[Answered]: An 82-year-old male resident was admitted to a…

An 82-year-old male resident was admitted to a skilled nursing facility (SNF) without a diagnosis of schizophrenia. After admission, the resident was prescribed an antipsychotic medication by the primary care physician for behaviors with a new diagnosis of schizophrenia. This is the only notation in the resident’s medical record, including history and physical, of the new schizophrenia diagnosis. Should schizophrenia be captured in item 16000? Yes, there is a physician’s diagnosis in place. No, there is not adequate documentation to support coding on MDS. No, the diagnosis of schizophrenia must come from a psychiatrist. No, but the ICD-10-CM code for schizophrenia can be captured in 18000.