DSM-5 Diagnosis Tool

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The streamlined DSM-5 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.

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.

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

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.

Quick 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 Diagnosis Code button.

Add additional diagnosis codes simply by typing in the next 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 (EDI) 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.

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.

Quick 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.
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Comments

  • Avatar
    Robin Wood

    I think it would be nice to see the DSM V options before we make the switch. is it possible to switch and then switch back if we are not comfortable with using it so far? I told one course in it but the changes are so drastic I may need more. Im afraid to switch over before I am ready.

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    Carol Fischbach

    Having a list of the changes would be helpful

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    Kimberly Knitter

    I agree with Robin, I would like to do a trial with this as well.

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    Annette Cockrell

    I do not have a Diagnosis Setting!

  • Avatar
    Beverly Taylor

    I do not have a diagnosis setting either!!!

  • Avatar
    Tanya McKeithen

    I also do not have a diagnosis setting, only an intervention setting

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    Danielle Jean-Pierre

    I do not have a diagnosis setting. Unable to complete paperwork, as the system will not accept Axis IV dx. Please help!!!!

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    Heather Gimpel

    Many of our therapists are also not showing a diagnoses setting? If this something that only practice admin or clinical admin can change for the group?

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    Don Brock

    When I switch the setting to DSM IV, it goes back to Custom. It will not stay on DSM IV nor DSM 5.

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    Jordan

    Don,

    The DSM-IV interface is no longer available for new notes. You will still see DSM-IV codes on past notes that were created with the DSM-IV. We apologize for any inconvenience. Please note that although we require it to be DSM-V, ICD-9 codes will remain unchanged. The only difference between DSM-4 and DSM-5 in TherapyNotes is that it no longer has the 5 Axis's and Gaf score on the note. We will automatically change to ICD-10 in October 2015 when it's required. Once again, we apologize for any inconvenience. If you have any additional questions please let us know. Thank you!

  • Avatar
    Fern Simon
    I need to submit individual invoices for each date of service so the client can get reimbursed by her employer for co-payments. I would prefer to write Therapy session 1 hour, instead of crisis counseling. It's unnecessary information that could possibly have a negatively effect on her. All she needs is a dated statement saying she had a session & paid a $40 co-payment. Is there anyway to modify this without making changes to my billing/progress notes. Thank you!
  • Avatar
    Laura
    Fern, You can change the description of the service code in the service code settings. User Icon > Settings > Service Codes Click on the service code itself. Type "Therapy Session 1 Hour" in the "Description" field. Then click the green "Save Changes" button. If you have any more issues with this specific issue please feel free to contact our support team 215-658-4550 or support@therapynotes.com.
  • Avatar
    Michelle Cantrell

    Since I have to complete a treatment plan before I can input any therapy notes, it would be nice to have a "diagnosis deferred" option. Am I missing that? It sometimes takes several sessions to do a full assessment before I'm ready to enter in a specific diagnosis.

  • Avatar
    Laura

    Michelle,

    Until you settle on a diagnosis you can write N/A in the ICD-10 and Description fields. Note that this is not a valid diagnosis to insurance, so in order to submit a claim to insurance you must have a valid ICD-10 diagnosis code in the note.

    In addition, if you are not ready to write a treatment plan you can schedule the appointments as Intakes or Consultations.

  • Avatar
    Patrick Henderson

    How do you specify if we are doing a "Rule Out" in this interface?

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    Sean Behan

    Hi Patrick,

    You can enter a rule out within the diagnosis fields. Although TherapyNotes offers to autofill the fields for you, you can always type whatever you would like in these fields. Please note, when you submit claims you will receive a warning dialog when you have a rule out code. This warning will indicate that you have included an invalid ICD-10 code, as rule outs are not considered a valid code. You can still bill for these items, as long as at least one valid code is present.

    Please let us know if you have any other questions. Thank you.