Skilled Nursing Facility (SNF) Documentation Requirements

It is expected that patient's medical records reflect the need for care/services provided. The listing of records is not all inclusive. Providers must ensure all necessary records are submitted to support services rendered. They may include:

Check
Brief Description
Physician/Non Physician Practitioner (NPP) order
History and Physical reports (include medical history and current list of medications)
Discharge Summary from hospital or other facility
Physician/Non-Physician Practitioner (NPP) certification and re-certifications
  • Justification for delayed certification/recertification, if applicable
Vital sign records, weight sheets, care plans, treatment records
Documentation to support each of the Health Insurance Prospective Payment System HIPPS code(s) billed
  • Skilled service provided
Practitioner, nurse, and ancillary progress notes
  • Medical necessity for SNF
  • ADL logs
  • Nurse aide notes
  • Consultations
PT/OT/SLP
  • Initial evaluation and re-evaluations
  • Plan of care/updates to Plan of Care
  • Treatment encounter notes
  • Therapy minutes log
  • Discharge summary
Quality Improvement Organization (QIO) letter
Itemization of services
Advance Beneficiary Notice
Signature log or signature attestation for any missing or illegible signatures within the medical record (all personnel providing services)
Facility process of how electronic signature is created if using electronic health record

Multiple CMS contractors are charged with completing reviews of medical records. See Identifying Which Entity Completed a Part A Claim Review for detailed information about each of these contractors.

Documentation Submission

Once a provider compiles all the necessary documentation, it is important to submit them to the appropriate contractor according to the request received. Select the request below to view the appropriate submission instructions.

View the Skilled Nursing Facility (SNF) webpage for additional information and resources.

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Documentation Requirements Disclaimer

The documentation requirements contents/references provided within this section were prepared as educational tools and are not intended to grant rights or impose obligations. Use of these documents are not intended to take the place of either written law or regulations.

The listing of records is not all inclusive. Providers must ensure all necessary records are submitted to support services rendered.

Important that physician intent, physician decision and physician recommendation to provide services derived clearly from the medical record and properly authenticated.

The submission of these records shall not guarantee payment as all applicable coverage requirements must be met.