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Selecting Medical Diagnoses on an Evaluation

6/14/2026

Selecting the right medical diagnoses on your evaluation is important for two reasons:

  1. It helps justify your plan of care.
  2. It supports accurate MDS coding and reimbursement.

Thoughtful diagnosis selection ensures your documentation reflects the patient’s medical complexity and helps the facility receive appropriate reimbursement.

Always List the Primary Diagnosis First

The first diagnosis on your evaluation should always match the patient’s Primary Diagnosis for admission.

In most EMRs, this is:

  • The first diagnosis listed
  • Often displayed in bold
  • The diagnosis driving the SNF admission

Because the Primary Diagnosis is the reason the patient is in the SNF, it should remain consistent across disciplines, including nursing, speech therapy, occupational therapy, physical therapy, etc.

Important: Even if the Primary Diagnosis is only indirectly related to your speech therapy plan of care, it should still be listed first. For example, the Primary Diagnosis may be S72.002D – Fracture of unspecified part of neck of left femur, subsequent encounter, and you still list it first on your evaluation.

Add Other Relevant Diagnoses

After the Primary Diagnosis, add diagnoses that are clinically relevant to the impairments you are evaluating and treating.

Think about:

  • Conditions that increase the risk of dysphagia
  • Conditions that increase the risk of cognitive-communication or language deficits
  • Diagnoses that help explain the patient’s presentation

When reviewing the chart, look for diagnoses that significantly increase a patient’s risk for dysphagia, cognitive-communication impairments, and/or language impairments.

You do not need to add every diagnosis in the chart. Focus on diagnoses that meaningfully contribute to the patient’s communication, cognition, or swallowing status.

Diagnoses Associated with Dysphagia

This is not an exhaustive list.

Respiratory Conditions

  • COPD
  • Obstructive Sleep Apnea (OSA)
  • Acute Respiratory Failure
  • Chronic Respiratory Failure
  • Emphysema

Neurological Conditions

  • Parkinson’s Disease
  • Amyotrophic Lateral Sclerosis (ALS)
  • Multiple System Atrophy (MSA)
  • Progressive Supranuclear Palsy (PSP)
  • Multiple Sclerosis (MS)
  • CVA (Stroke)
  • Traumatic Brain Injury (TBI)

Other Medical Conditions

  • Dementia
  • Hypertension

Diagnoses Associated with Cognitive-Communication Deficits

This is not an exhaustive list.

Sensory Impairments

  • Hearing loss
  • Macular Degeneration
  • Glaucoma

Metabolic Conditions

  • Type II Diabetes Mellitus

Cardiovascular Conditions

  • Atrial Fibrillation
  • Coronary Artery Disease (CAD)
  • Heart Failure
  • NSTEMI
  • STEMI

Neurological Conditions

  • Parkinson’s Disease
  • ALS
  • Multiple System Atrophy (MSA)
  • Progressive Supranuclear Palsy (PSP)
  • Multiple Sclerosis (MS)

Other Medical Conditions

  • Hypertension
  • Hyperlipidemia

Quick Rule of Thumb

When selecting diagnoses:

  • List the Primary Diagnosis first

  • Add diagnoses that help explain the patient’s swallowing, communication, or cognitive deficits

  • Do not add diagnoses simply to make the list longer

  • Do not omit the Primary Diagnosis, even if it is not directly related to your treatment focus