1.5 The SNF coverage criteria (the homebound replacement)
Home health hinges on homebound. A SNF stay has no homebound test. Under Pub 100-02 Chapter 8, a covered Part A day requires all of the criteria below. This is the single most important reframe for a nurse coming from the home-health catalog: every place a home-health note would reaffirm homebound, a SNF note instead reaffirms the daily skilled need and the practical-matter test.
Criterion
What the record must show
1 · Qualifying hospital stay
A medically necessary inpatient hospital stay of at least 3 consecutive days (admission day counts, discharge day does not; ED/observation time excluded). Verified at admission; reported with occurrence span code 70. Waivers exist (Medicare Advantage, certain ACO arrangements, and the TEAM model for five surgical episodes) — confirm which applies.
2 · 30-day window
SNF admission within 30 days of the qualifying discharge (unless a later admission is medically appropriate).
3 · Daily skilled need
Skilled nursing needed 7 days/week or skilled rehabilitation at least 5 days/week. “Daily” is the word that most often decides a denial — every day’s note must show a skilled service was required that day.
4 · Qualifying condition
The skilled care is for a condition treated during the qualifying stay, or one that arose while receiving covered SNF care for it.
5 · Practical matter / SNF-level
As a practical matter, the daily skilled services can be provided only in a SNF on an inpatient basis — reasonable and necessary in duration and quantity.
