Your Patient Is on a Medicare Nursing Home Stay. The X-Ray Your Office Took Is the Facility's to Pay.

On October 26, 2026, CMS issued Change Request 14658, the 2027 annual update of the HCPCS code files that Medicare uses to enforce skilled nursing facility (SNF) consolidated billing. It takes effect for dates of service from January 1, 2027. CMS will post the new physician code files after the final 2027 Physician Fee Schedule is released.

The update changes code lists, not the rule. The rule is the part a physician practice needs to understand. While a Medicare patient is in a covered Part A SNF stay, the facility receives one daily payment that covers almost all of the patient's services. Medicare still pays a physician or other listed practitioner directly for their own professional services. Most of the rest is the facility's to bill, even when the work was done in your office.

Where a routine office visit turns into a denial

Here is a hypothetical case. A patient in a nursing home after a hip fracture comes to an orthopedic office for a follow-up visit. The physician orders a hip x-ray, the office takes it on its own machine, and the claim goes out with the visit and the full x-ray code. Nobody asked whether the patient was still in a Medicare-covered stay. She was.

Medicare pays the visit. The x-ray is different. For a test with a technical and a professional component, CMS says the technical component must be billed by the SNF for its Part A patients, and the Medicare contractor pays only the professional component to the physician. If the SNF's claim is already on file, the technical part of the x-ray line is rejected. If the office's claim was paid first, Medicare's Common Working File finds it when the SNF's claim arrives, the contractor adjusts the claim, and the overpayment is recovered.

The office cannot send that amount to the patient. Under 42 CFR 489.21(h), a beneficiary cannot be charged for services that are bundled into the SNF payment. The office has to collect from the facility.

What your office can bill, and what belongs to the facility

CMS's manual sets out the split in Chapter 6 of the Claims Processing Manual:

• Professional services of physicians and certain other practitioners, such as physician assistants, nurse practitioners, clinical nurse specialists, certified nurse-midwives and clinical psychologists, are excluded from consolidated billing. Bill them to Medicare as usual.
• For a diagnostic test, the professional component (the interpretation) is separately billable, normally with modifier 26. The technical component (performing the test) is subject to consolidated billing.
• Services done by your staff incident to the physician's service are subject to consolidated billing, and the SNF must bill them.
• A task that does not ordinarily need the physician, such as a routine blood draw, stays bundled even if the physician does it personally.
• Physical therapy, occupational therapy and speech-language pathology are subject to consolidated billing even when a physician performs them. They stay with the SNF during a non-covered stay as well.

Place of service is part of the same picture. CMS asks for POS 31 while the patient is in a Part A covered stay and POS 32 during a non-covered stay. Medicare is already rechecking older POS 32 claims, so the two errors often appear together.

The facility owes you, even without a contract

CMS says the SNF remains responsible for paying an outside supplier for bundled services, even when no written arrangement exists. Its example is a scheduled physician visit at which the physician performs tests the SNF did not order. CMS also expects the SNF to give accurate stay information to the outside practitioner, especially where a professional component stays billable to Part B.

CMS also puts a duty on the office. Before furnishing services, a supplier should find out whether the patient is getting a bundled Medicare benefit, such as a SNF stay. If the patient is a SNF resident and there is no arrangement with that facility, CMS says to contact the SNF before furnishing services that fall under consolidated billing.

A short check for practices that see nursing home patients

This is general information, not legal advice. A practice can start with these steps:

• Add one question at scheduling and check-in: is the patient living in a nursing facility now, and is Medicare paying for the stay?
• For those patients, ask the facility for the Part A admission date and expected end date, and record it on the appointment.
• Set a rule in your billing system: while the stay is covered, diagnostic tests done in the office go out with modifier 26 only, and the technical component is invoiced to the facility.
• Agree in advance with the nursing facilities that send you patients how they want to be invoiced and how fast they pay.
• Pull the last 90 days of Medicare remittances for denied or recouped technical components and therapy lines on nursing home patients. Each one is revenue the facility may still owe you.

The bill nobody sends

Most practices lose this money twice. Medicare denies or takes back the technical component, and nobody invoices the facility because the denial is worked as a write-off. One question at booking keeps the claim on the right side of the split. If you want to know whether this is happening in your practice, a revenue review can look at one payer's denials and recoupments over the last 90 days and trace each one back to the step where it started.