The SNF Compliance Checklist for 2026: Billing, Documentation, and PDPM Readiness

A compliance checklist is only useful if it reflects the actual compliance risks the facility is managing not the generic billing and documentation standards that apply to every healthcare provider, but the specific requirements that apply to skilled nursing facilities and that CMS audit activity has consistently identified as the areas where SNFs fall short.

This checklist covers the billing, documentation, and PDPM compliance requirements that matter most for skilled nursing facilities in 2026. It is organized around the three compliance dimensions that correspond directly to audit risk: billing process compliance, clinical documentation standards, and PDPM coding accuracy. Each item reflects either a specific Medicare requirement or a pattern of audit findings that the SNF billing environment has produced consistently.

Use this checklist as a quarterly review tool not as a one-time exercise that gets filed and forgotten. The compliance items that generate the most audit risk are the ones that drift over time when no one is actively monitoring them.

Section 1: Billing Process Compliance

Eligibility Verification

• Medicare Part A eligibility and qualifying three-day inpatient hospital stay are verified at or before admission for every Medicare admission not assumed based on the hospital discharge summary
• Inpatient versus observation status is confirmed directly with the hospital for every admission not inferred from the patient’s description of their hospital stay
• Medicare Advantage enrolment is confirmed at admission, and the specific plan is identified before billing begins
• Medicare benefit period status days used, days remaining, and benefit period reset eligibility is tracked actively for every Part A resident

Triple Check Process

• Triple Check is completed before every Medicare Part A billing cycle not on the day claims are due, but with sufficient lead time to investigate and resolve exceptions
• The clinical dimension of Triple Check includes a specific PDPM component review, not just confirmation that the MDS was completed
• Physician certifications and recertifications are confirmed signed and dated within required windows as part of the compliance dimension of Triple Check
• Exceptions flagged during Triple Check are documented with specific resolutions not cleared with a status override

Claim Submission and Timely Filing

• Claims are submitted within the twelve-month Medicare timely filing window from the date of service for all payer types
• A timely filing exposure report identifying every open account within 60 days of the filing deadline is reviewed at minimum monthly
• Denied claims are tracked against their original date of service, not their denial date, for timely filing management purposes
• First-pass acceptance rates are tracked monthly, separated by payer, and benchmarked against prior months

Consolidated Billing Compliance

• Every outside vendor providing services to Medicare Part A residents has a written confirmation of their obligation to submit charges to the facility rather than to Medicare directly
• The CMS Excluded Services from SNF PPS list is reviewed annually to confirm which services may be billed separately and which must be consolidated
• Remittances are reviewed for adjustment patterns that may indicate consolidated billing conflicts with outside provider claims

Medicare Advantage Authorization Management

• Prior authorization is obtained before or at admission for every Medicare Advantage SNF admission
• Authorization coverage dates are tracked per resident and confirmed current before each billing cycle
• Concurrent review requests from MA plans are responded to within the plan’s specified timeframe
• No claims are submitted for MA residents for days beyond the authorized period

What this means for your facility: If any item in Section 1 requires you to say ‘I think so’ rather than ‘yes’ the uncertainty is the compliance risk. Billing compliance items that are probably in place but not confirmed are the ones that generate findings.

Section 2: Clinical Documentation Standards

Medical Necessity Documentation

• Daily nursing notes establish the skilled nature of the care provided specifically documenting why professional expertise was required, not just what was done
• Therapy notes describe the specific skilled intervention, the clinical rationale for that intervention, and the resident’s objective clinical response
• Documentation of skilled care need is present in the record every day of the covered stay not just at admission and recertification
• Physician orders supporting the skilled services are current, signed, and present in the chart for the billing period being claimed

Physician Certification and Recertification

• Initial certifications are signed by the certifying physician at or before the first claim for the admission
• Recertifications are completed within the required benefit period windows at the end of the first 30 days, the end of the second 30 days, and at least every 60 days thereafter
• Recertification documentation includes the required content physician attestation of continued skilled care need and the clinical basis for that attestation
• A certification deadline tracking system generates alerts in advance of upcoming recertification windows not after the window has passed

MDS Assessment Timelines

• Five-day PPS assessments are completed with reference dates on days one through eight of every new Medicare Part A admission
• Interim Payment Assessments (IPAs) are completed when a significant change in clinical status occurs that would materially affect PDPM payment
• OBRA assessment timelines admission, quarterly, annual, and significant change are tracked and met for all residents regardless of payer status
• MDS assessments are transmitted to the state MDS system within the required submission window

Notice of Medicare Non-Coverage

• NOMMCs are issued at least two days before the last day of covered services when Medicare coverage is ending due to a skilled care determination
• NOMNC content meets current CMS requirements, including the resident’s right to an expedited appeal and the BFCC-QIO contact information
• NOMNC delivery is documented the resident or responsible party signature confirming receipt is in the chart
• When a resident requests an expedited appeal, the BFCC-QIO is contacted same day, and coverage continues pending the appeal outcome

What this means for your facility: Medical necessity documentation is the clinical record a future auditor will read. If a documentation gap would be visible to a reviewer who reads the record cold without knowledge of the resident or the care context it is a gap that needs to be addressed in the documentation standard, not explained in an audit response.

Section 3: PDPM Readiness

MDS Coding Accuracy

• A pre-lockout MDS review is conducted for every five-day assessment, specifically validating Nursing and NTA component coding against the clinical record before the assessment is locked
• Primary diagnosis codes are reviewed against the CMS PDPM ICD-10 mapping table to confirm they map to the correct clinical category and do not fall in the non-case-mix (non-CC) group
• Section GG functional scores are based on direct clinical observation during the assessment reference period, not estimated from prior functional status or therapy goal projections
• Section I active diagnoses reflect only conditions that are actively diagnosed, documented, and being managed during the assessment period

NTA Component Management

• Secondary diagnoses in the clinical record are systematically reviewed against the NTA point table during each five-day assessment
• High-cost medications that carry NTA point values IV antibiotics, parenteral nutrition, specialty drugs are coded in Section N and cross-referenced against the medication administration record
• NTA comorbidities coded in the MDS are supported by active clinical documentation in the medical record not historical diagnoses or conditions no longer being managed

PDPM Case-Mix Monitoring

• A PDPM case-mix distribution report is reviewed monthly comparing the HIPPS code distribution against the clinical complexity of the resident population
• A formal PDPM case-mix audit is conducted at least annually reviewing HIPPS code accuracy against the clinical record for a sample of Part A residents
• Early versus late period PDPM rate adjustments are tracked per resident and applied correctly in the billing system
• Benefit period day-count tracking is current for every Part A resident, and NTA high-rate period days (one through three) are correctly identified for new admissions

ICD-10-CM Coding Currency

• Primary diagnosis codes used for PDPM billing are reviewed against the October 1 ICD-10-CM annual update deleted codes are removed and new codes are adopted before any claims use them
• The CMS PDPM clinical category mapping table is reviewed annually for changes that affect which categories specific diagnosis codes map to
• Billing staff and MDS coordinators receive annual training on ICD-10-CM updates relevant to the SNF resident population

What this means for your facility: PDPM readiness is not a static state. It requires active maintenance monthly case-mix monitoring, annual audits, annual ICD-10 updates, and ongoing clinical-billing coordination. A facility that was PDPM-ready in 2022 may not be PDPM-ready in 2026 if none of those maintenance functions have been consistently performed.

Using This Checklist

The value of this checklist is proportional to the honesty with which it is completed. Items that generate an ‘I think so’ response rather than a clear yes deserve immediate follow-up not a deferred review. The compliance gaps that generate audit findings are almost never the ones the facility knows about and is actively working to correct. They are the ones that have been operating undetected.

At MCA Medical Billing Solutions, L.L.C. we conduct billing compliance reviews for skilled nursing facility clients as part of our standard engagement reviewing billing processes, MDS coding accuracy, and documentation standards against the current compliance requirements. If you want an external assessment of where your facility stands against this checklist.