Diagnosis Management

Diagnoses Page Navigation

All Diagnoses Tab

Top Row:

• Search: type text or numbers to narrow down listed options
• +New Button: see "Add a Diagnosis" section for details
• GAF: Global Assessment of Functioning score (for children = C-GAS Children's Global Assessment Scale)
• Undo Button: removes changes
• Save Button: saves updates
• Top right icons

	Export all data to Excel
	Select Columns - ICD-10, Description, Specificity, DSM-5 Category, Status, Date, Billing Dx
	Clear Filters and Search
	Refresh Data

Columns:

• ICD-10
• Description
• Specificity
• DSM-5 Category
• Status
• Date
• Billing Dx

Clicking Edit at the right of the diagnosis line opens an "Edit Diagnosis" window

Date: defaults to current date, but can be edited

Status Drop Down Options

• Active
• Resolved
• Chronic
• Inactive

Specificity: allows the user to set the specifiers for a selected diagnosis. This is a free text field with unlimited length.

Billing Diagnoses Tab

• +New Button: see "Adding Diagnoses" section for details
• Patient Diagnoses: shows list of active diagnoses
• Billing Order: automatically set when a diagnosis is selected or added, can be manually adjusted
• Select Provider: shows list of active providers in the practice
• Undo Button: removes changes
• Save Button: saves changes

History Tab

Columns

• Event Type
• Description
• Time
• User

Adding Diagnoses

Adding a new diagnosis can be completed in several areas:

• Click +New from upper left in the "All Diagnosis" tab
• Click +New from the upper right in the "Default Billing Diagnoses" section
• Click +New from any added provider section

Any added diagnosis will be visible in the "All Diagnoses" tab

Any diagnosis added will be able to be selected in any "Patient Diagnoses" list

Once a diagnosis is saved, it cannot be deleted. The status can be updated to Resolved, Chronic, or Inactive. 

Adding From All Diagnoses Tab

Click + New in the upper left side of the screen if a desired diagnosis is not already on the list.

The "Add Diagnosis" window will appear.

The available fields on the Add Diagnosis Window are as follows:

• Date: the date that the problem was first diagnosed or when the problem started. This field will default to the current date but can be edited.
• Status: the current status of the diagnosis. The options for this field are as follows: Active, Chronic, Resolved, and Inactive. This field will default to Active when adding a new diagnosis.
• Add to Billing Diagnoses: when checked, marked as a billing diagnosis in the "Billing Diagnoses" tab.
• Code/Description: this field is used to search for a new diagnosis to add to the patient's chart. Either the diagnosis code or the diagnosis description can be used while performing a search.
• Show DSM-5 Diagnoses Only: when checked, this field will limit the results from the search to only diagnoses which appear in DSM-5. Unchecking this box will search across all ICD-10 diagnoses.
• Specificity: allows the user to set the specifiers for a selected diagnosis. This is a free text field with unlimited length.

Begin typing the diagnosis code or the diagnosis description in the "Code/Description" Field.

Click on the desired diagnosis code line and click OK

Adding From Billing Diagnoses Tab

Default Billing Diagnoses may be selected from the drop down "Patient Diagnoses" list (if the patient has diagnoses already entered).

Multiple diagnoses may be selected at one time from the list. "Billing Order" can be adjusted by using the drag tool to the right of the "Billing Order" diagnosis to drag the diagnosis to the desired position.

To link different providers to specific diagnoses, click on a provider from the "Select Provider" field drop down options and click +Add Provider List.

Select one or more "Patient Diagnoses" from the drop down list, or click +New to add a billing diagnosis unique for this provider.

Click Save to update any changes or additions made to the page.

Click +New from the upper right of the screen or the upper right of any added provider section if the desired diagnosis is not on the "Patient Diagnoses" drop down menu. Any active diagnosis from the "All Diagnoses" tab will be in the list. Any new "Billing Diagnosis" added in this tab will not be in the "All Diagnoses" tab list.

The "Add Diagnosis" window will appear.

The available fields on the "Add Diagnosis" window are as follows:

• Date: the date that the problem was first diagnosed or when the problem started. This field will default to the current date but can be edited.
• Status: the current status of the diagnosis. The options for this field are as follows: Active, Chronic, Resolved, and Inactive. This field will default to Active when adding a new diagnosis.
• Add to Billing Diagnoses: when checked, marked as a billing diagnosis in the "Billing Diagnoses" tab.
• Code/Description: this field is used to search for a new diagnosis to add to the patient's chart. Either the diagnosis code or the diagnosis description can be used while performing a search.
• Show DSM-5 Diagnoses Only: when checked, this field will limit the results from the search to only diagnoses which appear in DSM-5. Unchecking this box will search across all ICD-10 diagnoses.
• Specificity: allows the user to set the specifiers for a selected diagnosis. This is a free text field with unlimited length.

Diagnoses in Clinical Documentation

Word Templates

Word Templates that display patient diagnoses will display all of the patient's diagnoses.

Web Editor 

Web Editor documents that display patient diagnoses will display all of the patient's diagnoses.

Mobile Notes

Which diagnoses appear on the "Assessment - Diagnoses" tab in Mobile Notes and the resulting Mobile Note pdf is controlled at the practice-level by the "Diagnoses to Display in Mobile Notes" configuration on the Persons & Institutions | Practice | Preferences tab, in the "Clinical" section.

• When it is set for "Include ALL diagnoses", then all of the patient's diagnoses will be displayed.
• When it is set for "Include ONLY billing diagnoses", then only the billing diagnoses associated with the note's owner will be displayed, and in the case that the note's owner has no associated billing diagnoses, then the patient's default billing diagnoses will be displayed.

Treatment Plan

Which of the patient's diagnoses appear on the treatment plan document is controlled at the Treatment Plan Type-level by the "Diagnosis" configuration on the "Patient Fields" tab when configuring a Treatment Plan Type.

• If "Diagnosis" is not checked, no diagnoses will be displayed in the treatment plan document.
• If "Diagnosis" is checked, then there is a secondary configuration.
  • When it is set for "Include ALL diagnoses", then all of the patient's diagnoses will be displayed.
  • When it is set for "Include ONLY billing diagnoses", then only the billing diagnoses associated with the treatment plan's owner will be displayed, and in the case that the treatment plan's owner has no associated billing diagnoses, then the patient's default billing diagnoses will be displayed.

ICD and DSM Information

DSM-5 is the standard classification of mental disorders used by mental health professionals in the United States.

To maintain the standardized DSM-5 list, users are not able to manage their own diagnosis list. This includes the inability to make changes to the existing codes and descriptions or creating new diagnoses.

Diagnosis Descriptions

The descriptions used in the diagnosis list are all the long form versions for each code set.

The DSM-5 code description is used for ICD-10 codes that belong to DSM-5. 

The ICD-10 code description is used for ICD-10 codes which fall outside of DSM-5.

Non-Billable Diagnoses

The diagnosis list contains every possible mapping of ICD-10 as well as current DSM-5 descriptions.

The diagnosis list includes two non-billable diagnosis codes that can be assigned to patients:

• No Diagnosis Entered Into EHR
• Diagnosis Deferred

These codes are for providers who are not allowed to diagnose their patients or for services that do not require an insurance billable diagnosis.

Neither of the diagnoses are in DSM-5, so the “Show DSM-5 diagnoses only” checkbox should be unchecked when searching for these codes.

Note: Any claims billed to insurance using these codes will result in a rejection, so care should be taken when using these non-billable diagnoses.