Diagnosis discrepancies

Would someone be able to clarify a confusing situation for our HH agency? Our coders are seeing new diagnoses presented on the comprehensive assessment from nursing staff that wasn't documented in physician documentation (ex: memory loss on the assessment & physician never documented such in their note). In all other areas of coding you only assign dx based on provider documentation, not nursing documentation (with the exception of pressure ulcer staging and BMI from dieticians). I am not sure querying the physician for the memory loss is acceptable either as it introduces a new dx to the medical record.

Ultimately, can home health coders take dx from nursing documentation, or what is the best workflow for verifying new dx from nursing that wasn't previously documented from the provider.

I appreciate any clarification and references on this!


  • The nurses can query the MD with any diagnosis that is not in the physician documentation. If he confirms that diagnosis, then the clinician may use this. Diagnoses can only be given by physician

  • Thank you, is it your understanding that the querying for these missing dx should come from the nurse vs the coder? Coding query guidance explicitly says to not introduce new diagnoses or lead physicians. Do you have any reference in who should be contacting the provider in these cases?

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