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LTCFS Instructions Module 4: Diagnoses

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

Contents

Definition

Cognitive Impairment: 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.

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 they are eligible for Wisconsin’s Medicaid funded LTC 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 DHS for research, rate setting, federal reporting, and quality assurance activities.

4.2 Diagnoses Verification

To accurately complete the Diagnoses section of the LTCFS, a screener must verify the current diagnoses of the person being screened. A screener may need to consult with the person’s health care provider(s). It is best practice to verify all diagnoses with written documentation from the person’s health care provider(s).

Diagnoses Must Be Verified

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 a disability determination from the Social Security Administration. It is best practice to document in the Notes section the source of the verification. This could include the year, provider and/or clinic.

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. At times, a caregiver may report 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 or when 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. In addition, do not infer an individual’s diagnoses based on their 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 to contact this woman’s health care provider for verification of her current diagnoses.
  • Example B: A woman says her elderly father “is having trouble remembering things and is getting Alzheimer's.” The screener asks her if a health care provider 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 to contact this man’s health care provider for verification of his current diagnoses.

If a screener is performing a rescreen, then they 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 (for example, 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.)
  • Disclosure for a law enforcement purpose.
  • Disclosure required by federal law. For more specific information, see GN 03314.001.

The following guidelines should be followed when verifying diagnoses with the SSA:

  • 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 the individual’s records related to their disability are destroyed.

Diagnoses Must Be Current

In addition to verifying diagnoses, the screener needs to determine if the diagnoses are current. If a diagnosis was made more than a year ago, but is still current, the diagnosis may be entered on the screen. Screeners should not include diagnoses that pertain to a condition that has been cured or eliminated by medical treatment, therapy, or surgery.

4.3 Diagnoses Table

The screener will need to complete the Diagnoses Table after the diagnoses have been verified and determined to be current.

Diagnoses Table

  • The screener will enter verified diagnoses that are current. For every diagnosis, the screener will need to determine if the diagnosis is listed on the Diagnoses Table and select the relevant box. For convenience, the diagnoses on the Diagnoses Table are grouped by major categories (such as Heart/Circulation, Respiratory, Infections/Immune system). 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 or is not current, the screener must not select the box on the Diagnoses Table for this diagnosis. This information may be included in the Notes section of the LTCFS.
  • If an individual has no diagnoses, the screener must select the “No current diagnoses” box. In addition, the screener should provide some detail regarding the absence of any diagnosis in the Notes section.
    • 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, the screener must select the “No current diagnoses” box. In addition, the screener should enter this information in the Notes section. 
    • Example: Mr. Smith has not been to the doctor in over 30 years and continues to refuse to be seen by a health care provider.

Diagnoses Cue Sheet

If a diagnosis is not on the Diagnoses Table, the screener will need to find the code on the Diagnoses Cue Sheet, P-00814 (Excel), then select the corresponding code on the Diagnoses Table.

  • The Diagnoses Cue Sheet lists diagnoses in alphabetical order. While searching for a diagnosis on this cue sheet, the screener may find it helpful to search using “Control+F” and may need to search each of the words in the diagnosis to find the code. 
  • A key of “Ø” means that the diagnosis is not included on the Diagnoses Table and the screener should not code it. Screeners should include diagnoses of this nature in the Notes section.
  • Some diagnoses are noted on the cue sheet to be coded as K6 and the screener should select K6 for these specific diagnoses. K6 should also be selected when a diagnosis is NOT listed on the Diagnoses Table or the Diagnoses Cue Sheet and is NOT needed for a primary or secondary diagnosis. When selecting K6, the screener should record the diagnosis in the text box provided.
  • If a screener has a question about capturing or how to code a diagnosis, they should contact their screen liaison.
  • If a screen liaison has questions about capturing diagnoses or 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 contact dhsltcfsdiagnosis@dhs.wisconsin.gov prior to calculating the screen. If DHS LTCFS team provided consultation regarding diagnoses selections, this also must be documented in the Notes section and should be reviewed by the screener with each rescreen.
    • Example: DHS consulted regarding coding of neurocognitive disorder on 1/18/23. Based on information provided at the time of this screen neurocognitive disorder coded as E2. Dx should be reviewed with rescreens and questions should be addressed with liaison and Dx mailbox as needed.

Regarding Dementia

To select a dementia diagnosis, it must be irreversible which is not always discernible by diagnosis alone. A screener may need to consult with a health care provider to confirm whether the dementia experienced by a person being screened is irreversible.

Regarding IQ Scores

For diagnoses that are coded as A1-A10, an IQ score can be important for determining the correct target group and level of care. If the IQ is known, it should be recorded in the text box provided on the Diagnoses Table. Screeners should 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. If this information is not known, screeners are strongly encouraged to request records of the IQ testing.

The screener should use the most recent IQ score for individuals that have had multiple tests. In order to capture the FSIQ score on the screen, the name of the IQ test should be in the list below.

IQ Test

  • Comprehensive Test of Nonverbal Intelligence (C-TONI)
  • Differential Ability Scales (DAS)
  • Kaufman Adolescent & Adult Intelligence Test (KAIT)
  • Kaufman Assessment Battery for Children (KABC)
  • Leiter International Performance Scale (Leiter)
  • Stanford Binet Intelligence Scales (SB)
  • Test of Nonverbal Intelligence (TONI)
  • Universal Nonverbal Intelligence Test (UNIT)
  • Wechsler Intelligence Scale for Children (WISC)
  • Wechsler Nonverbal Scale of Ability (WNV)
  • Wechsler Adult Intelligence Scales (WAIS)
  • Woodcock Johnson – Test of Cognitive Skills (WJ III COG)

The screen liaison should contact DHS at dhsltcfsdiagnosis@dhs.wisconsin.gov if:

  • The name of the test is not known.
  • The test is not on the table including an abbreviated form of the test.
  • The clinician conducting the IQ test expressed concern about the validity of the results.
  • The IQ does not seem to generally match the current functioning of the individual.
  • The test was completed prior to the individual’s 7th birthday.
  • The test result is reported as a range.
  • There is an unexpected outcome.
  • There are any questions regarding IQ.

Regarding Memory Loss

A person may show signs and symptoms of memory loss but has not yet received a formal, verified diagnosis from a qualified health care provider. This apparent memory loss may impact the person’s ability to perform certain tasks without assistance. The following guidelines describe the circumstances under which a screener may select memory loss on the Diagnoses Table in the absence of a verified diagnosis of memory loss.

When a person, their family, caregivers, or other support suspect that memory loss could be impacting the person’s functioning, but there has been no verified diagnosis of a condition that may cause a cognitive impairment or memory loss such as dementia, TBI, I/DD, or SPMI, and the person is not under the influence of drugs or alcohol, a memory screen may be offered to the person. Memory screening is always voluntary. Refer to the DHS publication, Memory Screening in the Community, P-01622 (PDF), for specific guidance.

For purposes of the LTCFS, results of the memory screening conducted by a trained staff at a DHS approved screening agency using the Memory Screening in the Community manual may be used in the place of a verified diagnosis when ALL the statements below are true:

  1. The screener is completing a screen for a person who shows signs of apparent memory loss but does not have a verified diagnosis of a cognitive impairment or memory loss as described above.
  2. Memory Loss would be selected as a primary or secondary diagnosis for one or more areas of functioning on the functional screen.
  3. The results of the memory screening fall within the range when a referral to a provider is recommended as outlined below:
    Total Mini-Cog score = 0-2
    OR
    Animal Naming is less than 14 and score is zero (0) on either the word recall or the Clock Draw

Coding Memory Loss on the Diagnoses Table as a Result of Memory Screening

  • When the memory screening is administered and the results fall within the range where a referral to a provider is recommended, the screener may use E9 on the Diagnoses Table. While these results are not verification of diagnosis of memory loss, they are acceptable evidence of memory loss.
  • In absence of getting a diagnosis from a health care provider, for purposes of the LTCFS, administer the memory screen at least annually to continue using memory loss in lieu of a diagnosis.
  • If E9 is used, the screener must include the results and date of the memory screening in the text box provided.
  • If E9 is used longer than one year, the screener must explain why in the Notes section.
  • If a person declines to participate in the administration of one or both screening tools, then Memory Loss may not be selected on the Diagnoses Table.

If you have questions about conducting the memory screen, refer to the Memory Screening in the Community manual or consult your dementia care specialist or lead.

If there are accessibility or health equity concerns as outlined in the Memory Screening in the Community manual or questions about using the results of the memory screening in lieu of a memory loss diagnosis, the agency screen liaison is to contact DHS at dhsltcfsdiagnosis@wisconsin.gov.

Regarding Sensory Deficits

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 can be overcome with hearing aids.

Regarding Terminal Illness

The screener must select both “K3: Terminal Illness (prognosis less than or equal to 12 months)” on the LTCFS Diagnosis Table and the associated diagnosis that has created the terminal condition (such as “J2: Cancer in the past 5 years”). Written documentation from the health care provider of the person being screened that verifies the terminal nature of the condition is not required.

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. If symptoms or complications of a disease/condition require assistance from another person, the screener can use that diagnosis as the primary or secondary.

There is one exception to this guidance which is 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 everyone being screened.

Primary and secondary diagnoses carry equal weight regarding 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 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 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 11 Completion of the LTCFS can provide some guidance as to what factors into each target group.

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 should 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.

Regarding 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 cognitive impairment due to that diagnosis. This does not include impairments that may resolve when medications are taken appropriately or when engaged in ongoing therapy, are situational, or can be reasonably accommodated. The notes should justify why the mental health diagnosis has been used as a primary or secondary diagnosis.

Regarding Substance Use

A screener cannot use temporary effects of substance use intoxication, including physical, cognitive, or memory loss impairment, as a reason for a need for assistance.

Glossary

 
Last revised March 28, 2024