Add Client Diagnosis

You can add diagnosis codes to a Client Case and classify them as Primary, Secondary, Tertiary, and Quaternary. Diagnosis codes and their classifications will appear on the Behavioral Assessment and Progress Notes.  Once the Client Assessment is completed, signed, and locked, you may not edit a signed Assessment, but you can add an addendum for diagnosis edits and additional Notes.
 

 NOTE:  You can prevent your staff from submitting and signing progress notes that do not have a diagnosis code entered.  See Prevent Staff from Submitting/Signing Progress Note without a Diagnosis for more information.

 IMPORTANT: Â Diagnosis codes will pull into treatment plans & progress notes based on when the document is created.

• If the document is created before codes are entered on the initial assessment, the codes will not display automatically and you will need to manually link them. 
• If the document is created after codes have already been entered on the initial assessment the codes will display automatically from the initial assessment or most recent addendum.
• Any changes to diagnosis codes will not affect any existing progress note or treatment plan. If you want the updated codes to display on any existing documents you will need to manually link them. 
• If you select + Copy from last session to create a new progress note, the diagnosis codes from the last session will not copy over to the new note. 

Add Diagnosis to Behavioral Assessment & Diagnosis Codes

1. Locate Client and open Client Profile.
2. Click Notes in the left side menu. 
   • If a Case has not been created for this Client a new one will be created. 
   • If there are multiple Cases you are assigned to, you will need to select the appropriate Case.
3. Click the Behavioral Assessment tab inside the Case.
4. Click the + Add Diagnosis button. 
   
    
5. The Diagnosis codes pop-up opens with four code & classification search fields available. There is a field for you to add a diagnosis code description if needed.  
   • You can only classify up to four billable codes. Any additional codes will be unclassified.

      NOTE:  Click +Add diagnosis code to add as many fields as needed.
     
     
      

6. Click in the fields to search for diagnosis codes and assign a classification if needed (Primary, Secondary, Tertiary, Quaternary).
   NOTE:  Z-codes classified as Primary may not be accepted by payers. You will see this warning message.
   
7. Enter a description for the diagnosis code if needed.

    NOTE:  The description will display on printed behavioral assessments and progress notes.

   

   NOTE:  Non-billable codes have a blue exclamation point icon. They cannot be classified. 

   
    
8. The diagnosis codes, classification, and billable status are shown on the assessment under Diagnostic Impressions. Billable codes will appear on the claim & CMS 1500 in the order they were classified. 
   

    NOTE:  Hover over the code to see a description.
   

Add Diagnosis to Document Created Before Codes Entered on Behavioral Assessment

1. Open the existing progress note or treatment plan.
2. Click here in the Diagnostic Impressions message field.
   
   
   Add the desired codes when Initial Assessment opens as explained above.
   
    
3. Click Link Diagnostic Code(s). 
   
    
4. Select the diagnosis code(s) you want to add to the document.

   NOTE:  Click the Diagnostic Code box to select all codes. 

   
5. Click the Link Code(s).
   
    
6. The selected code(s) display in Diagnostic Impressions on the document.
   
    

Add Diagnosis to Document Created After Codes Entered in Behavioral Assessment

1. Create a new progress note or treatment plan after you have entered diagnosis code(s) in the Behavioral Assessment as explained above.
2.  All codes entered will automatically display from the Behavioral Assessment or most recent addendum.

    NOTE:  Diagnosis codes entered in the Behavioral Assessment will not pull into treatment Plan & Progress Note draft

3. Click Link Diagnosis Code(s) if you want to select/deselect specific codes. Otherwise, all codes will be included. 
   
    
4. Select the diagnosis code(s) you would like on the document and click Link Code(s).
   
    
5. The code(s) display in Diagnostic Impressions on the document.
   
    

Diagnosis Codes Deleted from Behavioral Assessment or Addendum

You will be alerted when diagnosis codes linked to a progress note or treatment plan are deleted from the Behavioral Assessment or most recent addendum. Deleted codes will remain in Diagnostic Impressions and will need to be manually unlinked.

1. Open an existing progress note or treatment plan. Deleted diagnostic codes will have an alert icon (Exclamation Point) and message in Diagnostic Impressions and the Link Diagnostic Code(s) modal to let you know the code has been deleted. 

   Diagnostic Impressions

   Link Diagnostic Code(s) ModalÂ

2. Open the Link Diagnostic Code(s) modal to unlink the code from the document.
3. Uncheck the box for the deleted code. The box will become inactive. 
4. Click Link Code(s). The code is removed from the Diagnostic Impressions list and Link Diagnostic Code(s) list.

    NOTE:  You must re-enter the code on the Behavioral Assessment if you want to re-use it in the document.