Revenue Cycle Insider

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 body mass index (BMI) from a dietician, at least one social determinant of health diagnosis from a social worker, and a pressure ulcer diagnosis from a nurse. The resident, who’s a Medicaid beneficiary, has a physician but that physician has not documented or otherwise commented on any of these diagnoses. Are these diagnoses by other providers putting us at risk of noncompliance?

Delaware Subscriber

Answer: According to the ICD-10-CM Official Guidelines for Coding and Reporting FY 2025 -- UPDATED October 1, 2024, released by the Centers for Medicare & Medicaid Services (CMS), there are some instances where clinicians other than physicians can diagnose conditions.

In fact, the conditions you mention are all specified by CMS as information other clinicians involved in patient care can make while abiding by ICD-10-CM and CMS guidelines.

However, CMS specifies that while the condition information can be recorded by other clinicians, the “associated diagnosis, (such as overweight, obesity, acute stroke, pressure ulcer, or a condition classifiable to category F10, Alcohol related disorders) must be documented by the patient’s provider. If there is conflicting medical record documentation, either from the same clinician or different clinicians, the patient’s provider should be queried for clarification.”

This health information is important contextual information for a patient/resident’s status, and CMS encourages its collection and documentation — and appropriate reporting, especially regarding billing the care provided.

Be sure, too, that you aren’t using any of these as primary diagnoses for this resident. CMS says, “The BMI, coma scale, NIHSS [National Institutes of Health Stroke Scale], blood alcohol level codes, codes for social determinants of health and underimmunization status should only be reported as secondary diagnoses.”

Rachel Dorrell, MA, MS, CPC-A, CPPM, Production Editor, AAPC