- Medical Review
- Medical Review Focus Areas
- Service Specific Post-Payment Audits of Home Health PDGM Bills
- Service Specific Post-Payment Audits for Hospice Length of Stay > 730 Days
- Service Specific Post Payment Review of Psychotherapy, 60 Minutes with Patient – CPT 90837
- Service Specific Post Payment Review of Ambulance Transport and Mileage When Billed With Modifiers RJ, JR, RG, GR, NJ, JN, NG, GN
- Service Specific Post-Payment Audits of Home Health Value Code 17 Bills
- Announcing Service Specific Post-Payment Audits of Hyperbaric Oxygen (HBO) Services for J6 A Regions: IL, WI, and MN
- Service Specific Post-Payment Medical Review Notice Home Health PDGM (Edit 5AAGP)
- Service Specific Post Payment Review of Botulinum Injection, onabotulinumtoxina, 1 Unit – CPT J0585
- Service Specific Post Payment Review of Floweramnioflo, 0.1 CC – CPT Q4177
- Service Specific Post Payment Review of Grafix Prime (CPT Q4133)
- Service Specific Post Payment Review of Nonemergency Ambulance Transport and Mileage
- Service Specific Post Payment Review - Hospice GIP Services Over 7 Days (5ANLP) for JK A Regions: NY/CT, MA, ME, NH/VT and RI
- Service Specific Post Payment Review of Home Health Homebound Criteria (Edit 5AAHP)
- Service Specific Post Payment Review of Fluoroscopic Guidance for Needle Placement - CPT 77002
- Service Specific Post Payment Review of Computed Tomography, Abdomen and Pelvis with Contrast Material(s) - CPT 74177
- Service Specific Post Payment Review of Darbepoetin Alfa Injection, 1 microgram (Non-ESRD Use)
- Service Specific Post Payment Review of Therapeutic Procedure, 1 or More Areas, Each 15 Minutes; Aquatic Therapy With Therapeutic Exercise – CPT 97113
- Service Specific Post Payment Medical Review Summary Results of Hospice Services with Length of Stay > 730 Days
- Service Specific Post Payment Medical Review Summary Results of Home Health Value Code 17 Bills
- Review Results For Service Specific Postpayment Review of Psychotherapy, 60 Minutes With Patient
- Service Specific Post-Payment Medical Review Notice Hospice with Length of Stay over 730 Days (Edit 5ANKP)
- Service Specific Post-Payment Audits of Hospice GIP Care, DOS 3/1/2020 and After
- Service Specific Post-Payment Audits of Home Health LUPA Claims
- Service Specific Post Payment Review of Debridement, Subcutaneous Tissue (Includes Epidermis and Dermis, If Performed); First 20 Square Centimeters or Less– CPT 11042
- Service Specific Post-Payment Review of Tangential Biopsy of Skin-Single Lesion CPT 11102 with Destruction-Premalignant Lesion-First Lesion CPT 17000
- Service Specific Post Payment Review Summary Results – Home Health PDGM Bills (Edit 5AAGP)
- Review Results for Service Specific Post-Payment Review of Artacent Wound, per Square Centimeter - CPT Q4169
- Review Results for Service Specific Post-Payment Review of Q4133 - Grafix Prime
- Announcing Service Specific Post-Payment Audits of Group Psychotherapy Services for J6 A Regions: IL, WI and MN
- Service Specific Post Payment Medical Review Summary Results of Hospice Services with GIP > 7 Days
- Service-Specific Postpayment Medical Review Summary Results of Home Health PDGM Bills
- Review Results for Service Specific Post-Payment Review of Hyaluronan or Derivative - CPT J7326
- Review Results for Service Specific Post Payment Review of Hyaluronan or Derivative – CPT J7327
- Review Results for Service Specific Post-Payment Review of Fluoroscopic Guidance for Needle Placement
- J6_B_Review Results for Service Specific Post-Payment Review of J0585 – Botulinum Injection, Onabotulinumtoxina
- Review Results for Service Specific Post-Payment Review of Computed Tomography, Abdomen And Pelvis; With Contrast Material(s)
- Review Results for Service Specific Post-Payment Review of Therapeutic Procedure, 1 or More Areas, Each 15 Minutes; Aquatic Therapy with Therapeutic Exercise - CPT 97113
- Review Results for Service Specific Post Payment Review of Floweramnioflo
- Review Results for Service Specific Postpayment Review of Tangential Biopsy of Skin; Single Lesion CPT 11102 with Destruction, Premalignant Lesion; First Lesion CPT 17000
- Review Results for Service Specific Post-Payment Review of Darbepoetin Alfa Injection (Non-ESRD Use)
- Service Specific Post-Payment Review Summary Results – Home Health Homebound Criteria (Edit 5AAHP)
- Service Specific Post-Payment Review Summary Results – Hospice GIP Services Greater than 7 Days (Edit 5ANLP)
- Service Specific Post Payment Medical Review Summary Results of Hospice Services with General Inpatient Care, Date of Service 3/1/2020 and After
- Service Specific Post Payment Medical Review Summary Results of Home Health Low Utilization Payment Adjustment Claims
- Announcing Service Specific Post-Payment Audits of Individual Psychotherapy Services for J6 A Regions: IL, WI and MN
- Review Results for Service Specific Post Payment Review of Debridement, Subcutaneous Tissue (Includes Epidermis and Dermis, if Performed); First 20 Square Centimeters or Less – CPT 11042
- Service Specific Post Payment Review of Artacent Wound, Per Square Centimeter - CPT Q4169
- Service Specific Post-Payment Audits of Hospice GIP Care
- Service Specific Post Payment Review of Hyaluronan or Derivative - HCPCS J7326, J7327
- Skilled Nursing Facility Education Center
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
- General Required Documentation Resources
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.
The medical record should contain patient specific information detailing:
- Rationale detailing need for skilled services.
- Patient response to skilled services.
- Complexity of service.
- Services are reasonable and necessary.
- Services are consistent with nature and severity of illness and medical needs.
- Services promote documented goals.
- Plan for future care.
Certification and Recertification Requirements
- 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.
- 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.
- The routine admission order is not a certification of the necessity for post-hospital extended care services.
- 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.
- 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.
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.
Acceptable documentation when the Therapy Plan of Care is not certified/recertified
- A valid SNF cert/recert form or required elements found in the records.
- A physician’s/NPP progress note indicating plan is for therapy.
- A physician/NPP order for therapy services.
Acceptable documentation to validate therapy services
- 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.
- 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.
- 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.
- 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.
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.
Therapy End Date
The date the most recent therapy regimen ended. This is the last date the resident received skilled therapy treatment.
MD History and Physical
Physician Required and other Medically Necessary Visits in SNFs
- 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.
- 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.
- The initial comprehensive visit must occur no later than 30 days after a resident’s admission into the SNF.
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
Revised 8/8/2023
Targeted Probe and Educate Manual
The preferred method to submit Medical Records is NGSConnex
Visit our Contact Us page for other methods of submission
Targeted Probe and Educate Manual
The preferred method to submit Medical Records is NGSConnex:
Visit our Contact Us page for other methods of submission.
Targeted Probe and Educate Manual
The preferred method to submit Medical Records is NGSConnex:
Visit our Contact Us page for other methods of submission.
Targeted Probe and Educate Manual
The preferred method to submit Medical Records is NGSConnex:
Visit our Contact Us page for other methods of submission.
Targeted Probe and Educate Manual
The preferred method to submit Medical Records is NGSConnex:
Visit our Contact Us page for other methods of submission.
Targeted Probe and Educate Manual
The preferred method to submit Medical Records is NGSConnex:
Visit our Contact Us page for other methods of submission.
Targeted Probe and Educate Manual
The preferred method to submit Medical Records is NGSConnex:
Visit our Contact Us page for other methods of submission.
Targeted Probe and Educate Manual
The preferred method to submit Medical Records is NGSConnex:
Visit our Contact Us page for other methods of submission.