PDPM Documentation Essentials for the IDT: Primary Diagnosis Determination and Section I-Additional Handouts

Additional Handouts

Pdf Summary

This AAPACN document provides guidance for accurate MDS and ICD-10-CM coding in long-term care by emphasizing the need for complete, consistent provider and hospital documentation.

Key points include:
- <strong>Hospital records needed for MDS support</strong>: discharge summaries, operative notes, history and physicals, progress notes, transfer summaries, imaging/lab reports, IV intake records, feeding tube records, physician orders, and dietitian notes.
- <strong>Purpose of source documents</strong>: to confirm diagnoses, recent surgery details, IV fluids/feeding, tube feeding intake, postoperative complications, and continuity of care.
- <strong>Provider documentation requirements</strong>: coders can only assign codes based on diagnoses documented by a physician or non-physician practitioner. They cannot infer diagnoses from labs, imaging, medications, or family/resident reports alone.
- <strong>Important diagnosis details</strong>: documentation should specify type, onset, cause, location, laterality, severity, acuity/status, complications, healing stage, and symptoms/findings.
- <strong>Common LTC conditions needing more specificity</strong>:
  - <strong>Diabetes</strong>: type and all related complications.
  - <strong>CVA/cerebrovascular disease</strong>: exact type and any sequelae such as cognitive, speech, motor, swallowing, or other deficits.
  - <strong>Dementia</strong>: severity and whether behavioral, psychotic, mood, or anxiety symptoms are present.

The document also includes several quick-reference tools for coding:
- <strong>CVA sequelae</strong>
- <strong>Diabetes</strong>
- <strong>Pneumonia</strong>
- <strong>Sepsis/septic shock/SIRS</strong>

A separate section on <strong>sepsis documentation</strong> explains updated MDS guidance: if there is inflammation due to sepsis plus evidence of microbial process, code it as <strong>septicemia</strong>; otherwise, document sepsis in the additional diagnoses section. Nurses are advised to assess and document inflammatory symptoms and collect supporting evidence such as labs and infection source.

Overall, the document is a practical reference for ensuring diagnosis coding is supported by precise, physician-documented clinical details.

Keywords

MDS coding

ICD-10-CM

long-term care

provider documentation

hospital records

diagnosis specificity

diabetes coding

cerebrovascular accident

dementia documentation

sepsis documentation