Required Documentation

Table of Contents

• Required Documentation
• The medical record should contain patient specific information detailing
• Certification and Recertification Requirements
• Signature Requirement for Certifications and Recertifications
• Acceptable documentation when the Therapy Plan of Care is not certified/recertified
• Acceptable documentation to validate therapy services
• Therapy Start Date
• Therapy End Date
• MD History and Physical
  • Physician Required and other Medically Necessary Visits in SNFs
• General Required Documentation Resources

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Required Documentation

Utilize the links below to understand the Medical Review Process better. Refer to your ADR letter for edit/audit-specific documentation request. These letters will highlight all required and suggested supplemental documentation.

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The medical record should contain patient specific information detailing:

1. Rationale detailing need for skilled services.
2. Patient response to skilled services.
3. Complexity of service.
4. Services are reasonable and necessary.
5. Services are consistent with nature and severity of illness and medical needs.
6. Services promote documented goals.
7. Plan for future care.

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Certification and Recertification Requirements

1. No specific procedures or forms are required for certification and recertification statements, the provider may adopt any method that permits verification. The certification and recertification statements may be entered on forms, notes, or records that the appropriate individual signs, or on a special separate form.
2. The certification must be obtained at the time of admission or as soon thereafter as is reasonable and practicable. The certification must be made no later than the 14th day of admission for inpatient extended care services because that is when the first recertification is due.
3. The routine admission order is not a certification of the necessity for post-hospital extended care services.
4. The first recertification must be made no later than the 14th day of admission for inpatient extended care services. The date of admission is considered Day 1.
5. If the recertification is done earlier than necessary, it goes into effect the date signed even if it is signed same day as the certification. The next recertification would be due 30 days from that recertification date.

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Signature Requirement for Certifications and Recertifications

Certification and recertification statements may be signed by: the physician responsible for the case or, with his or her authorization, by a physician on the SNF staff or a physician who is available in case of an emergency and has knowledge of the case; or a physician extender (that is, a nurse practitioner, a clinical nurse specialist, or a physician assistant as those terms are defined in section 1861(aa)(5) of the Act) who does not have a direct or indirect employment relationship with the facility but who is working in collaboration with a physician.

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Acceptable documentation when the Therapy Plan of Care is not certified/recertified

1. A valid SNF cert/recert form or required elements found in the records.
2. A physician’s/NPP progress note indicating plan is for therapy.
3. A physician/NPP order for therapy services.

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Acceptable documentation to validate therapy services

1. The documentation must support daily skilled therapy services provided were indeed “skilled”. Daily therapy treatment notes are not required; however, they are recommended to support the daily services provided were skilled, and at least 15 minutes of skilled therapy was performed for each type of therapy provided and billed.
2. A matrix log can be used to verify the days and total number of therapy minutes performed for each day; however, there still must be some type of documentation to support the therapy services provided were skilled.
3. Therapy evaluations and discharge summaries can be used to support the medical necessity for skilled care. Progress notes can also be used to show the therapy services provided are skilled, progress towards therapy goals are being achieved, and the need for ongoing skilled therapy services are medically necessary.
4. A day of therapy is defined as skilled treatment for 15 minutes or more during the day. The treatment notes, and/or logs, validate the number of days therapy services were provided in the last seven days during the look-back period.

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Therapy Start Date

The date the most recent therapy regimen started. This is the date the initial therapy evaluation is conducted regardless if treatment was rendered or not or the date of resumption, in cases where the resident discontinued and then resumed therapy.

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Therapy End Date

The date the most recent therapy regimen ended. This is the last date the resident received skilled therapy treatment.

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MD History and Physical

Physician Required and other Medically Necessary Visits in SNFs

1. All required physician visits must be made by the physician personally and cannot be delegated. A required physician visit includes the initial comprehensive visit in a SNF and every alternate required visit thereafter.
2. The initial comprehensive visit in a SNF is the initial visit during which the physician completes a thorough assessment, develops a plan of care and writes or verifies admitting orders for the resident.
3. The initial comprehensive visit must occur no later than 30 days after a resident’s admission into the SNF.

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General Required Documentation Resources

Learn more about Required Documentation by accessing valuable resources via the links below.

• CMS IOM Publication 100-08, Medicare Program Integrity Manual, Chapter 6- Medicare Contractor Medical Review Guidelines for Specific Services
• CMS IOM Publication 100-08, Medicare Program Integrity Manual, Chapter 3- Verifying Potential Errors and Taking Corrective Actions 
• CMS IOM Publication 100-02, Medicare Benefit Policy Manual, Chapter 8- Coverage of Extended Care (SNF) Services Under Hospital Insurance
• Code of Federal Regulations section 424.20
• CMS IOM Publication 100-02, Medicare Benefit Policy Manual, Chapter 15- Covered Medical and Other Health Services
• Code of Federal Regulations Section 483.30

Reviewed 6/26/2024