DSM-5 Diagnosis Tool

The streamlined DSM-5-TR interface includes an area to enter one or more codes with descriptions, followed by an area to enter additional details, diagnostic justification, rule-out diagnoses, and any assessment measures you used to support your diagnosis.

To Use Our DSM-5-TR Diagnosis Tool:

1) Begin typing either the diagnosis code or the description in the Diagnosis section of your note, and our inline search tool will present a list of suggested matches which include the ICD-10 code, ICD-9 code in parentheses, and the description. The ICD-9 code is only for your reference - this will not be visible on your note or included on insurance claims.

2) Select the correct result, and TherapyNotes will autofill the ICD-10 code and description.

3) Once you select a code, you can add additional specifiers or details to the description. If you can't find the code you are looking for, type whatever code and description you would like.

Tip: Click the User Icon > Settings > Diagnosis Codes to create a custom diagnosis code list. You may delete codes that are already included with TherapyNotes, or add new codes using the + Add Custom Diagnosis Code button.

Add or Reorder Diagnosis Codes

Add additional diagnosis codes simply by typing in the next empty field and remove codes by clicking the X icon.

Reorder codes using the up and down arrows.

The first diagnosis code in your list, which appears in bold, is the primary diagnosis and will be used for billing. Electronic claims may include only the primary diagnosis code or up to four diagnosis codes. This setting can be configured by a Practice Administrator or Practice Biller by clicking on the User Icon > Settings > Diagnosis Codes on Claims.

Diagnoses will pull forward into other notes. Once you enter a client’s diagnosis, it will automatically copy forward to any additional notes you do for that client. Any time you update a client's diagnosis on a note, TherapyNotes will also prompt you to create a new Treatment Plan.

TherapyNotes will always remain consistent with the most current coding guidelines. However, whenever coding changes are implemented that affect your clients’ diagnoses, be sure to update each individual’s diagnosis accordingly. TherapyNotes will not make any changes to your data.

Tip: If you need to update a diagnosis due to coding changes, be sure to complete all notes for dates of service prior to the effective date of the change first. Once you make the change, the new diagnosis will carry forward to all notes completed afterward.