Skip to main content

Set up a billing episode

Use a billing episode to identify the primary payor, billing provider, disciplines, and dates for therapy services in an admission. The primary payor determines the reimbursement model, while the billing provider identifies the legal provider used for reimbursement.

Before you start​

Make sure you have:

Understand billing episodes​

Think of an admission as a patient's connection to a facility. In some long-term care facilities, one admission can span years.

During that time, the patient may be picked up for therapy many times. RehabAlpha records each period as a therapy case within the admission.

A billing episode answers a simple question: Who pays for therapy? It identifies:

  1. The payor responsible for reimbursement
  2. The billing provider submitting the services, when applicable
  3. The time period
  4. The disciplines

Like therapy cases, billing episodes live within an admission. One admission can have many billing episodes—for example, when a patient switches payors from Med B to Med A.

An admission can also have billing episodes that run at the same time when they cover different disciplines. For example:

Billing episodes can affect clinical documentation​

When a therapist works on a clinical document, RehabAlpha matches it to a billing episode by discipline and effective date. Your organization's schema can use the matched primary payor, payor type, or payment model to show or require different documentation.

For example, your organization can show Section GG assessments when the matched payor type is Medicare Part A or Managed Care Part A.

In this example, the evaluation in PT case 1 maps to billing episode 1, which uses Med A. The evaluation therefore shows documentation geared toward Med A.

Evaluations, re-evaluations, and discharges use their document date to match a billing episode. Treatments and progress reports use their start date.

For details about configuring these rules, see Schemas overview.

Weird scenarios​

A therapy case does not require a billing episode. You can create the case and its clinical documentation without one, but RehabAlpha will not have a matched primary payor or payment model for payor-dependent documentation and billing workflows.

A therapy case can span two or more billing episodes for the same discipline. For example, if the payor changes during a PT case, end the first PT billing episode and start a new, non-overlapping one. You do not need to start a new therapy case just because the payor changed. Documents on either side of the change use the billing episode that matches their effective date.

Billing episodes can also run at the same time when they cover different disciplines. For example, one episode can cover PT and OT while another covers SLP for the same dates. Two billing episodes cannot overlap when they share any discipline.

PDPM case-mix per diem​

When you select a primary payor that uses PDPM case-mix per diem, RehabAlpha shows the fields it needs to calculate daily SNF reimbursement:

FieldWhat to enter
Service locationThe SNF location for the stay. It applies to every matched document and service. Other payment models use an optional billing-episode Default service location that documents can override. See Facility vs service location.
Initial stay dayThe stay day for the episode's first covered date. It controls variable per-diem adjustments.
Initial benefit dayThe benefit day for the first covered date. It tracks the patient's 100 Medicare Part A SNF benefit days.
Prior hospitalizationThe preceding hospital stay and any qualifying major procedure. These details inform clinical category and case-mix suggestions.
PDPM assessmentsStart with a 5-day assessment and reference date. Add an Interim Payment Assessment when the case-mix classification changes. Assessments supply the OT/PT, SLP, Nursing, and NTA case-mix groups.
Interrupted-stay periodsNon-covered dates inside the interrupted-stay window. RehabAlpha omits them from the Part A revenue table and resumes day counts on the next covered date.

Important rules​

  • Stay day and benefit day usually start at 1. They can differ if a new SNF stay begins in the same benefit period, but stay day cannot exceed benefit day. See Stay day vs Benefit day.
  • An interrupted-stay period can contain no more than three days. Create a new PDPM billing episode if the patient returns after that window or goes to a different SNF. See Interrupted stays.
  • PDPM episodes always cover PT, OT, and SLP, so Disciplines cannot be changed.

For payor arrangement and facility contract setup, see PDPM case-mix per diem.

Create a billing episode​

  1. Open the patient's admission.
  2. Find Billing episodes.
  3. ➕ Click Add billing episode.
  4. Select the Primary payor. RehabAlpha shows its payment model type.
  5. Review Billing provider. RehabAlpha applies the facility's first matching default rule. You can select another provider or clear the field for this episode.
  6. Select one or more disciplines.
  7. Enter the period start and end dates.
  8. For PDPM case-mix per diem, select the skilled nursing facility service location.
  9. For PDPM case-mix per diem, enter the initial stay day and initial benefit day. For most stays, enter 1 for both.
  10. For PDPM case-mix per diem, add interrupted-stay periods if the patient temporarily leaves Part A-covered SNF care and returns within the interrupted-stay window.
  11. For Custom fee schedule, Duration-based payment, or Medicare Part B MPFS, select a default service location when appropriate. RehabAlpha selects it automatically when the facility has only one option; you can clear the selection.
  12. Save the admission.

You should know​

The billing episode saves snapshots of the selected primary payor and billing provider. Later name changes do not change those snapshots. If the current provider record becomes unavailable, the saved provider name remains visible for history and audit.

Facility rules apply only when you select a payor for a new episode, change an episode's primary payor, or change the admission's facility. Opening or otherwise editing an existing episode keeps its saved provider. Rule changes also do not update existing episodes.

Patient coverages are separate, patient-specific records for dates, benefits, and authorizations. Billing episodes do not select or sequence patient coverage records.

You can save a billing episode before payor arrangements are configured for its payor and billing provider. This lets you set up cases and clinical documentation first. Payor reimbursement remains unavailable until a matching arrangement covers the service date. The episode's billing provider remains fixed even when matching arrangements change across effective periods.

Frequently asked questions​

Which billing episode applies to a progress report?​

RehabAlpha matches a progress report by discipline and Start date. Its end date does not select the billing episode, even though the report summarizes a date range. If the report spans a payor change, the primary payor and payor-dependent documentation come from the episode containing the report's start date.

When should I add another billing episode?​

Add another billing episode when the responsible payor changes, the current episode period ends, a managed care plan begins, or the patient moves to another billing arrangement. End the previous episode and start the next one on the change's effective date. For the same discipline, make sure the episode periods do not overlap.