Clients Diagnostic Code

Diagnostic code/s can be entered under assessment and treatment plan and the code will carry over from the assessment and treatment plan to progress notes (daily, SOAP notes), superbill and CMS-1500.

Note: By default diagnostic code/s field is not required. This means that if you don't need to enter one, you can skip this field. However if you need to enter diagnostic code and you want to ensure that you or your team don't skip diagnostic code/s, you can make this field required on the assessment note templates.

To make diagnostic code required on assessment and treatment plan first adjust the note template/s:

Step 1: Click on Settings 

Step 2: Next click on Notes < Assessment and treatment plan.

Step 3: If you sat up your assessment and treatment templates before, click on the green edit button next to the name of your assessment and treatment plan.

Step 4: At the pop-up, mark in blue Require diagnostic code and Save changes.

Adding Diagnostic Code/s

Here are the steps for adding diagnostic code/s under your assessment:

Step 1: Click on Client.s

Step 2: Click on the eye icon next to the name of your client or start typing the name of your client in the top search Client bar to open the chart.

Step 3: Click on Notes.

Step 4: Click on Assessment and Treatment Plan < Add Plan.

Step 5: A pop up box will pull- under Diagnostic Code field start typing diagnostic code's description (e.g. depression). The system will show a list of codes related to your keyword and you can select the one that meets your needs. To enter multiple codes, return to the diagnostic code field and type your next description and repeat the steps.

Step 6: Click on Save Changes once complete

Editing Diagnostic Codes

Here are the steps for editing diagnostic codes:

Step 1: Click on Clients

Step 2: Click on View next to the client

Step 3: Click on Notes

Step 4: Click on Assessment and Treatment Plan

Step 5: Click on the green edit button next to the assessment and treatment plan you've written.

Step 6: Under Diagnostic Codes field select the X next to the code that you need to remove.

Step 7: To add the new Diagnostic Code, please start typing in the description and select the correct one that pops up

Step 8: Click on Save Changes once complete.

Note: If you don't wish to write the assessment and treatment plan (because the client was already evaluated in the past; you only see this client for treatment, etc.) you can create your own assessment and treatment plan template and title it "Diagnostic Code" without adding any additional fields. This way you will not have to document your assessment but still can enter your diagnostic code/s. To build your own template go to Settings< Notes< Assessment and treatment plan< Add note.