Coding from HPI for LTC


Horton, MI
Best answers
Hello All,

I work in LTC and I got a notification from one of my MDS nurses that they had added a dx of Dementia for a resident, but I did not have it on my diagnosis sheet for that particular resident. I went through all the documentation and could not find a dx or dx code of Dementia for said resident. I sent her an e-mail asking her where she found it, and she did. Out of 30+ encounters our physician's have had with this resident, plus hospital documentation, and the resident's 77/78, this is the ONLY thing indicating the dx of Dementia. The NP that saw her on this day didn't even give a dx code for it, which they usually do. Our social worker doesn't even have it on her 77.

History of Present Illness
Patient is seen today to review labs and for follow-up of
hypertension and leg edema. No concerns from nursing. Review
patient's weight shows she is down 2 pounds from last week. Labs
reviewed today sodium 140 potassium 3.6 BUN 30 creatinine 1.16
magnesium 1.9 vitamin D 46. Patient is pleasant denies concerns or
complaints, unreliable historian secondary to dementia. Medications
verified, as per MAR.

Can I code this on my diagnosis sheet? This one time small blurb? I go round and round with the MDS nurses on a daily basis in regards to coding, so I'm cautious.

Thank you,

Brandi McKessy, CPC