Documentation for Skilled Nursing Facilities

March 8th, 2018 - Medicare Learning Network
Categories:   Documentation Guidelines   Skilled Nursing   Medicare  

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

###

Questions, comments?

If you have questions or comments about this article please contact us.  Comments that provide additional related information may be added here by our Editors.


Latest articles:  (any category)

Artificial Intelligence in Healthcare - A Medical Coder's Perspective
December 26th, 2023 - Aimee Wilcox
We constantly hear how AI is creeping into every aspect of healthcare but what does that mean for medical coders and how can we better understand the language used in the codeset? Will AI take my place or will I learn with it and become an integral part of the process that uses AI to enhance my abilities? 
Specialization: Your Advantage as a Medical Coding Contractor
December 22nd, 2023 - Find-A-Code
Medical coding contractors offer a valuable service to healthcare providers who would rather outsource coding and billing rather than handling things in-house. Some contractors are better than others, but there is one thing they all have in common: the need to present some sort of value proposition in order to land new clients. As a contractor, your value proposition is the advantage you offer. And that advantage is specialization.
ICD-10-CM Coding of Chronic Obstructive Pulmonary Disease (COPD)
December 19th, 2023 - Aimee Wilcox
Chronic respiratory disease is on the top 10 chronic disease list published by the National Institutes of Health (NIH). Although it is a chronic condition, it may be stable for some time and then suddenly become exacerbated and even impacted by another acute respiratory illness, such as bronchitis, RSV, or COVID-19. Understanding the nuances associated with the condition and how to properly assign ICD-10-CM codes is beneficial.
Changes to COVID-19 Vaccines Strike Again
December 12th, 2023 - Aimee Wilcox
According to the FDA, CDC, and other alphabet soup entities, the old COVID-19 vaccines are no longer able to treat the variants experienced today so new vaccines have been given the emergency use authorization to take the place of the old vaccines. No sooner was the updated 2024 CPT codebook published when 50 of the codes in it were deleted, some of which were being newly added for 2024.
Updated ICD-10-CM Codes for Appendicitis
November 14th, 2023 - Aimee Wilcox
With approximately 250,000 cases of acute appendicitis diagnosed annually in the United States, coding updates were made to ensure high-specificity coding could be achieved when reporting these diagnoses. While appendicitis almost equally affects both men and women, the type of appendicitis varies, as dose the risk of infection, sepsis, and perforation.
COVID Vaccine Coding Changes as of November 1, 2023
October 26th, 2023 - Wyn Staheli
COVID vaccine changes due to the end of the PHE as of November 1, 2023 are addressed in this article.
Medicare Guidance Changes for E/M Services
October 11th, 2023 - Wyn Staheli
2023 brought quite a few changes to Evaluation and management (E/M) services. The significant revisions as noted in the CPT codebook were welcome changes to bring other E/M services more in line with the changes that took place with Office or Other Outpatient Services a few years ago. As part of CMS’ Medicare Learning Network, the “Evaluation and Management Services Guide” publication was finally updated as of August 2023 to include the changes that took place in 2023. If you take a look at the new publication (see references below),....



Home About Terms Privacy

innoviHealth® - 62 E 300 North, Spanish Fork, UT 84660 - Phone 801-770-4203 (9-5 Mountain)

Copyright © 2000-2024 innoviHealth Systems®, Inc. - CPT® copyright American Medical Association