LTCFS Instructions Module 4: Diagnoses

Glossary of Acronyms (PDF) | LTC FS Paper Form (PDF)

Contents

• 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

Objectives

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.

4.1 The Importance of Diagnoses

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.

4.2 Diagnoses Must be Verified

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 rescreen, then he or 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 rescreening 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). 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.

4.3 Completing the Diagnoses Table

The Diagnoses Table is not meant to be all-inclusive; the screener should reference the Diagnoses Cue Sheet, P-00814 (Excel) 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.

IQ Scores
For some diagnoses, IQ score can be important for determining the correct target group; therefore, it is important to include IQ. If the IQ is known, it should be recorded 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.

Diagnoses must be current
Enter verified diagnoses that are current. If a diagnosis was made more than a year ago, but is still current, the diagnosis may be entered on the screen. A screener may need to consult with the person’s health care provider(s) to ensure that previously verified medical information is still current. 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 Diagnoses Table or the Diagnoses Cue Sheet and is not needed for a primary or secondary diagnosis, 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 listed on the Diagnoses Table or the Diagnoses Cue Sheet and it is a primary or secondary diagnosis needed to complete the LTCFS, the screen liaison is to email DHS at DHS LTCFS Diagnosis 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 list a diagnosis, only enter a diagnosis. Do not enter other text, such as 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.”)

Regarding Memory Loss:
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 and, therefore, as a primary or secondary diagnosis, 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.

4.4 Identifying Primary and Secondary Diagnoses

To be selected as a primary or secondary diagnosis that causes a need for assistance or support from another person, the need must be due to a physical, cognitive, or memory loss impairment, with one exception as outlined in the section titled “Exception to Physical, Cognitive, or Memory Loss Impairment Requirement.”

For each need or additional support identified in the LTCFS, including some selections of adaptive equipment, 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. FSIA will use these diagnoses to assign the correct target group(s) for each individual being screened.

Primary and secondary diagnoses carry equal weight in regard to assignment of target group by FSIA. One diagnosis must be selected from the drop-down menu under primary diagnosis for each need or support identified on the screen. Under secondary diagnosis, a selection must be made from the drop-down menu. If there is no secondary diagnosis contributing to the need for assistance, the screener must select “None.”

When determining which diagnosis to select from the primary or secondary diagnosis drop-down menu, the screener is to be thoughtful and consistent. The diagnosis selected should justify and explain the need for assistance from another person. If there is only one diagnosis that affects the need for assistance, the screener would select “None” from the drop-down menu under secondary diagnosis. If a person has more than one diagnosis that corresponds to the person’s need, the screener could choose one of the other diagnoses as the secondary diagnosis. However, if both diagnoses are clearly related to a single target group it is not necessary to list both of them on the functional screen. For example, a 74-year-old man needs assistance with getting into the shower due to right-sided weakness after a cerebral vascular accident (CVA). The diagnosis that corresponds to why he needs assistance is a CVA. If he also has a diagnosis of right hemiparesis (right-sided weakness) due to the CVA, while the diagnosis of right hemiparesis could be selected as secondary, it is not required because it is actually caused by the identified primary diagnosis and it clearly relates to the same target group.

If the need for assistance is due to multiple diagnoses that are related to different target groups, the screener should select diagnoses from different categories on the Diagnoses Table. This is important for accurate assignment of target group(s). For example, a 43-year-old woman needs hands-on assistance with bathing due to obesity (B8) and cueing with bathing due to intellectual disability (A1). In this example, both the obesity and intellectual disability diagnoses should be selected; one from the drop-down menu under primary diagnosis and one from the drop-down menu under secondary diagnosis. The diagnosis of obesity is relevant to the Physical Disability target group and the diagnosis of intellectual disability is relevant to the Intellectual/Developmental Disability target group. A review of Module 2 Target Groups can provide some guidance as to what factors into each target group.

Mental Health Diagnoses: For a mental illness to be selected as a primary or secondary diagnosis that causes a need for assistance or support from another person, the person must have a permanent impairment of thought due to a severe and persistent mental illness.
 
A screener should always consider if the diagnosis creates a permanent cognitive impairment that cannot be controlled by medications or therapy, is not situational, or varying to the degree that the person can complete the task another time. In the notes, the screener should clearly state what it is about the diagnosis that makes it permanent and not able to be overcome to complete the task.

A cognitive impairment in the LTCFS is defined as a permanent impairment of thought due to a severe and persistent mental illness, dementia, brain injury, intellectual/developmental disability, or other organic brain disorder.

• A cognitive impairment does not include temporary impairment due to medications and/or substance use intoxication.
• A cognitive impairment does not include temporary impairment due to a temporary medical condition such as infection, electrolyte imbalance, or dehydration.

Exception to Physical, Cognitive, or Memory Loss Impairment requirement
There are occasions when the need for assistance is not due to a physical, cognitive, or memory loss impairment. This is relevant only to certain skilled tasks captured on the HRS Table (Module 7) and IADL Medication Administration and Medication Management (Module 5.14). These skilled tasks may include Medication Administration, Medication Management, Ostomy-related Skilled Services, Oxygen and/or Respiratory Treatments, Dialysis, Transfusions, Tracheostomy care, Ulcer care, Urinary Catheter-related skilled tasks, other Wound Cares, Ventilator-related interventions, RNAI, and Skilled Therapies.

In these cases, the screener should determine why a primary or secondary diagnosis is selected even though it may not be the cause of a physical, cognitive, or memory loss impairment requiring assistance from another person. The screener must document this in the Notes section.

Examples include (this is not an all-inclusive list):

• A person who is paralyzed from the waist down has a stage 4 ulcer on their coccyx region requiring dressing changes every three days. He has no physical, cognitive, or memory loss impairment preventing him from performing the wound care, but due to the location of the ulcer, he is unable to complete the needed care. In addition, due to the depth of the wound, the physician has ordered a wound care nurse to complete the wound care. The screener would select K4: Wound/Burn/Bedsore/Pressure Ulcer as the primary diagnosis for Ulcer – Stage 3 or 4 on the HRS Table and explain in the Notes section why this selection was made.
• A person has a verified diagnosis of chronic pain treated with a Fentanyl patch. The patch is placed on her back, near the scapula, and the site is changed every three days. She does not have a physical, cognitive, or memory loss impairment, but cannot reach the site, and she requests assistance to place and remove the patch. The screener needs to confirm with the person or her medical professional if the patch must be placed in a location that she cannot reach, or if an alternate accessible location is possible. If the location of the patch does indeed need to be in an inaccessible spot, the screener would select D12: Other Chronic Pain or Fatigue as the primary diagnosis for Medication Administration and explain in the Notes section why this selection was made.
• A person has a verified diagnosis of end-stage kidney disease and receives hemodialysis three times a week at a dialysis center. His need for assistance at a dialysis center is not due to a physical, cognitive, or memory loss impairment. The screener would select G1: Renal Failure, other Kidney Disease as the primary diagnosis for dialysis on the HRS Table and explain in the Notes section why this selection was made.