Medical Diagnosis vs. Treatment Diagnosis - The Guide to Getting it Right in the SNF

Selecting accurate medical and treatment diagnosis codes areincredibly important when evaluating and documenting a plan of care for patientsin the SNF setting; both for billing purposes, as well as accurately developinga patient’s profile and course of treatment. The evaluating therapist mustdocument the correct codes, and should understand how they interact.  

First, let’s consider the difference between a medical and atreatment diagnosis.

Medical diagnosis:

  • Determined by a medical professional such as aphysician or nurse practitioner
  • Identifies a disease or a medical condition
  • Provides information about the patient’spathology

Treatment Diagnosis:

  • Selected by the evaluating PT, OT, or ST
  • Represents the patient’s functional limitationas a result of the disease or medical condition
  • Shouldidentify the signs, symptoms, and/or conditions that the therapeuticintervention is treating

Now let’s look at an example of a medical diagnosis vs a treatmentdiagnosis, and how they interact.

Patient X is admitted to a SNF after an acute hospital stayfollowing a L MCA stroke.

The medical diagnosis would have been determined by the MD in the hospital:
I63.412 Cerebral infarction due to embolism of left middle cerebral artery.

When that patient is evaluated by the Speech Language Pathologist in the SNF setting, they may identify numerous functional deficits as a result of the medical diagnosis of I63.412.

The treatment diagnosis may consist of:
 I69.320 Aphasia following cerebral infarction
I69.322 Dysarthria following cerebral infarction
I69.391 Dysphagia following cerebral infarction

Jennifer Maher, MA, CCC-SLP is a treating Speech Language Pathologist with Language Fundamentals in New York, New York.

In this case, the medical diagnosis (CVA) identifies the pathology, and all three treatment diagnoses (aphasia, dysarthria, and dysphagia) are complimentary diagnosis that indicate the functional change that occurred as a result of the patient’s stroke and will be targeted during the therapeutic intervention. Having an accurate medical and treatment diagnosis will provide the therapist with a clear picture of what they are treating and why.

I hope this article is helpful in providing some clarity. Have any thoughts or questions? I'd love to hear. Feel free to comment in the box below.

About the Author:

Originally from Port Jefferson, New York, Jennifer Baquet Maher, MA, CCC-SLP has a Masters Degree from St. John's University Communication Sciences and Disorders program.   Jennifer and her husband, Noel, recently welcomed their daughter Ella Josephine to the world on August 3, 2018.  In her spare time, Jen also enjoys cooking and traveling.