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
  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
  • If not signed and dated timely, letter of delay that is signed and dated by physician must be submitted
  Records of patient's condition before, during and after this billing period to support medical necessity and reason the service was provided
  • Hospital discharge summary and transfer form
  • Emergency room records
  • Hospital history and physical
  • Nurses and nurse aid notes
  • Physician progress notes
  • Operative reports
  • Treatment records
  • Care plans
  • Consultation reports
  • Medication administration record (MAR)
  Records supporting skilled level of care
  • History and physical exam pertinent to patient's care, including response of changes in behavior to previously administered skilled services
  • Skilled services provided
  • Patient's response to the skilled services provided during current visit
  • Plan for future care based on rationale of prior results
  • Complexity of service to be performed
  Physical Therapy (PT), Occupational Therapy (OT) and Speech Therapy (ST/SLP) records, if applicable
  • Initial evaluation
  • Plan of care
  • Progress reports
  • Treatment encounter notes
  • Discharge summary
  • Therapy minute logs
  Documentation for look back period for each Minimum Data Set (MDS) billed, if applicable
  • May be prior to billing period
  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.

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 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.