The physician’s role in the nursing facility is essential to delivering skilled, quality care for Skilled and Long-Term Care residents. Physicians are our lead in providing clinical decision making and properly defining, clarifying, and verifying diagnoses.

Only the verified diagnosis is to be used on the MDS. Once a diagnosis is verified, MDS Coordinators must then determine if the verified diagnosis is active within the 7-day look back of the assessment reference date (ARD) window (exception: UTI is a 30-day look back). The diagnosis must first be present before determining if it falls under the scrutiny and definition of an active diagnosis as defined in the RAI manual.

The ExistEnce of a Diagnosis

To understand Section I of the MDS (Active Diagnoses), we need to start at the beginning: the existence of a diagnosis.

The existence of a diagnosis starts with clinical decisions made by clinicians. In the SNF/NF setting, these clinicians are known as our physicians and physician extenders (PA, NP, etc.).

CMS defines physicians treating residents in a nursing facility as providers. Specifically, a provider is a physician or qualified health care practitioner who is legally accountable for establishing patient diagnoses (see MLN006764 Evaluation and Management Services Guide).

Providers undertake 4 steps before they formulate a diagnosis:

    1. Resident history
    2. Physical examination/mental examination
    3. Diagnostic testing
    4. Data summarization to determine the diagnosis

It is the fourth step that the SNF/NF needs and relies upon. Physician documentation is the foundation from which we abstract diagnoses and build our plan of care in the nursing home.

Physician Documentation…

Diagnoses can only come from the documentation of the physician/physician extender providing the care.

This is why, for example, we should not use x-rays signed off by a physician specializing in radiology (radiologist) as this physician would not be legally accountable for the resident. On the other hand, independent physicians, consulting physicians, NPs, PAs, and medical residents who are licensed and rendering direct care (thereby meeting the definition of a “qualified health care practitioner who is legally accountable for establishing the patient’s diagnosis”) can assign codes based on documentation.

For documentation to be compliant, physicians must adhere to rules and guidelines established by CMS and other regulatory groups.

Physician documentation must be legible and possess patient identification, visit dates, signatures, and credentials. All conditions and diseases must be documented to substantiate the diagnosis. Missing any one of these pieces will place the documentation out of compliance and make the diagnosis unusable (and subsequently unsuitable for coding in Section I of the MDS).

A common acronym used in the medical physician community is MEAT, which describes the basic information needed in physician/provider documentation to make a diagnosis legitimate for the SNF/NF to use on the MDS and UB04:

M = Monitoring

E = Evaluation

A = Assessment

T = Treatment for documentation practices

Do not confuse diagnoses with the RAI’s definition of active diagnoses. The diagnoses must first exist before we may define them as active. The RAI definition states that the diagnosis must be documented in the last 60 days and have a direct relationship to the resident’s current functional, cognitive, mood or behavior status, medical treatments, nursing monitoring or risk of death during the 7-day look back of the assessment. Page I-7 of the RAI states “Medical record sources for physician diagnoses include progress notes, the most recent history and physical, transfer documents, discharge summaries, diagnosis/problem list, and other resources as available. If a diagnosis/problem list is used, only diagnoses confirmed by the physician should be entered.”

…And Active Diagnosis

As a MDS Coordinator coding an “active diagnosis” on the MDS, this can often be confusing. A MDS Coordinator must verify that there is in fact physician documentation of an “active diagnosis” in the last 60 days. The physician must first indicate that the resident has the diagnosis before you can code the diagnosis as active.

 “A joint effort between the healthcare provider and the coder is essential to achieve complete and accurate documentation, code assignment, and reporting of diagnoses and procedures. These guidelines have been developed to assist both the healthcare provider and the coder in identifying those diagnoses that are to be reported. The importance of consistent, complete documentation in the medical record cannot be overemphasized. Without such documentation accurate coding cannot be achieved. The entire record should be reviewed to determine the specific reason for the encounter and the conditions treated.” ICD-10-CM Official Guidelines for Coding and Reporting

This also applies to malnutrition, stroke, and morbid obesity. While there are other qualified healthcare practitioners who may document a condition for a resident, such as a dietitian for BMI and risk for malnutrition, the associated diagnosis of obesity or malnutrition must be documented by the provider.

Armed with this knowledge, the next time you review a resident for active diagnosis, check to see if the physician has documented the diagnosis or condition. When we look at orders, we verify they are signed off by the physician with a diagnosis next to them. However, we should also ensure the diagnosis is included in the provider’s documentation to support the existence of the diagnosis.


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