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Managing Diagnosis Codes

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Diagnosis codes document your clients' conditions for insurance billing. Add them to a client record, a service, or a note, and Practice Better fills them into your superbills and claims for you. This article shows you where to add, edit, and remove diagnosis codes, and which codes Practice Better uses first.

In this article:

Before You Begin

  • Diagnosis codes vs. procedure codes: You can save diagnosis codes to a client record, a service, and a note, and use them in claims and superbills. Procedure (CPT) codes are not saved to the client record. Add procedure codes on the service or on the claim line separately. Learn more in Adding Insurance Billing Codes to Services →
     
  • Saved codes vs. attached codes: Saving a code in your Insurance Billing settings only adds it to your list of choices. A code attaches to a client, service, or note only after you select it there.
     
  • Add codes where you need them: We recommend adding diagnosis codes in each place where you need them to appear: client records, services, notes, etc.
     
  • Changes are not retroactive: Adding or changing codes does not update notes, claims, or superbills you already created. The exception is a service. When you update the diagnosis codes on a service, sessions that use that service take on those changes for any claims you create afterward.

Adding Diagnosis Codes to a Client Record

  1. Go to your client's record and select Medical History from the left navigation menu.
     
  2. Scroll down to the Diagnosis Codes section.
     
  3. Click the Add code button and select a code from the pop-up.

     
  4. After you add all your diagnosis codes, click Save Changes in the top-right corner.

Adding Diagnosis Codes to a Service

Apply a diagnosis code to a service when you see a group of clients with the same diagnosis or condition.

  1. Go to My Practice > My Services and click Edit next to the service.
     
  2. Click the Advanced Options tab and scroll down to the Diagnosis Codes section.
     
  3. Click the Add code button and select a diagnosis code from the pop-up.

     
  4. Click Save Changes in the top-right corner.

Adding Diagnosis Codes in Notes

Diagnosis codes you added to a service are included automatically in new session notes linked to that service. If the service has no diagnosis codes, Practice Better pulls the codes from the client's Medical History, if available. This includes notes created by automation.

To add diagnosis codes to a note yourself:

  1. Open the Procedure & Diagnoses tab of the note. This tab appears after the note has at least one code. To add the first code, click the Fast Action Button in the bottom-right corner and select Add insurance codes.
     
  2. Select the type of insurance code you need to add, CPT Procedure Code or ICD-10 Diagnosis Code. 

     
  3. Select from one of your saved codes or click Add new to save a different code in your Note. 

     
  4. Click Add Another to include more codes.

     
  5. Click Save in the top-right to preserve your changes. 

Learn more in Adding Insurance Codes to Session Notes →

Adding Diagnosis Codes in Superbills and Claims

When you add a session to a superbill or claim, Practice Better adds diagnosis codes in this order of precedence:

  1. Diagnosis codes from the note associated with the session.
  2. Diagnosis codes from the service associated with the session.
  3. Diagnosis codes from your client's Medical History.

To add or change a diagnosis code in a superbill or claim:

  1. In the editor, click the Edit icon beside the service.

     
  2. Click in the Associated diagnosis codes field.
     
  3. Select a code from the drop-down list of your saved codes, or start typing to search the code database.

     
  4. Click Done to save your selections.

📍 Note: Each service or procedure line on a claim needs at least one procedure code and one diagnosis code.

Saving Frequently Used Diagnosis Codes

Practice Better includes a searchable database of ICD-10 diagnosis codes. Save the codes you use most so you can add them in a few clicks.

  1. Go to Settings (gear icon) > All Settings > Insurance Billing.
     
  2. Click the Fast Action Button in the bottom-right corner and select Add ICD-10 Diagnosis Code.

     
  3. Search by code or description to find the code you want. If you cannot find it, click Add new and enter the code and a description yourself.

     
  4. With your code selected or entered manually, click Done in the pop-up.
     
  5. Click Save Changes near the top-right of the page.

On a Team plan, you can share saved codes with your team. Learn more in Adding CPT and ICD Codes to Practice Better →

Using ICD-9 Codes

Practice Better uses ICD-10 codes by default. If you submit claims with legacy ICD-9 codes, turn on ICD-9 for your profile:

  1. Go to Settings (gear icon) > All Settings > Insurance Billing.
     
  2. In the My Profile section, click the checkbox next to Use ICD-9 diagnosis codes?

     
  3. Click Save Changes.

Learn more in Setting Up Your Insurance Billing Profile →

Editing, Reordering, and Removing Diagnosis Codes

Editing a Saved Code

  1. Go to Settings (gear icon) > All Settings > Insurance Billing.
     
  2. Click Edit next to the code you want to change.
     
  3. Make your changes and click Update.
     
  4. Click Save Changes near the top-right of the page.

📍 Note: Edits to saved codes are not retroactive. Update existing superbills and claims manually to reflect the change.

Changing a Code in a Superbill or Claim

  1. In the editor, click the Edit icon beside the service.
     
  2. In the Associated diagnosis codes field, click the x next to the code you want to replace.

     
  3. Select another code from the drop-down list of your saved codes, or start typing to search the code database.
     
  4. Click Done, then click Save Changes at the top of the page.

Changing a Code in a Client Record, Service, or Note

To change a code in a client record or a note, remove the code and add the correct one.

  1. Click the trash icon next to the code.
     
  2. Click the Add Code button and select another code.
     
  3. Click Save or Save Changes at the top of the page.

Reordering Codes

Codes appear in the order you added them. In a client record or service’s advanced options, click and drag the group of dots beside a code to change its order. Release the item to set its new place. Click Save Changes near the top-right of the page. 

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