CMS SOM App. A, Tag A-1641

Interpretive Guidelines §482.61(c)(1)(i)

The substantiated diagnosis serves as the basis for psychiatric treatment interventions. A

substantiated diagnosis is the psychiatric diagnosis identified by the qualified practitioner

and agreed upon by the treatment team to be the primary focus upon which treatment

planning will be based.

Data to substantiate the psychiatric diagnosis may be found in, but is not limited to, the

psychiatric evaluation, the medical history and physical examination, laboratory tests,

medical and other psychological consults, assessments done by disciplines involved in

patient evaluations and information supplied from other sources such as community

agencies and significant others.

Survey Procedures §482.61(c)(1)(i)

• Review the sample of medical records to verify the substantiated psychiatric

diagnosis is documented and the psychiatric diagnosis matches the specific

problems listed in the individualized, comprehensive treatment plan.

• Verify identified physical problems and other health conditions are included as a

part of the substantiated psychiatric diagnosis if they require treatment, or

interfere with treatment during the patient’s hospitalization.

• When a psychiatric evaluation results in a new diagnosis or additional

psychiatric diagnosis, verify that the treatment or intervention recommendation is

added to the comprehensive treatment plan. Review the treatment plan to verify

that the diagnosis is addressed.