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Diagnosis - Cal-PM

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Manage a client’s principle diagnosis record in myAvatar Cal-PM.

Diagnosis data is filed by date, and uses DSM and ICD codes.Diagnosis entries that are resolved will maintain a bill order and will be used on claims where the service date is prior to the Resolved Date.

  1. Go to: Avatar PM > Client Management > Client Information > Diagnosis
  2. In the Select Client screen, enter the client ID in the Client Name/ID field, select the Search button, and select the corresponding entry.
    • The Episode Selection pre-display shows if the client has multiple episodes. Select an episode and then OK.
    • If the client has previous diagnosis records, select the record. Select Edit to change information, or Add to create a new record.
  3. In the Type Of Diagnosis field, select how the diagnosis is associated with the client. Selecting Admission or Discharge populates the client's admission or discharge date in the Date of Diagnosis field.
    Note: The selection in this field cannot be changed when editing an existing diagnosis.
  4. In the Date Of Diagnosis field, enter the diagnosis date.
  5. In the Time Of Diagnosis field, enter the diagnosis time.
  6. In the Select Episode To Default Diagnosis Information From field, select the previous episode that includes diagnosis information to be carried forward.
  7. In the Select Diagnosis Entry to Default Information From field, select the diagnosis entry to carry forward (for example, Admission Date of Diagnosis: 10/1/2013).
  8. The Diagnoses grid controls the diagnosis records for the client. Voided diagnoses appear with a strike-through. Use the New Row and Delete Row buttons to add or remove records as appropriate.
  9. In the Show Active Only field, select Yes to restrict the grid to display only those entries with a status of Active or Working. Selecting No includes all entries in the grid.
    Note:
  10. In the Diagnosis Search field, enter a term to describe the client's condition, or enter an ICD-9/ICD-10 code (e.g. Depression or 296.20). The search results will return the following:
    • ​ICD-9 Code
    • ICD-10 code
    • DSM-IV Code or DSM-5 Term (depending on the DSM Classification registry setting)
  11. The Code Crossmapping field displays the ICD-9 code, ICD-10 code, DSM-IV code, DSM-5 term and SNOMED code for the selected diagnosis.
  12. In the Status field, select where this diagnosis is active, working, a rule-out, resolved or void.
    • ​Active - A diagnosis for which the client is currently being treated. The diagnosis will be included in claim information.
    • Working - A diagnosis for which the client is currently being treated in order to confirm whether they are active or should be ruled out. The diagnosis will be included in claim information.
    • Rule-out - A diagnosis that was in a working state but has now been ruled out. The diagnosis will not be included in claim information.
    • Resolved - A diagnosis for which the client is no longer being treated. The diagnosis will not be included in claim information if the date of service is past the date entered in the Resolved Date field.
      Note: The diagnosis 'Bill Order' cannot be edited for diagnoses with a status of Resolved and should not have a bill order value.
    • Void - A diagnosis that was saved to a client's record in error. The diagnosis will not be included in claim information.
      This option replaces the ability to delete diagnoses from a client's record.
      Note: The diagnosis 'Bill Order' cannot be edited for Void diagnoses and should not have a bill order value. All other diagnosis field values are also unavailable.
  13. In the Estimated Onset Date field, enter the approximate starting date for this diagnosis.
  14. If the diagnosis has been updated to a status of Resolved, enter the ending date for the diagnosis in the Resolved Date field.
  15. In the Ranking field, select whether this is the primary, secondary or tertiary diagnosis code. There can be only one primary code, but multiple secondary and tertiary codes.
    Note: This functionality replaces the principal diagnosis and is used for clinicians to rank diagnoses. It is not used for billing purposes.
  16. In the Bill Order field, enter the order in which the diagnoses will appear on a claim. The entry marked as Primary in the Ranking field will default to a billing order of '1'. The system will calculate billing based on the diagnosis billing order. This can be adjusted regardless of the diagnosing practitioner and will be recalculated for the remaining entries.
  17. In the Present On Admission Indicator field, select the option that best represents if the diagnosis was present when the client was admitted. The default is Yes when Admission is selected in the Type of Diagnosis field.
  18. The Classification field is used for reporting purposes and for sorting diagnosis records in the Diagnoses grid. The values in this field are determined by the DSM Classification registry setting:
    • When DSM-IV is entered, the selections Axis I , Axis II or Axis III are available.
    • When DSM-5 or no DSM is entered, the selections Medical , Mental Health, Substance Abuse, and Environmental are available.
  19. In the Diagnosis Practitioner field, enter the clinician responsible for the client diagnosis. This value should default for each individual diagnosis entered within a session.
    Note: The diagnosing practitioner can be someone other than the user entering the diagnosis to account for users who enter records on another user's behalf.
  20. In the Remarks field, enter specific diagnosis remarks.
  21. In the Add To Problem List? field, select whether or not to push the problem to the Problem List. It will only be added if the problem has an Active status. If the problem already exists in the Problem List, it will not be added again.
  22. Select Void All to void all active diagnoses at once.
  23. Select Submit.
► Additional Sections
► Registry Settings
► SQL Tables
  • SYSTEM.client_diagnosis_codes
  • SYSTEM.client_diagnosis_entry
  • SYSTEM.client_diagnosis_record
  • SYSTEM.history_diagnosis