Inpatient 3-Day Stays Resulting in Admission to Skilled Nursing Facility (SNF): Probe Medical Review

August 16, 2013
Rick Gawenda

Based on Kentucky and Ohio CERT data, J15 Part A Medical Review will implement a service specific probe for 3-Day Inpatient Stays resulting in a SNF Admission. The service specific probe edit for bill type 11X will be implemented in Kentucky and Ohio.

What to Send
If you receive an Additional Documentation Request (ADR) from CGS, submit the requested medical record information within 30 days. Before you send the requested records, we suggest you double-check the accuracy of your submitted claim.

Send the following documentation when responding to the ADRs, along with other supporting documentation. Please note: the documentation you submit in response to this request should comply with these requirements. This may require you to contact the hospital or other facility where you provided the service and obtain your signed progress notes, plan of care, discharge summary, etc.

  • Physician’s orders for the admission and all services billed
  • Itemized list of all charges
  • Hospital admission assessment and hospital discharge summary
  • Hospital history and physical
  • Physician progress notes
  • Consultation reports
  • Plan of care
  • Diagnostic test results/reports, including imaging reports
  • Clinical/therapy notes
  • Physician certification of the need for skilled daily post-hospital care in a skilled nursing facility
  • Please submit all documentation to support the medical necessity of services billed and the DRG code submitted
  • A signature log or an attestation statement, if you question the legibility of your signature. Medicare requires that medical records entries for services provided/ordered be authenticated by the author. The signature may be hand-written or electronic; stamp signatures are not acceptable. Patient identification, date of service, and provider of the service should be clearly identified on the submitted documentation.For further details, please click HERE.

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This article is not intended to and does not serve as legal advice or as consultative services, but is for general information purposes only.

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