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Checklist: Nursing home

This checklist is being provided as a tool to assist providers when responding to medical record documentation requests for nursing home services. 

It is the responsibility of the practitioner who provided the services to ensure the correct submission of documentation. 

Check Documentation description
  Valid and legible dated signature of treating physician / NPP. 
  Physician / NPP progress notes / Evaluation & management (E/M) note to support medically necessity and level of (E/M) service billed. 
  Documentation supports that a face-to-face visit occurred. 
  Physician orders or intent to order services billed on the dates of service requested.
  Diagnostic test / lab results / reports, including imaging reports, if appropriate.
  Any Advanced Beneficiary Notice of non-coverage (ABN) issued to the beneficiary for each date of service. 
 

To support the level of service (code), include documentation to address the following:

  • Chief complaint
  • History
  • If history is taken by ancillary staff, ensure the billing practitioner indicates this was reviewed
  • Physical exam
  • Medical decision-making
  • Any additional documentation that may support medical necessity of the level of service(s) billed
  • Initial history and physical (for initial admission to SNF).
 

Documentation based on counseling or coordination of care to include:

  • Total time (e.g., start/stop time).
  • Amount, or percent, of time involved in counseling or coordination of care.
  • Description of the discussion.

Note: Time alone does not determine the level of service. Documentation must support the level of service billed.
 

Initial nursing facility care, per day: (99304, 99305, and 99306):

  • Reported by a physician for visit performed in a SNF (skilled nursing facility) or NF (nursing facility).
  • Exception: May be completed by qualified NPP in NF setting who is not employed by the facility and when State law permits).
 

Subsequent nursing facility care, per day (99307, 99308, 99309 and 99310):

  • Documentation for new episode of illness or an acute exacerbation of a chronic illness:
    • Medical record should clearly reflect circumstances requiring increased frequency.
    • Documentation must support:
    • Instability or change in condition; requires timely medical/mental eval/exam.
    • Therapeutic issues: requires timely follow-up eval/assess effectiveness.
    • Medical conditions including delirium, dementia, or changes in mental status manifest with behavioral symptoms that require timely evaluation.
    • Requests to address a documented medical issue of concern that requires a physical (or mental status) examination.

 

Disclaimer
This checklist was created as an aid to assist providers. This aid is not intended as a replacement for the documentation requirements published in national or local coverage determinations, or the CMS documentation guidelines. It is the responsibility of the provider of services to ensure the correct, complete, and thorough submission of documentation.