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Adding Insurance Codes to Session Notes

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You can add procedure (CPT) and diagnosis (ICD) codes to your session notes so your documentation and insurance billing stay connected. This article shows you how codes get onto a note, how to add and manage them yourself, and how to share them with clients.

In this article:

Before You Begin

  • Available on all plans: You can add insurance codes to notes on any Practice Better plan. You do not need to set up an Insurance Billing profile first.
     
  • Saved codes are not attached codes: Saving a code in your Insurance Billing settings only adds it to your list of choices. A code appears on a note only after you add it there. Learn more in Adding CPT and ICD Codes to Practice Better →
     
  • Team members: On a Team plan, any team member with the appropriate permissions and access can add codes to a note.
  • Signed notes are locked: You cannot add, edit, or remove codes after you sign a note. Review your codes before you sign.

How Codes Are Added to a Note

Where a code comes from depends on how you create the note:

  • A note created from a session: When you create a note from a session, Practice Better adds the procedure and diagnosis codes from that session's service.
     
  • A note created from the client's record: When you create a note from the client's Notes & Recordings section, with or without a template, Practice Better adds the diagnosis codes saved in the client's Medical History. Procedure codes are not saved to the client record, so these notes start with diagnosis codes only.
     
  • A note you link to a booking: When you link a note to a booking, Practice Better adds the codes from the booking's service. Any code already on the note, such as one from the client's Medical History, stays on the note. To link a note to a booking, use the Fast Action Button. Lean more about Attaching Resources to Client Session Notes → 

Adding Codes to a Note Manually

  1. Open the session note.
     
  2. Click the Fast Action Button (the red circle in the bottom-right corner) and select Add insurance codes.
  3. Select the type of code to add: CPT Procedure Code or ICD-10 Diagnosis Code.

     
  4. Select one of your saved codes or a code that a team member shared with you. For a diagnosis code, you can also search the ICD-10 database. To use a code that is not saved, click Add new in the pop-up and enter it.
     
  5. After adding the first code, click Add Another to include more codes.

     
  6. Click Save in the top-right corner.

Managing Codes in the Procedures & Diagnoses Tab

After a note has at least one code, a Procedures & Diagnoses tab appears in the white bar at the top of the note editing page. From this tab, you can:

  • Click Edit to change a procedure code.
  • Drag the group of dots beside a procedure or diagnosis code to change its order (when you have more than one).
  • Click the trash icon to delete a code of either type.
  • Click Add another to add more codes of either type.
  • Turn on the option to make either code type visible to your client.
  • To change a diagnosis code, delete it and add the correct one.

Sharing Codes with Clients

Insurance codes are private to you by default. For your client to see them, you need to turn on two settings:

  1. Near the top of the note, select Share notes and attached documents with my client.

     
  2. In the Procedures & Diagnoses tab, turn on Make codes visible to client for the code type you want to share. You turn this on for each code type, not for each code.

     
  3. Save the note.

When both settings are on, your client sees the insurance codes in a section at the bottom of the session note in their Client Portal. If only one setting is on, your client does not see the codes.

Learn more about Signing and Cosigning Session Notes → 

⚠️ Important: Signing a note locks its sharing settings. Choose what to share before you sign.

How Note Codes Are Used on Claims and Superbills

Adding codes to a note does not create a claim or a superbill. You create those separately. When you create a claim or superbill, 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.

You can always add procedure or diagnosis codes on the service or on the claim line separately. Learn more in Managing Diagnosis Codes →

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