The Diagnosis Dilemma and Timely Documentation Needs for MDS Accuracy

Aprescriber, who has been asked by the nurse to address diagnoses on admission for several residents, replies, “I will get to that when I have time.” But the nurse explains that prompt, accurate diagnosis coding helps to ensure accurate care planning and payment under Medicare’s Patient-Driven Payment Model (PDPM). To be included on the Minimum Data Set (MDS), any supporting documentation must be done within a very short window of time, ranging from one to eight days. Additionally, federal regulations require a baseline plan of care, including diagnoses, be in place in the first 48 hours of a resident’s stay.