Coding, Classification and Reimbursement

SNF/LTC diagnosis

  • 1.  SNF/LTC diagnosis

    Posted 02-08-2019 08:35

    I have a situation where I am not sure which way to go.  We have a UHC NP working in our SNF for their insured.  She does very good indepth dictation where she includes diagnosis that are very detailed and specific.  The primary care physician does his dictation and has very non-specific diagnosis along with the admission hospital paperwork which is also not very specific.  Do I update the diagnosis to reflect the NP's diagnosis or do I go with the primary physician/hospital paperwork.  Querying is not an option!  I will also say that they all have access to EPIC which I do not so they have alot better history at their disposal than I do.  I also do not have the available history except for the admission paperwork we get from that hospitalization that they were admitted for so there is nothing more to justify why I am "upcoding"(lack of a better term)without any other documentation.  I know other facilities are going this route with insurance companies(NP in house).  Am I safe to follow the NP documentation.  This is all new to me and becoming extremely time consuming reading all these multiple dictation from not only the physician but his NP's and the UHC NP.

    Please steer me in the right direction!

  • 2.  RE: SNF/LTC diagnosis

    Posted 02-10-2019 14:28
    Hi Debra,
    There is no reason why you cannot use the NP's diagnosis.  Just make sure any provider notes you code from are in the medical record, you will be fine.

    Amy Logsdon, RHIA
    HIM Director