Regulatory Visit Frequencies in SNF and Long-Term Care: What Physician Groups Need to Track

Many post-acute physician groups have been in this situation: the facility calls to say it is performing an audit and needs a list of residents seen. The providers are busy and seeing plenty of residents. What the group often lacks is a clear view of who is coming due, so the facility is the one asking.

The rules for how often residents must be seen are simple. Keeping up with them is harder because each resident’s required visits run on their own clock, and the rules for which provider may perform them differ by setting and stay. Required visits are also only part of the work. Patients’ needs don’t follow the schedule, so changes in condition and nurse requests add visits in between, and each one still has to be seen and documented. This post covers the federal schedule, who can make each visit, what to track for every resident, and how to plan rounds around required visits and the unplanned ones in between.

Know the schedule, and what the clock runs from

The minimum visit schedule for residents of Medicare skilled nursing facilities (SNFs) and Medicaid nursing facilities (NFs), also known as long-term care, is set in 42 CFR 483.30.

In a SNF, the initial comprehensive visit is the physician’s first visit, where the physician completes a thorough assessment, develops the plan of care, and writes or verifies admitting orders. The 30 days is the outer limit for the initial visit. The facility has its own, shorter deadlines, such as the baseline care plan within 48 hours of admission and the comprehensive assessment within 14 days, and those are separate from the physician’s visit.

In practice, groups see new admissions much sooner than day 30. I aim for the first couple of days, because patients usually arrive with the acute needs that brought them from the hospital.

Each required visit includes a review of the resident’s total program of care, including medications and treatments. The facility’s comprehensive care plan, which the attending physician helps develop as part of the interdisciplinary team, must also be reviewed and revised after each assessment (42 CFR 483.21): at least every three months, and again after a significant change. That is why required visits need to happen on time: they are one of the regular points when the resident’s care gets reviewed.

A required visit is on time if it is made no later than 10 days after the date it was required, which gives groups a 10-day grace period. The first 90 days are counted from the resident’s admission date, which makes it the date to track for every resident.

Who can make a required visit depends on the setting and the stay

The CMS letter clarifying physician delegation in SNFs and NFs (S&C 13-15) sets out the distinctions that trip groups up:

1. In a SNF, the physician may not delegate the initial comprehensive visit. After the initial visit, required visits may alternate, at the physician’s option, between the physician and an advanced practice provider (APP): a nurse practitioner (NP), physician assistant (PA), or clinical nurse specialist (CNS). Some states and facility policies may require more physician involvement than this federal minimum.
2. In an NF, an NP, PA, or CNS who isn’t employed by the facility and works in collaboration with a physician may make the initial visit and other required visits, if the state allows it. NPs, PAs, and CNSs employed by the facility can’t make the required NF visits.
3. At any point, NPs, PAs, and CNSs may make other medically necessary visits, before and after the physician’s initial visit.

A patient’s status can change during a stay. A resident on a Part A skilled stay follows the SNF rules, and a resident on a long-term care stay follows the NF rules. When a Part A stay ends and the patient stays in the building for long-term care, the rules on who can make required visits can change, along with the place of service on the claim, which I covered in the first post in this series.

Required visits are only part of the schedule

The federal schedule is a minimum. Patient acuity in SNFs has risen over time (Siskind et al., J Am Geriatr Soc, 2023), and in my experience these patients often need more frequent visits due to changes in condition. Many are seen weekly or more often, and nurse requests add visits in between.

Those other visits compete with the required ones for the same provider time. A nurse request after a concerning lab result or a change in condition can’t wait for the next required visit. Providers also plan follow-ups of their own. A provider who sees a patient and wants to reassess in three days doesn’t want to miss or forget that visit, so it needs to be scheduled, the same way a required visit is. A provider covering several facilities has to fit the required visits in around all of it.

That is why the required-visit schedule can’t be the only list a provider works from. Required visits and planned follow-ups need a place on the schedule early, and the unplanned visits need to land on the same list so they are all seen and documented.

What to track for every patient

A due date alone isn’t enough to schedule the next visit. For each patient, groups need:

1. Admission date and facility
2. Patient status: Medicare Part A skilled stay (SNF rules) or long-term/Medicaid stay (NF rules)
3. Initial comprehensive visit: date and who made it
4. Last required visit: date and whether the physician or an APP made it
5. Next required visit: due date, last on-time date (due date plus 10 days), and who is eligible to make it
6. Open follow-ups: nurse requests and rechecks the provider planned

Several of these fields change during a stay: a Part A stay ends, or an APP makes a visit the physician made last time. The list needs to be updated when those changes happen, not rebuilt at the end of the month.

Plan rounds around required visits

Post-acute providers tend to work Monday through Friday and cover several facilities, so the week has to be planned around required visits and the unplanned visits that come between. The groups that keep up do a few things consistently:

1. Look one to two weeks ahead, pull every patient coming due at each facility, and group them so a provider sees them in one trip instead of returning to the same building on different days.
2. Keep due dates in one place the whole group can see, not on a provider’s personal list.
3. Decide in advance which required visits the physician will make personally and which an NP or PA will make, so the right provider is on the schedule.
4. Leave room each day for nurse requests and changes in condition, and keep planned follow-ups on the same list as required visits so they don’t slip.
5. Review weekly for patients who are past their due date but still inside the 10-day grace period, and see them before it ends.
6. Share the list with each facility’s director of nursing or case management team, so the group and the facility are working from the same dates.

A dated record of every visit

Planning rounds only works if the group can see who has been seen and when. Every visit a provider charges in Charge Pro is a dated record of which patient was seen, at which facility, and by which provider. When charges are entered at the point of care, that record stays current, and groups can report on visits by facility and provider rather than piecing them together from notes in each facility’s EHR.

At facilities without an EHR interface, new admissions are the hardest patients to get onto the group’s records. In November, the Charge Pro mobile app adds face sheet auto-registration: the provider photographs the face sheet, the app registers the patient, and the provider goes straight to the charge, so the initial visit is recorded from the first encounter.

Go deeper on October 28

I’ll cover visit schedules alongside the other post-acute revenue gaps in our webinar on October 28: 3 Places Physician Groups in Post-Acute Care Settings Lose Revenue, and How to Close the Gaps. The next posts in this series cover what to do when a facility won’t provide an interface and how to move beyond paper lists and provider memory. You can also see how medaptus supports physician groups in post-acute care.