Set up a billing episode
RehabAlpha is still under active development. It is not yet HIPAA compliant and should only be used with dummy data.
Use a billing episode to identify the primary payor, billing provider, dates, and therapy services within 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:
- A patient
- A facility
- An admission
- A payor
- A billing provider, when the reimbursement setup requires one
- One or more existing therapy cases, when you want to pick specific cases instead of disciplines
Understand billing episodes
Think of an admission as one period of care for a patient at the facility that owns the patient record. 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:
- The payor responsible for reimbursement
- The billing provider submitting the services, when applicable
- The time period
- The services covered, selected by discipline or by specific therapy case
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. The following example uses discipline selection to apply each episode to PT, OT, and SLP during a different period:
Choose which services apply
For payment models other than PDPM, use To which services does this billing episode apply? to choose how RehabAlpha selects services:
| Choice | What the episode covers | When to use it |
|---|---|---|
| Pick by discipline | Service lines from every case in the selected disciplines, when the service date is also within the billing episode's date range | One billing arrangement applies to all cases for the selected disciplines |
| Pick specific therapy cases | Service lines from only the selected existing cases, when the service date is also within the billing episode's date range | Concurrent cases in the same discipline use different payors or other billing arrangements |
A service line must satisfy both parts of the episode: its case or discipline must be selected, and its service date must be within the episode's date range. RehabAlpha allows each service line to match no more than one billing episode. If episode selections and dates could make the same service line match twice, adjust the cases, disciplines, or dates before saving.
For example, a patient can have two PT cases at the same time: one paid by a commercial plan and one paid privately. Create one billing episode for each payor, choose Pick specific therapy cases, and select the corresponding PT case in each episode. Their dates can overlap because the episodes apply to different cases.
Billing episodes can affect clinical documentation
When a therapist works on a clinical document, RehabAlpha matches it to a billing episode by the episode's service selection and the document's 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 their service selections do not overlap. For example, one discipline-based episode can cover PT and OT while another covers SLP for the same dates. Specific-case episodes can use the same dates when they select different cases. RehabAlpha does not allow a combination of dates and selections that could match the same service line to two episodes.
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:
| Field | What to enter |
|---|---|
| Service location | The 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. |
| Part A stay start date | The actual first date of the Part A stay. Keep the original date when a billing episode starts partway through that stay or continues after an interrupted stay. It determines the initial Section GG observation period. |
| Initial stay day | The stay day for the episode's first covered date. It controls variable per-diem adjustments. |
| Initial benefit day | The benefit day for the first covered date. It tracks the patient's 100 Medicare Part A SNF benefit days. |
| Prior hospitalization | The preceding hospital stay and any qualifying major procedure. These details inform clinical category and case-mix suggestions. |
| PDPM assessments | Start 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 periods | Non-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 use Pick by discipline and cover PT, OT, and SLP, so the selection and Disciplines cannot be changed. Specific-case selection is not available for PDPM.
For payor arrangement and facility contract setup, see PDPM case-mix per diem.
Complete a PDPM assessment
- Confirm the Part A stay start date. For a new stay with Initial stay day set to
1, RehabAlpha suggests the episode's first covered date. For a continued stay, enter the actual original date. - In PDPM Assessments, click Add PDPM assessment. Choose the Type and enter the Reference date. Review the displayed Section GG observations and Other RAI observations date ranges.
- Review the suggested values and open Review source observations to see their source documents, clinical dates, disciplines, and signature status. Saved unsigned, partially signed, and signed documentation can contribute observations. Suggestions update automatically when clinical documentation is saved. If observations cannot load, use Retry.
- Apply individual suggestions or choose Fill unanswered values. The bulk action preserves values already entered, including an explicit None selection. Review all seven BIMS responses together before choosing Use this complete BIMS interview; that action replaces the seven interview responses together. BIMS interview suggestions are unavailable when Comatose is set to Yes. Resolve any conflicting Comatose and completed BIMS values before applying calculated cognitive or SLP scores.
- Review the calculated OT/PT and SLP information, enter any remaining assessment values and Nursing/NTA case-mix groups, then save the admission.
Suggestions can come from evaluations, re-evaluations, progress reports, treatments, and discharges that contain supported assessment items. RehabAlpha selects the earliest eligible observation and shows differing observations for review. The source must belong to this admission and the same Part A stay at the selected SNF service location. Earlier billing episodes can contribute when they belong to that same stay. Values copied from prior-document references do not count as fresh observations.
There is no single allowable gap between a therapy document and every PDPM input. Medicare uses different observation periods:
| Assessment information | Observation period |
|---|---|
| Initial Section GG performance | The first three calendar days beginning with the actual Part A stay start date. |
| Interim Payment Assessment Section GG performance | The reference date and the preceding two calendar days. |
| Other supported RAI items | Generally the seven days ending on the reference date, subject to the item's instructions. |
The routine 5-day assessment reference date falls on Part A days 1–8. A late date shows a warning and remains available for review. Schedule BIMS on the reference date or the preceding day when possible, and use one complete interview. Confirm the final coding against the CMS MDS 3.0 RAI Manual, chapters 2 and 3.
An eligible therapy observation supports the clinical manager's review. Section GG coding still requires the resident's usual performance across the assessment period; an earliest observation alone does not establish usual performance. If no eligible source is available, enter the value from the appropriate clinical assessment.
Create a billing episode
- Open the patient's admission.
- Find Billing episodes.
- ➕ Click Add billing episode.
- Select the Primary payor. RehabAlpha shows its payment model type.
- Review Billing provider. RehabAlpha applies the facility's first matching default rule. You can select another provider or clear the field for this episode.
- For payment models other than PDPM, answer To which services does this billing episode
apply?
- Select Pick by discipline, then select one or more Disciplines.
- Select Pick specific therapy cases, then select one or more existing Therapy cases.
- Enter the period start and end dates. These dates limit the selected disciplines or cases.
- For PDPM case-mix per diem, review the fixed PT, OT, and SLP discipline selection, then select the skilled nursing facility service location.
- For PDPM case-mix per diem, enter the initial stay day and initial benefit day. For most
stays, enter
1for both. Confirm the Part A stay start date, using the original date for a continued stay. - 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.
- 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.
- Save the admission.
If you are creating a new admission and need to pick specific cases, save the admission first and create its therapy cases. Then edit the admission, add or update the billing episode, and select those cases.
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 or change an episode's primary payor. The admission's facility comes from the patient route and cannot be changed. 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 its therapy case or discipline, depending on the episode's selection, and by 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 matching 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. Episodes may use overlapping dates only when their discipline or specific-case selections cannot apply to the same service line.