Add an Admitting Diagnosis

NextGen Behavioral Health Suite Help 5.5

Add an Existing Diagnosis to the Current Encounter

Open NextGen® Enterprise EHR. For a patient encounter, open an assessment template. From the Assessment/Diagnosis panel, select a diagnosis in the Active Diagnosis grid. The Diagnostic description and ICD Code field fills in. Alternatively, in the Last Encounter Diagnosis for Current Provider section, select Copy Forward. Note: When all the diagnoses from the last encounter for the current provider are active, the data is forwarded to the Diagnosis grid. If one or more such diagnosis is not active, the Copy Forward button is not available. You can select the diagnoses manually to add them to the Diagnosis grid. Add Status, Severity, Differential Dx, and Impression. To enter specifiers in the Specifiers field, do one of the following: Select in the field and enter free text. Select the My Phrases link and select a phrase from the list. In the Present on Admission field, select a description from the list. The Description field fills in based on the selection made. Select admitting diagn

NextGen Behavioral Health Suite Help 5.5

Add Diagnostic Details

In the Assessment/Diagnosis panel, confirm the assessment selected displays in the Description details and ICD Code field. If not, select the assessment in the grid to fill in the details. Add Status, Severity, Differential Dx, and Impression. To enter specifiers in the Specifiers field, do one of the following: Select in the field and enter free text. Select the My Phrases link and select a phrase from the list. If applicable, select Present on Admission and then select a description from the list. To indicate the diagnosis is chronic, add the diagnosis to the client’s clinical problems list, and/or add the assessment to my tracked problems, select the respective checkbox. Select Add To Grid. The information displays in the grid. To add psychosocial stressors, select the Psychosocial Stressors link. To add referrals, select the Referrals link. To reorder the diagnoses, select Sort. To update a diagnosis, select the diagnosis in the grid, modify the details, and select Update. Parent t

NextGen Behavioral Health Suite Help 5.5

Add a Diagnosis Using Common Assessment

From the Assessment/Diagnosis panel, select the Add Common Assessment link. The Common assessment window opens. Select a diagnosis. If the diagnosis you selected has a + in front of it, more than one code exists. You need to select the link and select from a secondary list. The BH – Severity window opens. Select the severity from the list and then select Close. To add additional diagnoses, repeat steps 2 and 3. Select Save & Close to save your assessment and return to the previous screen. The assessments display in the grid on the Assessment/Diagnosis panel. Enter the diagnostic details. Parent topic: Behavioral Health Assessment and Diagnosis

NextGen Behavioral Health Suite Help 5.5

Add a Diagnosis Using Diagnosis Code Lookup

From the Assessment/Diagnosis panel, open the Diagnosis Search window by doing one of the following: Select into the Diagnostic description field. Select the Diagnosis Code Lookup link. In Enter Search Item, you can type a key work or diagnosis code to begin the search. To filter the search results, you can use one of the following filters: To view new diagnoses from the ICD-10 library, select All Diagnoses in the left-hand panel. To view the client’s diagnoses or chronic diagnoses, select the respective option in the left-hand panel. To view diagnoses added to your favorites list, select Favorites from the left-hand panel. To search by specific categories, select Categories in the left-hand panel. Search results matching the keyword or diagnosis code entered displays in the right-hand panel. Select the assessment and then select Select. The Diagnosis Search window closes. The Diagnostic description and ICD Code fields display the selected diagnosis information. Enter the diagnostic de

NextGen Behavioral Health Suite Help 5.5

Behavioral Health Assessment and Diagnosis

You can link a diagnosis to the current encounter and enter assessment details from the Assessment/Diagnosis panel. Practices that use institutional billing must provide an admitting diagnosis. You can enter the diagnosis in the Admitting Diagnosis field. If your practice does not use institutional billing, this field is not required and can be left blank. You can use the following links on the panel to search for a diagnosis code: Active Diagnosis allows you to use a diagnosis from a previous encounter for the client. Diagnosis Code Lookup allows you to add a diagnosis to the client’s medical chart. This should only be completed by staff members authorized to assess and diagnosis a client. Common Assessment allows you to select from a limited set of diagnoses to add to the client’s encounter. This should only be completed by staff members authorized to assess and diagnosis a client. Common assessments are an alternative method of diagnosing a client without having to search through th

Help Guide for NextGen® Enterprise PM 8

Encounter-Level Diagnosis Codes

Diagnosis codes are typically entered during charge posting. Charge-level diagnosis codes then display in the ICD-CM section on the General sub-tab on the Encounters tab in the Patient Chart. After charge posting, you can add additional encounter-level diagnosis codes, if needed. You can also add encounter-level diagnosis codes prior to charge posting, so they default to each charge during charge posting. Note: Diagnosis codes added to an appointment from the Ins/Diag tab in the Add/Modify Appointment window automatically default to the ICD-CM section on the General sub-tab in the Patient Chart > Encounters tab when the appointment is checked-in and the encounter is created. Add Encounter-Level Diagnosis Codes You can add diagnosis codes at an encounter-level for a patient. Select an Admitting Diagnosis for UB Claims You can use the admitting diagnosis as an institutional claim to indicate the patient's primary diagnosis at the time of inpatient admission. Enter Present on Admission In

Add an Admitting Diagnosis

Recommendations

Add an Existing Diagnosis to the Current Encounter

Add Diagnostic Details

Add a Diagnosis Using Common Assessment

Add a Diagnosis Using Diagnosis Code Lookup

Behavioral Health Assessment and Diagnosis

Encounter-Level Diagnosis Codes

Add an Existing Diagnosis to the Current Encounter

Add Diagnostic Details

Add a Diagnosis Using Common Assessment

Add a Diagnosis Using Diagnosis Code Lookup

Behavioral Health Assessment and Diagnosis

Encounter-Level Diagnosis Codes