What should we be documenting when an individual admits under waiver without a three-day qualifying hospital stay?

The Centers for Medicare & Medicaid Services continues to waive the requirement for a three-day prior hospitalization for coverage of a SNF stay during the Public Health Emergency. While this is a blanket waiver, documentation needs to support how the skilled stay relates to the PHE, and in the absence of the pandemic, that the condition would have required an inpatient hospital stay.

This calls me back to the March 13, 2020, letter to HHS from then-CMS Administrator, Seema Verma, which states, “SNF care without a 3-day inpatient hospital stay will be covered for beneficiaries who experience dislocations or are otherwise affected by the emergency, such as those who are (1) evacuated from a nursing home in the emergency area, (2) discharged from a hospital (in the emergency or receiving locations) in order to provide care to more seriously ill patients, or (3) need SNF care as a result of the emergency…”

Furthermore, CMS states in its FAQ document: “SNF coverage isn’t based on particular diagnoses or medical conditions, but rather on whether the beneficiary meets the statutorily-prescribed SNF level of care definition of needing and receiving skilled services daily which, as a practical matter, can only be provided in a SNF on an inpatient basis.”

To avoid potential denials, the IDT should determine and document: (1) what the skilled service(s) is/are, (2) how SNF level of care is met, (3) how the skilled stay relates to the PHE, and (4) how an inpatient hospital stay would have likely been necessary to manage the condition(s) in absence of the pandemic.