- 4.1 The Importance of Diagnoses
- 4.2 Diagnoses Must be Verified
- 4.3 Completing the Diagnoses Table
- 4.4 Identifying Primary and Secondary Diagnoses
By the end of this module the screener should be able to:
- Accurately complete the Diagnoses section of the LTCFS.
- Explain how to verify a diagnosis.
Complete and accurate functional screening cannot occur without a thorough understanding of the diagnoses of the person being screened. Although an individual's diagnoses do not determine whether he or she is eligible for publicly funded long-term care programs, both diagnoses and functional limitations are important factors in determining whether a person's condition meets one or more of the target group definitions required for eligibility. Functional limitations correlate closely with diagnoses and diagnoses often explain and provide context for limitations that may be observed by the screener and health care professionals. In addition, diagnoses and functional limitations are included in data used by the Department of Health Services (DHS) for research, rate setting, federal reporting, and quality assurance activities.
To accurately complete the Diagnoses section of the LTCFS, a screener must verify the diagnoses of the person being screened.
All psychiatric, behavioral, dementia, brain injury, and intellectual disability diagnoses must be verified directly with a health care provider, health record, the Children’s Long Term Support Functional Screen, or the disability determination from the Social Security Administration.
Other diagnoses are verified if:
- Stated to screener by a medical doctor (MD), registered nurse (RN), or other health care provider; or
- Copied from current health records; or
- Very clearly stated, in exact medical terms, by the person, family, guardian, advocate, etc.
Do not interpret an individual's complaints or symptoms as verified diagnoses and record them on the LTCFS. In addition, do not infer an individual’s diagnoses based on his or her prescribed medications because any single medication may be prescribed for a variety of different diagnoses.
- Example A: An 82-year-old woman has diabetes mellitus and is complaining of increasingly poor vision. The screener does NOT check I2: Visual Impairment (for example, cataracts, retinopathy, glaucoma, macular degeneration) based solely on the woman’s self-report. The screener will need to obtain a release of information in order to contact this woman’s doctor for verification of her current diagnoses.
- Example B: A woman says her elderly father is “really losing it,” and “He's getting Alzheimer's.” The screener asks her if a doctor has made this diagnosis. She says, “No, father hasn't been to a doctor for a while, but he must have it, he forgets so much now.” In this case, the screener does NOT check E1: Alzheimer's Disease or E2: Other Irreversible Dementia. The screener will need to obtain a release of information in order to contact this man’s doctor for verification of his current diagnoses.
It is best practice to verify all diagnoses with written documentation from the person’s health care provider(s).
People commonly say someone has "Alzheimer's," “anxiety,” "depression," or “attention deficit/hyperactivity disorder” without a verified diagnosis. At times, a family member reports a person being screened has a diagnosis of intellectual disability or a psychiatric, behavioral, or dementia diagnosis when there is limited or no documentation to substantiate that diagnosis. In addition, the person’s functioning does not match the usual functional limitations associated with that diagnosis. While such statements may be helpful in the assessment process, they are insufficient evidence to support selecting these diagnoses on the screen.
If a screener is performing a re-screen, then he/she may rely on verification of diagnoses that were obtained and documented for previous screen calculations for the person, unless the person has had a change in condition. However, if no verifications have been documented, then the screener responsible for re-screening the person must obtain verification of diagnoses prior to re-calculating the person’s eligibility using the LTCFS.
Verifying Diagnoses with the Social Security Administration (SSA)
The Social Security Administration’s disclosure of personal information to state and local agencies falls under the following categories:
- Disclosure under a routine use (e.g., to administer an income maintenance or health maintenance program similar to an SSA program, or for another purpose that meets SSA’s compatibility criteria, that is, disclosure is compatible with a purpose for which SSA collects the information.) For more specific information, see GN 03314.001.
- Disclosure for a law enforcement purpose (see GN 03314.001F).
- Disclosure required by federal law.
While verifying diagnoses with the SSA is an option for screeners, the following are some guidelines to follow:
- Agencies should attempt to verify diagnoses with the health care provider or medical record before contacting SSA.
- The need for additional information should be indicated on the SSA’s Consent for Release of Information form SSA-3288 (PDF, 187 KB). Only the minimal information that is relevant and necessary should be requested. Unless more information is needed, such as IQ scores or results of other cognitive testing or evaluations, agencies should only request diagnoses codes from SSA. To just select diagnoses codes, agencies should select box #8 Other record(s) from my file (you must specify the records you are requesting, e.g., doctor report, application, determination, or questionnaire) and write “Diagnoses codes only” in the space provided.
- Agencies should also be sure that the language in any cover letter that accompanies the Consent for Release of Information form only asks for the information requested on the SSA-3288 form.
- Requests for diagnoses verification should not be sent to SSA once an individual meets the retirement age of 65 years old. Once that age is met, all of that individual’s records related to their disability are destroyed.
The Diagnoses Table is not meant to be all-inclusive; the screener should reference the Diagnoses Cue Sheet (Excel, 103 KB) in order to accurately complete the Diagnoses Table. For convenience, the diagnoses on the Diagnoses Table are grouped by major categories (such as Heart/Circulation, Respiratory, Infections/Immune system). The Diagnoses Cue Sheet indicates which box the screeners should select on the Diagnoses Table.
Several diagnoses require that an IQ score is known before a selection can be made on the Diagnoses Table. Refer to the Diagnoses Cue Sheet to determine the diagnoses that require an IQ score. Include the IQ score in the text box provided on the Diagnoses Table. It is best practice to include the following in the Notes section, if available: name of the clinician who conducted the test, date of the test, and the name of the IQ test used.
On the Diagnoses Table, select ALL diagnoses that apply. Only enter a diagnosis once on the Diagnoses Table.
A screener must ensure that any information used to complete the Diagnoses Table is current. “Current” is defined as no more than 12 months old and still applicable. A screener must consult with the person’s health care provider(s) to verify that medical information is still applicable. Do not list any diagnosis that pertains to a condition that has been cured or eliminated by medical treatment, therapy, or surgery.
If a diagnosis is not listed on the LTCFS Diagnoses Table or the Diagnoses Cue Sheet, then a screener must select the “K6: Additional Diagnoses” box, and enter the name of the diagnosis in the text box provided. A screener may not assign a Diagnoses Table category for a diagnosis not listed on the Diagnoses Cue Sheet. While searching for a diagnosis on the Cue Sheet, the screener may need to search each of the words in the diagnosis to find the code. Be aware of alternate names or other terms used for the same diagnosis.
If a diagnosis is not on the Diagnoses Table or the Diagnoses Cue Sheet and it is a primary and/or secondary diagnosis needed to complete the LTCFS, the screener is to contact DHS LTCFS Diagnosis mailbox prior to proceeding with the screen until the DHS screen team has responded with coding information.
When selecting a code that requires the screener to enter a diagnosis, only enter a diagnosis. Do not enter a treatment, “see below,” or “history of.”
If a diagnosis cannot be verified, do not select a box on the Diagnoses Table for this reported diagnosis; enter this information in the Notes section of the LTCFS.
If an individual has no diagnoses, choose the “No current diagnoses” box.
- If after review of health records and contact with health care providers, it is determined the person has no current diagnosis, the screener must choose the “No current diagnoses” box. In addition, the screener should provide some detail regarding the absence of any diagnosis in the Notes section of the LTCFS. (Example: “After talking with Mr. Smith's doctor, it was determined that Mr. Smith has no diagnosis.”)
- If an individual refuses to see a health care professional and does not have any health records to verify a diagnosis, enter this information in the Notes section of the LTCFS. (Example: “Mr. Smith has not been to the doctor in over 30 years and refuses to be seen by a health care provider today.”)
When a diagnosis of memory loss is not verified by a qualified health care provider and there is evidence of memory loss, Memory Loss can only be selected on the Diagnoses Table if the Animal Naming Tool is administered and the score is less than 14 AND the Mini-cog is administered with results of 0,1, or 2. While these results are not verification of diagnosis of memory loss, they are acceptable evidence of memory loss and the screener may select Memory Loss based on these results. If a person declines to participate in the administration of one or both of these screening tools, then Memory Loss cannot be selected on the Diagnoses Table. It is best practice to include the results of the Animal Naming Tool and Mini-cog in the Notes section.
Regarding Sensory Deficits diagnoses:
The selection of I1: Blind is correct when the person’s vision loss cannot be corrected to 20/200 or their visual field with both eyes is less than or equal to 20 degrees. The selection of I2: Visual Impairment is correct when a person’s vision loss can be corrected to 20/200 or their visual field with both eyes is more than 20 degrees.
The selection of I3: Deaf is correct when the person’s hearing loss cannot be overcome with hearing aids. The selection of I4: Other Sensory Disorders is correct when a person has a partial hearing deficit or when a person’s hearing loss is able to be overcome with hearing aids.
For each need or additional support identified in the LTCFS, the diagnoses that cause the need or necessary support must be selected from options prepopulated in a drop-down menu. Only diagnoses that were previously identified on the Diagnoses Table will be prepopulated in the drop-down menus. These diagnoses will be used by FSIA to build the correct target group assignment for each individual who is being screened.
In regard to assignment of target group by FSIA, primary and secondary diagnoses carry equal weight. A primary diagnosis must be identified for each need or support identified in FSIA. A secondary diagnosis is not mandatory for each need or support that is identified. When a secondary diagnosis is not identified, the screener must select “None” from the drop-down menu that appears after each need or support that is identified.