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Add Client Diagnosis (My Clients Plus 3.0)

Carrie B.
  • Updated

  Permissions: Must be Therapists assigned to Case or Administrator.

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 initial assessments and progress notes. Once the Client Assessment is completed and signed locked, you may not edit a signed Assessment , but you can add an addendum for diagnosis edits and additional Notes.

[Add Diagnosis to Initial Assessment & Diagnosis Codes]
[Add Diagnosis to Document Created Before Codes Entered on Initial Assessment]
[Add Diagnosis to Document Created After Codes Entered in Initial Assessment]
[Diagnosis Codes Deleted from Initial Assessment or Addendum]



IMPORTANT: The diagnosis code, classification and billable status 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.
  • When linking diagnosis codes, the codes available for linking will pull from the Initial Assessment or most recent addendum.
  •  Any changes to diagnosis codes will not affect existing progress notes or treatment plans, regardless if they are signed or unsigned. If you want the updated codes to display on any existing documents, you will need to manually link them.

    • If a diagnosis code is no longer active for the case, it will not be removed from existing documents. A tooltip will appear next to the code in the document letting you know the code is no longer active. If you manually un-link the code, it cannot be re-linked unless it is added back to the case.

  • 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 Initial Assessment & Diagnosis Codes

  1. Locate Client and open Client Profile.
  2. Click Notes in 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 appropriate Case.
  3. Click Initial Assessment & Diagnostic Codes tab inside the Case.
  4. Click the + Add Diagnosis button. 

    Snag_126b36b.png

  5. The Diagnosis codes pop-up opens with four code & classification search fields available.
    • 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. 


      Snag_143c32d.png

  6. Click in the fields to search for diagnosis codes and assign a classification if needed (Primary, Secondary, Tertiary, Quaternary).


    2023-08-28_16-00-52.gif

    NOTE: Non-billable codes have a blue exclamation point icon. They cannot be classified. 
    Snag_1641d29.png

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

    Snag_1a8e30e.png

NOTE: Hover over the code to see a description.

Snag_1a3361d.png

Add Diagnosis to Document Created Before Codes Entered on Initial 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 Assessmblobid0.pngent opens as explained above.
    2023-06-13_14-41-12.png
  3. Click Link Diagnostic Code(s). 
    2023-06-13_15-16-24.png
  4. Select the diagnosis code(s) you want to add to the document.

    NOTE: Click the Diagnostic Code box to select all codes. 
    2023-06-13_15-48-55.png

  5. Click the Link Code(s).
    2023-06-13_16-02-22.png

  6. The selected code(s) display in Diagnostic Impressions on the document.
    2023-06-13_16-05-21.png

Add Diagnosis to Document Created After Codes Entered in Initial Assessment

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

    NOTE: Diagnosis codes entered in the initial assessment will not pull into treatment Plan & Progress Note drafts. 

  3. Click Link Diagnosis Code(s) if you want to select/deselect specific codes. Otherwise, all codes will be included. 
    2023-06-14_15-26-27.png

  4. Select diagnosis code(s) you would like on the document and click Link Code(s).
    2023-06-14_15-24-28.png
  5. The code(s) display in Diagnostic Impressions on the document.
    2023-06-14_15-51-20.png

Diagnosis Codes Deleted from Initial Assessment or Addendum

You will be alerted when diagnosis codes linked to a progress note or treatment plan are deleted from the initial 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 2023-06-14_16-34-34.png and message in Diagnostic Impressions and the Link Diagnostic Code(s) modal to let you know the code has been deleted. 

    Diagnostic Impressions

    Screen     		Link Diagnostic Code(s) Modal 

    2023-06-14_16-54-16.png
    Screen
  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 Initial Assessment if you want to re-use it in the document. 


    2023-06-14_17-00-11.png

 

 

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