Harmony Healthcare Blog

PDPM - Where are We Now Q&A: Part 5

Posted by The Harmony Team on Thu, Feb 20, 2020


Edited by Kris Mastrangelo

C.A.R.E.

Compliance • Audits/Analysis • Reimbursement/Regulatory/Rehab • Education/Efficiency


H19-7419-1Question 5 of 9: Is it appropriate to use diagnoses added by consulting physicians?

It is appropriate to use diagnoses added by consulting physicians, in addition to those listed by the admitting physician and those identified by non-physician providers such as nurse practitioners and physician assistants.  According to the RAI User’s Manual, active diagnoses are intended to code diseases that have a direct relationship to the resident’s current functional status, cognitive status, mood or behavior status, medical treatments, nursing monitoring, or risk of death. 

One of the important functions of the MDS assessment is to generate an updated, accurate picture of the resident’s current health status. Medical record sources for physician diagnoses include the most recent history and physical, transfer documents, discharge summaries, progress notes, and other resources as available.

Direction from the RAI User’s Manual indicates that the medical record should be carefully and comprehensively reviewed to assure appropriate capture of all active diagnoses, which includes the physician-documented diagnoses in the last 60 days that have a direct relationship to the resident’s current functional status, cognitive status, mood or behavior, medical treatments, nursing monitoring, or risk of death during the 7-day look-back period.

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Harmony Healthcare International (HHI) is available to assist with any questions or concerns that you may have.  You can contact us by clicking here.  Looking to train your staff?  Join us in person at one of our our upcoming Competency/Certification Courses.  Click here to see the dates and locations. 


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Tags: MDS, PDPM, Physician Diagnosis

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