0004 - Skilled Nursing Facility: Medical Necessity and Documentation Requirements

Issue Name
0004 - Skilled Nursing Facility: Medical Necessity and Documentation Requirements
Date
Review Type
Complex
Provider Type
Skilled Nursing Facility (SNF)
MAC Jurisdiction
All A/B MACs

Description

Documentation will be reviewed to determine if the Skilled Nursing Facility stay meets Medicare coverage criteria, meets applicable coding guidelines, and/or is medically reasonable and necessary.

Affected Code(s)

TOB 21X

Applicable Policy References

1. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, Section 1862(a)(1)(A)- Exclusions from Coverage and Medicare as a Secondary Payer
2. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, Section 1833(e)- Payment of Benefits
3. 42 CFR §405.980- Reopening of Initial Determinations, Redeterminations, Reconsiderations, Decisions, and Reviews, (b)- Timeframes and Requirements for Reopening Initial Determinations and Redeterminations Initiated by a Contractor;  and (c)- Timeframes and Requirements for Reopening Initial Determinations and Redeterminations Requested by a Party
4. 42 CFR §405.986- Good Cause for Reopening  
5. 42 Code of Federal Regulations § 409.30-409.36 Basic Requirements
6. 42 Code of Federal Regulations § 424.20 Requirements for posthospital SNF care
7. 42 Code of Federal Regulations § 483.20 Resident assessment
8. 42 Code of Federal Regulations §§411.15(k)(1)
9. Medicare Program Integrity Manual, Chapter 3- Verifying Potential Errors and Taking Corrective Actions, §3.2.3.8- No Response or Insufficient Response to Additional Documentation Requests
10. Medicare General Information, Eligibility and Entitlement Manual, Chapter 4- Physician Certification and Recertification of Services, §40.4- Timing of Recertifications for Extended Care Services, §40.5- Delayed Certifications and Recertifications for Extended Care Services
11. Medicare Program Integrity Manual, Chapter 6 Medicare Contractor Medical Review Guidelines for Specific Services, §6.1- Medical Review of Skilled Nursing Facility Prospective Payment System (SNF PPS) Bills, §6.1.4- Bill Review Process, §6.3- Medical Review of Certification and Recertification of Residents in SNFs
12. Medicare Benefit Policy Manual , Chapter 8- Coverage of Extended Care (SNF) Services Under Hospital Insurance, §20- Prior Hospitalization and Transfer Requirements, §30- Skilled Nursing Facility Level of Care- General, §40- Physician Certification and Recertification for Extended Care Services
13. Medicare Benefit Policy Manual, Chapter 15- Covered Medical and Other Health Services, §220.1.3-  Certification and Recertification of Need for Treatment and Therapy Plans of Care