Audits are on the rise! Skilled nursing facilities (SNFs) are at an all-time high when it comes to active medical review. From the SNF 5 Claim Probe and Educate and individual Medicare Advantage reviews, to recovery audit contractors (RACs) and Supplemental Medical Review Contractor (SMRC) audits – SNFs are increasingly on the radar to determine if their skilled documentation supports billed services. Of course, MDS accuracy is a critical component of success under medical review, but documentation must also validate the skilled services provided and prove medical necessity for the full duration of the stay. In this blog, let’s review common documentation shortcomings and how to remedy them…


  1. SNF certification/recertification compliance

Ensure that staff responsible for this process understand signature requirements, along with the SNF certification/recertification technical elements. Review our blog which details compliance standards and provides a sample form and recommendations for strong facility processes.

  1. Physician oversight as evidenced through signed orders

Determine the most appropriate reporting option to generate EMR order summary reports with compliant physician or physician extender e-signature stamps. When the facility is using electronic methods to send the provider records for review and signature, take time to conduct routine audits to ensure each provider is receiving the communication and following facility policy.

  1. Effective documentation to support active conditions

Review the process for maintaining an active diagnosis list. MDS Section I coding impacts each of the PDPM reimbursement components. Any diagnosis captured in Section I must be documented by a physician or physician extender within the past 60 days from the ARD. The condition must also have a direct relationship to the resident’s current functional, cognitive, mood or behavior status, medical treatments, nursing monitoring, or risk of death. RAI pg. I-7

  1. Sole use of EMR checkbox documentation methods

Daily nursing notes must focus on the resident’s clinical picture and how that resident is responding to treatment. Consider establishing clinical condition documentation guides and emphasize the importance of charting to demonstrate person centered clinical assessments. Empower nurses to write narrative notes detailing what skilled services the resident is receiving, why they need them to be provided in the SNF, and why it requires the knowledge and skill of the skilling discipline(s). See additional guidance below from Chapter 8 of the Medicare Benefit Policy Manual, Documentation to Support Skilled Care Determinations.

  1. Gaps in documentation to support MDS coding accuracy

Involve nurse leaders in training staff on assessment skills and providing constructive feedback on documentation, noting both strengths and opportunities for improvement. At least annually, train staff to understand the elements that impact PDPM reimbursement. For example, documentation to effectively support isolation, surgical wound care, shortness of breath while lying flat, etc. See examples below.

  1. Section GG facility process

Although there is no specific CMS mandate on how section GG documentation must be completed, providers should follow best practices and comply with documentation requirements. The documentation needs to: 1) Clearly support how the clinicians determined the usual performance for each of the section GG tasks. 2) A reviewer must be able to reach the same conclusion as to the Section GG MDS coding based solely on the documentation available during the allowable assessment period. Proactive recommends including an IDT collaborative note when the data collection alone doesn’t reveal a clear usual performance. If using assessments within the EMR, work with your software vendor to ensure the clinician’s signature is validated on the report.

  1. Lack of documentation to support skilled rehabilitation services

Even if therapy is the main skilling service, document the daily skilled nursing measures being provided. Establish questions for the IDT to routinely review and document. For example, 1.) Why is therapy in the SNF needed to meet the resident’s needs and achieve discharge goals as opposed to home health or outpatient therapy? 2) What are the hindrances to safe discharge?


Proactive assists SNFs in improving success rates under medical review through MDS/chart review consultation, ADR response support and appeals services. Contact us to learn how we can support your facility through the SNF 5 Claim Probe & Educate or other payer audits.




Written by Stacy Baker, OTR/L, RAC-CT, CHC

Director of Audit Services

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