Diagnosis codes are essential for documenting medical conditions in client records. They can be saved to both services and clients' medical histories, facilitating automatic insertion into session notes, superbills, and claims.
- Adding Diagnosis Codes to a Client Record
- Adding Diagnosis Codes to a Service
- Adding Diagnosis Codes in Notes
- Adding Diagnosis Codes in Superbills and Claims
Adding Diagnosis Codes to a Client Record
To add a diagnosis code to a client's record, follow these steps:
- Go to your client's record, and select Medical History from the left navigation menu.
- Scroll down to find the Diagnosis Codes section on the Medical History page.
- Click the Add code button, and select a code from the popup.
- After adding all necessary diagnosis codes, click Save Changes in the top right corner of your screen.
Adding Diagnosis Codes to a Service
You can apply a diagnosis code to a service if you conduct sessions with a particular group of clients with the same diagnosis or condition. Here’s how:
- Go to My Practice > My Services and click the Edit button next to the relevant service.
- Click the Advanced Options tab and scroll down to the Diagnosis Codes section.
- Click on the Add code button and select a diagnosis code from the popup.
- Click Save Changes in the top-right corner of your screen.
Adding Diagnosis codes in Notes
When you add diagnosis codes to a service, they will automatically be included in new session notes linked to that service.
If no diagnosis codes are associated with the service, the system will pull codes from the client's Medical History, if available.
To manually add diagnosis codes in a note:
- Go to the Procedure & Diagnoses tab of the Note.
- Click Add Code if no codes have been added yet.
- Click Add Another to include additional codes.
Adding Diagnosis Codes in Superbills and Claims
If you're adding a session to an insurance form, diagnosis codes will be automatically added based on the following order of precedence:
- Diagnosis codes from a Note associated with the session
- Diagnosis codes from the Service associated with the session
- Diagnosis codes from your client's Medical History section
To manually add a diagnosis code in your claim or Superbill.
- In the editor, click the Edit icon beside the Service.
- Click in the field for Associated diagnosis codes.
- Your saved codes will be displayed in a drop-down list, or you can start typing to select a code from the database.
- Click Done to save your selections.