Psychology follow-ups—

1. The patient’s BIMS score will now be forwarded to every follow-up note. You will also be
prompted to give a rationale when continuing treatment for a patient with a BIMS score below
7.

2. New prompts will be displayed when the patient’s Initial and/or Semi-annual assessment has
been completed by another provider. – You will now be prompted to give the reason why the
patient is not being seen by the original provider.

3. In addition to this new feature is that when the previous note is documented by another
provider – You will now be asked to confirm that you have read and reviewed the
documentation of the previous provider.

4. When a patient goes over their suggested frequency you will be notified and prompted provide
rational.

5. To ensure we stay under the suggested frequency documented for a patient. When a patient is
seen more than once a week – rationale will now be required.

6. 90785 – Recently we updated the app to require you to give the need for the use of the
interactive complexity code. We have now added the ability to describe how you got around the
complexity. So, you will now see a free text box where you can document this information.

7. Adjustment disorder is a disorder that should only be documented for six months according to
the DSM-5. Due to this, we have now added a function that will alert you when an adjustment
disorder has been in use for 6 months. This function will prompt you to address the codes that
are listed and verify if the issue is still active.

Evaluation – 90791 Changes

1. Expanded options for re-eval- You will now be able to indicate different reasons such as:
a. Change in condition
b. Return from Hospital/BH Facility
c. change in dx, progression of disease and/or hospitalization

2. Advance care planning –has now been added to your options. You will now be able to document
with free note.

3. Risk Factors – now have an added free text section. We have also changed the description that is
listed here. You will now see the prompt to “Describe how it impacts the patient’s condition.”
4. Goals and objectives will no longer carry over from note to note. You will be required to now
document these during every encounter. This is to ensure that we no longer have cookie cutter
notes when we copy information forward. You will still be able to select from the goals and
objectives as outlined in the evaluation and the ability to add new ones.