Repeatedly, I hear MDS Nurses stating that it’s “not their job” to oversee or manage the diagnosis. Honestly, as a previous MDS Nurse, I cannot believe there is even a question as to who is responsible. So, I ask them: Who signs Section I of the Minimum Data Set (MDS)?

Managing the Diagnosis

Diagnoses are obtained with admission/readmission physician orders, changes in resident status, therapy needs, etc.  All active diagnoses are to be included in Section I of the MDS reflecting the resident status at that point in time.  Diagnoses support the Resource Utilization Grouper (RUG) score obtained with completion of the MDS assessment.  Therefore, the person completing Section I is charged with either manually entering the diagnoses and/or validating those that pull from the Electronic Health Record (EHR).

Some software programs used in LTPAC have the diagnoses auto-populate or push into the MDS, and usually the claim as well, from the Diagnosis section of the EHR.  Where auto-population occurs, the MDS Nurse or person responsible for Section I should review & update (oversee & maintain) the Diagnosis section of the EHR for accuracy.

Diagnosis Review

Diagnosis should be reviewed at least at the time of each MDS completion.  If the Diagnoses are not maintained in the Diagnosis section, an inaccurate/incomplete diagnosis listing can occur in the MDS.  As with anything (maintenance is easier when completed on a routine basis), and an accurate listing of diagnoses in the MDS is imperative.

A client I met the other day asked “what’s the big deal if say the therapy diagnosis doesn’t get added?” At first I thought they were being flip, but quickly realized they really weren’t seeing the big picture. They didn’t understand they are telling a story - one that needs to reflect an accurate picture of the resident at that point in time - the (ARD) Assessment Reference Date in not only the MDS but the EHR, including the diagnosis record, care plan, documentation from clinical, therapy, physician and the claim. If diagnoses are omitted or inaccurately entered, the record will not reflect the resident status at that point in time. This can lead to:

• Incomplete/inaccurate resident care
• Inaccurate MDS
• Incomplete/inaccurate care planning
• Inaccurate medical record
• Inaccurate claim
• And of course this could cause failure of an audit and/or survey tag(s)

Thus the story of the resident must be complete with consistency throughout the medical record.  There is also the “Attestation” that is signed by persons completing the MDS, attesting to the accuracy of the document.  An Attestation should not be taken lightly, if you haven’t read it before and you typically just sign and move on, stop and read it because you are responsible for accurate documentation.   As the person signing, you can be personally subject to substantial criminal, civil and/or administrative penalties for submitting false information.   Who cares, you ask? All of the parties that are paying based on your answer, that’s who.  Those parties, whether it is The Centers for Medicare and Medicaid Services (CMS), your State, Medicare Advantage plan or some other insurance are paying the claims (or not) based on your responses.  If you fail to include diagnosis codes for which therapy is treating and the RUG score on the MDS is indicating therapy was provided, there will be inconsistencies in the story of the resident, which in turn can impact the resident and/or facility as listed above.

So to the question of “who is responsible for diagnoses management?”  The answer should be as clear to you as it is to me: that if you are attesting to the accuracy in Section I of the MDS, YOU are responsible.

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