SNF Inpatient Stays

The CERT contractor has seen increased denials of SNF inpatient stays due to missing or incomplete physician certification statement of medical necessity. Certification of medical necessity of inpatient skilled nursing services has been a longstanding CMS requirement.

MLN Matters article SE1428 describes details as a guide for physicians and SNFs to document certification by the physician regarding the medical necessity of the skilled nursing inpatient stay.

An acceptable certification statement must contain:

• The individual needs skilled nursing care (furnished directly by or requiring the supervision of skilled nursing personnel) or other skilled rehabilitation services
• Such services are required on a daily basis
• Such services can only be practically provided in a SNF or swing-bed hospital on an inpatient basis
• Such services are for an ongoing condition for which the individual received inpatient care in a hospital
• A dated signature of the certifying physician or NPP

An acceptable recertification statement must contain:

• The reasons for the continued need for post hospital SNF care
• The estimated time the individual will need to remain in the SNF
• Plans for home care, if any
• If the reason for continued need for services is a condition that arose after admission – this must be indicated
• Dated signature of recertifying physician or NPP

There is no specific format or procedure for documentation of the certification, but this certification is required to be in the patient’s medical record.

The following are the required timeframes for physicians or NPPs to document the certification or recertification statement(s):

• The certification must be obtained at the time of admission or as soon thereafter as is reasonable and practicable.
• The first recertification is required no later than the 14th day of post hospital SNF care.
• Subsequent recertification is required at least every 30 days after the first recertification.