Can we query the MD AFTER the MDS assessment is completed for documentation of an active diagnosis, or does it have to be prior to the ARD?



Unfortunately, the documentation needs to be present during the appropriate assessment reference period (which ends with the Assessment Reference Date). The RAI defines Active Diagnosis as: Physician-documented diagnoses in the last 60 days that have a direct relationship to the resident’s current functional status, cognitive status, mood or behavior, medical treatments, nursing monitoring, or risk of death during the 7-day look-back period.

If a diagnosis or condition arises or becomes active after the ARD, you may consider completing an IPA if it is a condition that would impact payment under PDPM.

Blog by Eleisha Wilkes, RN, RAC-CTA, Proactive Medical Review

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