Documentation for Skilled Nursing Facilities

by  Medicare Learning Network
March 8th, 2018

The Medicare Learning Network provides guidance on required documentation for Skilled Nursing Facilities (SNF).

Claims for skilled care coverage need to include sufficient documentation to enable a reviewer to determine the following:

• The beneficiary requires skilled involvement for the services in question to be furnished safely and effectively.
• The services themselves are reasonable and necessary for the treatment of a resident’s illness or injury. For example, the services must be consistent with:
  • The nature and severity of the individual’s illness or injury
  • The individual’s particular medical needs, and accepted standards of medical practice

The documentation must also show that the services are appropriate in terms of duration and quality and promote the documented therapeutic goals.

Beneficiary goals must be routinely assessed and documented to provide a sufficient basis for determining Medicare coverage. Therefore, the resident’s medical record must document as appropriate:

• The history and physical exam pertinent to the resident’s care (including the response or changes in behavior to previously administered skilled services)
• The skilled services provided
• The resident’s response to the skilled services provided during the current visit
• The plan for future care based on the rationale of prior results
• A detailed rationale that explains the need for the skilled service in light of the resident’s overall medical condition and experiences
• The complexity of the service to be performed
• Any other pertinent characteristics of the resident

The documentation in the beneficiary’s medical record must be accurate and avoid vague or subjective descriptions of the resident’s care that would not be sufficient to indicate the need for skilled care.

Medical records must also support the medical necessity of SNF services provided. For example, required documents include, but are not limited to:

• A certification that the beneficiary needed daily skilled care could only be provided in a SNF setting
• An authenticated plan of care
• The time (in minutes) for the therapy service provided

References:

• MLN Fact Sheet: Provider Compliance Tips for Skilled Nursing Facility Services