CMS SOM App. A, Tag A-1623

the time of admission, and must include the diagnosis of intercurrent diseases as

well as the psychiatric diagnosis.

Interpretive Guidelines §482.61(a)(2)

Every psychiatric patient must have an admission or provisional psychiatric diagnosis

documented utilizing the most current edition of the American Psychiatric Association’s

Diagnostic and Statistical Manual (DSM) or the approved International Classification of

Diseases (ICD) nomenclature. This diagnosis is made and documented on each patient at

the time of the inpatient admission order is entered into the medical record. A

provisional diagnosis is determined by the admitting psychiatrist, physician, or licensed

practitioner, based on the patient’s medical and psychiatric condition, and information

gathered at the time of admission. The admitting psychiatrist, physician or licensed

practitioner issues a provisional diagnosis when he/she first evaluates the patient to form

the basis of the initial treatment until further tests, assessments, and information are

available to determine a final diagnosis. Provisional in this sense means existing until

being permanently replaced. The final diagnosis may differ from the provisional

diagnosis if subsequent evaluation and observation support a change.

If a diagnosis is absent, there must be justification for its absence. For example, if a

patient was psychotic on admission and was not accompanied by family or significant

others.

Intercurrent (other than psychiatric) diagnoses are diseases that occur during the course

of another disease and must be documented when they are made. Intercurrent diagnoses

may also be identified as co-morbidities. Attention should be paid to physical

examination notes, including known medical conditions, allergies, recent exposure to

infections, illness, or substance abuse. In addition, attention should be paid to available

laboratory or test reports that identify abnormal findings to see that these are reflected

by an appropriate diagnosis.

These diagnoses may be found in a variety of locations in the medical record, e.g., the

identification/face sheet, the findings of admission physical examination, the psychiatric

evaluation, the admission workup, or the physician’s progress notes. Diagnostic

categories should include physical illness when present.

Survey Procedures §482.61(a)(2)

• Review the sample of patient records and verify that a provisional or admitting

diagnosis is present; verify the diagnosis was made at the time of the inpatient

admission.

• Review the medical records to verify intercurrent diagnoses are documented to

include known medical conditions or co-morbidities as well as the psychiatric

diagnosis.