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 appliable
  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.

 

Last Updated Thu, 20 Aug 2020 14:13:41 +0000

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.