Swing Bed Facilities · p. 70 · 1 subsections
- Open section 100 in the PDF
- 100.1 Swing Bed Services Not Included in the Part A PPS Rate · p. 71
110 A/B MAC (B)/DME MAC Claims Processing for Consolidated Billing for Physician and Non-Physician Practitioner Services Rendered to Beneficiaries in a SNF Part A Stay · p. 72 · 12 subsections
- Open section 110 in the PDF
- 110.1 Correct Place of Service (POS) Code for SNF Claims · p. 72
- 110.2 CWF Edits · p. 72
- 110.2.1 Reject and Unsolicited Response Edits · p. 72
- 110.2.2 A/B Crossover Edits · p. 74
- 110.2.3 Duplicate Edits · p. 76
- 110.2.4 Edit for Ambulance Services · p. 77
- 110.2.5 Edit for Clinical Social Workers (CSWs) · p. 77
- 110.2.6 Edit for Therapy Services Separately Payable When Furnished by a Physician · p. 78
- 110.2.7 Edit to Prevent Payment of Facility Fees for Services Billed by an Ambulatory Surgical Center (ASC) when Rendered to a Beneficiary in a Part A Stay · p. 78
- 110.3 CWF Override Codes · p. 79
- 110.4 Coding Files and Updates · p. 79
- 110.4.1 Annual Update Process · p. 79
120 Skilled Nursing Facility (SNF) Patient Driven Payment Model (PDPM) · p. 80 · 6 subsections
- Open section 120 in the PDF
- 120.1 HIPPS Updates and Structure Changes · p. 80
- 120.2 Interrupted Stay Policy · p. 81
- 120.3 Variable Per Diem (VPD) Adjustment · p. 83
- 120.4 AIDS Adjustments · p. 84
- 120.5 Transition Claims · p. 84
- 120.6 Default Billing · p. 85
Using this chapter in a denial or appeal
Start with the remittance. The claim adjustment reason code says what happened to the line, the remark code narrows it, and the group code says who is liable. Match that to the section of the chapter that sets the rule, then read the section in the official PDF rather than a summary: the wording that matters, such as a time limit, a modifier requirement or a documentation element, is usually a single sentence. Check the revision note under the section heading, because a rule that changed after the date of service may not apply to the claim, and an effective date earlier than the issue date can make a new rule reach back.
When the chapter supports the claim, cite it precisely in the redetermination request: the publication number, chapter, section and revision. When it does not, the fix is usually a corrected claim or better documentation rather than an appeal, and a coding or format rejection is corrected and resubmitted because it carries no appeal rights. Manual instructions bind the Medicare Administrative Contractor, so they settle most first-level disputes; at the hearing level, administrative law judges give them substantial deference without being bound by them. If the issue turns on whether a service is covered at all, read the matching Benefit Policy Manual chapter and any national coverage determination or local coverage determination as well, because coverage and billing rules are written in different places.
How QuickIntell works with Claims Processing Manual chapter 6
QuickRCM covers eligibility, claim readiness, denials, posting and A/R with configurable automation and human review, which is where the billing rules in this chapter are checked before a claim goes out. QuickCode supports qualified coder review of the coding and modifier questions the chapter answers.
Frequently asked questions: chapter 6
What is SNF consolidated billing?
Under chapter 6 section 10, a skilled nursing facility must bill Medicare for nearly all services its residents receive during a covered Part A stay, including those furnished by outside suppliers, which then look to the SNF for payment. Section 20 lists the exclusions.
How does the PDPM interrupted stay policy work?
Section 120.2 says that if a resident leaves Part A coverage and returns to the same SNF no later than 11:59 pm on the third consecutive calendar day, it is the same stay: no new assessment is required and the variable per diem schedule is not reset.
Which place of service do physicians use for SNF residents?
Section 110.1 says POS 31 for patients in a covered Part A stay and POS 32 for residents in a noncovered stay.
Sources
Every figure on this page is taken from the CMS publications below, as released by the Centers for Medicare & Medicaid Services. Projection built 2026-10-10. Verify against the primary file before billing or contracting decisions. The reference methodology explains how each figure is computed from these files.
- Medicare Claims Processing Manual, Chapter 6: SNF Inpatient Part A Billing and SNF Consolidated BillingVersion Rev. 13089, issued 2025-02-21 · effective 2025-05-22 · file clm104c06.pdfSHA-256 5745c7e11db0c2ae…
- Medicare Claims Processing Manual (Pub. 100-04)Version 39 chapter PDFs; newest revision Rev. 13836 (chapter 14), issued 2026-06-24 · effective 2026-09-27 · file 100-04-claims-processing-manual/*.pdf (39 chapters; SHA-256 of their sha256sum listing)SHA-256 f87bc3bcd9d1570d…
Disclaimer
This guide summarizes a CMS manual chapter in our own words for billing teams; section headings and transmittal subjects are quoted from the chapter PDF. The chapter itself is the authority, and it changes by transmittal. Not legal, clinical or billing advice.
Found a figure that does not match the CMS file? Report a data correction with the CMS file and the value you expected; the request reaches the editorial team through the contact form.