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Medicare Compliance & Reimbursement

Compliance:

Know Who Can Record Diagnosis Information

Published on Thu Aug 21, 2025

Question: I’m new to coding and am looking over an internal audit at a skilled nursing facility (SNF).  The audit flagged a resident’s record because there are diagnoses listed in the medical record that weren’t documented by a physician. I know that the provider is supposed to provide the diagnosis in the documentation, but this resident’s records show a low [...]
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