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July 1, 2024

SNF Certification Requirements

The term "extended care services" means the following items and services furnished to an inpatient of a skilled nursing facility (SNF) either directly or under arrangements as noted in the list below:

Nursing care provided by or under the supervision of a registered professional nurse
Bed and board in connection with furnishing such nursing care
Physical or occupational therapy and/or speech-language pathology services furnished by the skilled nursing facility or by others under arrangements with them made by the facility
Medical social services
Such drugs, biologicals, supplies, appliances, and equipment, furnished for use in the skilled nursing facility, as are ordinarily furnished by such facility for the care and treatment of inpatients

Three-Day Prior Hospitalization

To qualify for post-hospital extended care services, the individual must have been an inpatient of a hospital for a medically necessary stay of at least three consecutive calendar days. In addition, the individual must have been transferred to a participating SNF within 30 days after discharge from the hospital, unless the exception in the CMS Medicare Benefit Policy Manual (Pub. 100-02), chapter 8, §20.2 applies.

The 3 consecutive calendar day stay requirement can be met by stays totaling 3 consecutive days in one or more hospitals. In determining whether the requirement has been met, the day of admission, but not the day of discharge, is counted as a hospital inpatient day. Time spent in observation or in the emergency room prior to (or in lieu of) an inpatient admission to the hospital does not count toward the 3-day qualifying inpatient hospital stay. Even if a beneficiary's care during a qualifying hospital stay becomes less intensive during the latter part of the stay, the date of hospital "discharge" in this context is still considered to be the day that the beneficiary physically leaves the hospital, and the level of care being furnished at that particular point is not a determining factor as long as some portion of the stay included at least 3 consecutive days of medically necessary inpatient hospital services, "alternate placement" days spent in the hospital can be included in the 3-day count toward meeting the SNF benefit's qualifying hospital stay requirement. The 3-day hospital stay need not be in a hospital with which the SNF has a transfer agreement (see the CMS Medicare General Information, Eligibility, and Entitlement Manual (Pub. 100-01), chapter 5, §30.2 for a discussion of the SNF's required transfer agreement with a hospital).

NOTE: While a 3-day stay in a psychiatric hospital satisfies the prior hospital stay requirement, institutions that primarily provide psychiatric treatment cannot participate in the program as SNFs. Therefore, a patient with only a psychiatric condition who is transferred from a psychiatric hospital to a participating SNF is likely to receive only non-covered care. In the SNF setting, the term "non-covered care" refers to any level of care less intensive than the SNF level of care that is covered under the program. (See §§30ff.).

To be covered, the extended care services must have been for the treatment of a condition for which the beneficiary was receiving inpatient hospital services (including services of an emergency hospital) or a condition which arose while in the SNF for treatment of a condition for which the beneficiary was previously hospitalized. In this context, the applicable hospital condition need not have been the principal diagnosis that actually precipitated the beneficiary's admission to the hospital but could be any one of the conditions present during the qualifying hospital stay. In addition, the qualifying hospital stay must have been medically necessary.

Physician Certification and Recertification of Extended Care Service

The SNF must obtain and retain the required certification and recertification statements. The SNF will determine how to obtain the required certification and recertification statements. There is no requirement for a specific procedure or form as long as the approach adopted by the facility permits verification that the certification and recertification requirement is met. Certification or recertification statements may be entered on or included in forms, notes, or other records that would normally be signed in caring for a patient, or on a separate form. Except as otherwise specified, each certification and recertification is to be separately signed.

Certifications must be obtained at the time of admission, or as soon thereafter as is reasonable and practicable (see the CMS Medicare Claims Processing Manual (Pub. 100-04), chapter 6, §120.2, regarding the circumstances under which a resumption of SNF care following a temporary break in SNF coverage would be considered a new "admission" under the SNF PPS's interrupted stay policy). The routine admission order established by a physician is not a certification of the necessity for post-hospital extended care services for purposes of the program. There must be a separate signed statement indicating that the patient will require on a daily basis SNF covered care. In addition, only physicians may certify outpatient physical therapy and outpatient speech-language pathology services.

Who May Sign the Certification or Recertification for Extended Care Services

A certification or recertification statement must be signed by the attending physician or a physician on the staff of the skilled nursing facility who has knowledge of the case, or by a physician extender (that is, a nurse practitioner (NP), a clinical nurse specialist (CNS) or a physician assistant (PA) who does not have a direct or indirect employment relationship with the facility, but who is working in collaboration with the physician.

The certification must clearly contain the following information:

The individual needs skilled nursing care (furnished directly by or requiring the supervision of skilled nursing personnel) or other skilled rehabilitation services.
Services are required daily.
Services can only be provided in a SNF or swing-bed hospital on an inpatient basis.
Services are for an ongoing condition for which the individual received inpatient care in a hospital, or for a new condition that arose while the individual was receiving care in the SNF or swing-bed hospital for a condition for which he or she received inpatient care in a participating or qualified hospital.
A dated signature of the certifying physician or NPP.

Recertification Statement Required Criteria

The recertification statement(s) must contain the following information:

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 to the SNF (and while the individual was still under treatment for the condition for which the individual received inpatient care in a hospital), this must be indicated.
A dated signature of the recertifying physician or NPP.

Timing of Certifications and Recertifications

Certifications must be obtained at the time of admission, or as soon thereafter as is reasonable and practicable (see the CMS Medicare Claims Processing Manual (Pub. 100-04), chapter 6, §120.2). The initial certifications are required no later than as of the 12th day of hospitalization. The first recertification must be made no later than the 14th day of inpatient extended care services. Subsequent recertifications must be made at intervals not exceeding 30 days. The skilled nursing facility should have available in its files a written description of the procedure it adopts with respect to the timing of recertifications. The procedure should specify the intervals at which recertifications are required, and whether review of long-stay cases by the utilization review committee serves as an alternative to recertification by a physician in the case of the second or subsequent recertifications.

Delayed Certifications and Recertifications for Extended Care Services

Skilled nursing facilities are expected to obtain timely certification and recertification statements. However, delayed certifications and recertifications will be honored where, for example, there has been an isolated oversight or lapse. In addition to complying with the content requirements, delayed certifications and recertifications must include an explanation for the delay and any medical or other evidence which the skilled nursing facility considers relevant for purposes of explaining the delay. The facility will determine the format of delayed certification and recertification statements, and the method by which they are obtained. A delayed certification and recertification may appear in one statement; separate signed statements for each certification and recertification would not be required as they would if timely certification and recertification had been made.