Wednesday, August 8, 2012

What are the documents needed for SNF

Documentation needed for Skilled Nursing Facility (SNF), Part A

•    Please be sure documentation submitted is legible.
•    Please submit records for all dates of service on the claim.
•    Please ensure the medical records submitted provide proof the service(s) was ordered and rendered. Also, ensure the medical records provide justification supporting medical necessity for the service by submission of the following documentation:
o    All applicable Minimum Data Set (MDS) assessments for the period billed, including documents to support the number of days of the MDS look-back period.
o    Medical records for 30 days prior to each Additional Documentation Request (ARD).
o    Acute hospital discharge summary and transfer form.
o    History and physical.
o    Admission assessment.
o    Any relevant hospital documentation to support five-day MDS assessment.
o    Physician’s certification and recertification for skilled care.
o    Physician’s orders specifying need for SNF care.
o    Physician’s orders physician/Non-Physician Practitioner (NPP) order/intent.
o    Physician’s progress notes.
o    Care plans.
o    Skill sheets/records.
o    Treatment records.
o    Medication Administration Records (MAR).
o    Nurse’s notes.
o    Intake and output log.
o    Vital sign log.
o    Weight records.
o    Treatment and medication sheets.
o    Rehabilitation notes.
o    Initial therapy evaluation.
o    Therapy evaluation/re-evaluation.
o    Therapy progress notes.
o    Treatment logs to identify therapy minutes.
o    Signatures/credentials of professionals providing services.
o    Any other documentation a provider deems necessary to support medical necessity of services billed, as well as documentation specifically requested in the ADR letter.

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