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:
| Legible handwritten physician and/or clinician signatures |
| Valid electronic physician and/or clinician signatures |
|Physician or Non-Physician Practitioner (NPP) order for date of service|
| Signed and dated physician certification (and recertification, if applicable) for skilled level of care |
| Records of patient's condition before, during and after this billing period to support medical necessity and reason the service was provided |
| Records supporting skilled level of care |
| Physical Therapy (PT), Occupational Therapy (OT) and Speech Therapy (ST/SLP) records, if applicable |
| Documentation for look back period for each Minimum Data Set (MDS) billed, if applicable |
|Quality Improvement Organization (QIO) letter, if applicable|
|Itemization of services|
|Advance Beneficiary Notice of Noncoverage (ABN), if applicable|
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.
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.
- Noridian Medical Review - Additional Documentation Request (ADR)
- Comprehensive Error Rate Testing (CERT) - CID Request
- Level One Appeal - Redetermination Request
View the Skilled Nursing Facility (SNF) webpage for additional information and resources.
Last Updated Feb 08, 2019
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.