PDPM tip: Who can code diagnosis?

Nov 22, 2019
The Bottom Line

There is no requirement that a coder in SNFs be certified. It would be ideal to have certified coders in the SNF, but this is not a realistic expectation. Those responsible for coding need medical terminology, anatomy, and pathophysiology knowledge. This can be a medical records professional (associate degree), bachelor’s degree, or master’s degree educational preparation. A degree does not ensure that the person has a coding certification. Many health unit coordinator programs include diagnosis in the course curriculum. Frequently, nurses have chosen to work in the health information management field. Nurses make good coders due to their educational background but need to careful not to read into a provider’s documentation or assume relationships between documentation entries.

Coding certification is done by the American Health Information Management Association (AHIMA) and American Academy of Professional Coders. There are many types of coding certifications available, including diagnosis and procedure coding. Procedure coding is not used in the SNF environment. Procedure coding is specialty-specific and can involve a separate certification in each specialty.

There are many online educational institutions and professional associations that offer training programs and certifications. Maintaining certification varies greatly by certifying organization and can be costly in time and dollars to meet the continuing education requirements and testing requirements. Employers may have specific certification requirements and may not recognize a given certification. Any and all forms of education will benefit the employee and employers, but buyer beware.

A time study done by the American Association of Nurse Assessment Coordinators in 2015 identified that approximately 55% of MDS coordinators who completed the survey were responsible for diagnosis coding in their facilities.

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