CMS Pub. 100-01, ch. 4, § 40.2

The certification must clearly indicate that posthospital extended care services were

required to be given on an inpatient basis because of the individual's need for skilled care

on a daily basis for an ongoing condition for which he/she was receiving inpatient

hospital services prior to transfer to the SNF (or for a new condition that arose while in

the SNF for treatment of that ongoing condition). Alternatively, under the regulations at

42 CFR 424.20(a)(1)(ii), the initial certification can simply affirm that the individual has

been correctly assigned one of the case-mix classifiers that CMS designates as

representing the required SNF level of care, as provided in the regulations at 42 CFR

409.30 (see Pub. 100-02, Medicare Benefit Policy Manual, chapter 8, §30.1, for a

discussion of the administrative level of care presumption under the SNF PPS).

Certifications must be obtained at the time of admission, or as soon thereafter as is

reasonable and practicable (see Pub.100-04, Medicare Claims Processing Manual,

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 procedure

followed by a physician would not be sufficient certification of the necessity for

posthospital extended care services for purposes of the program.

If ambulance service is furnished by a skilled nursing facility, an additional certification

is required. It may be furnished by any physician who has sufficient knowledge of the

patient's case, including the physician who requested the ambulance or the physician who

examined the patient upon his arrival at the facility. The physician must certify that the

ambulance service was medically required.