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 the entire code library. Your practice can configure the Common Assessment window to display only practice appropriate or desired diagnoses. This provides users with a faster alternative to diagnosing a client.

The Assessment/Diagnosis panel has links that allows you to view and document additional details regarding the client’s assessment/diagnosis.

• Mandated Care Coordination
• Psychological Stressors
• Referrals
• WHO Disability Assessment Schedule 2.0 (WHODAS 2.0)