Diagnosis Codes

The Diagnosis Autocomplete Service offers the complete ICD-10 database of diagnoses. These diagnoses, when added to the patient chart, travel seamlessly from intake through discharge. Diagnosis codes have been updated to the 2023 ICD-10 code set, as mandated by CMS.

To configure the ICD-10 Autocomplete Service, including which ICD and DSM categories can be used, check out these instructions. 

Preliminary Diagnosis 

A preliminary diagnosis can be issued during intake and recorded on the patient's Information tab (facesheet).

To enter the diagnosis, you can start typing the code or name of the diagnosis (at least three characters). Select the appropriate diagnosis from the drop-down.

• Valid diagnoses: These diagnosis codes are complete/billable codes that appear in black.
• Invalid diagnoses: These diagnosis codes are incomplete (unspecific) codes that appear in a lighter gray color.

Adding/Editing Diagnosis Codes

Once a diagnosis code has been added to a patient's information, you cannot add or edit it from the facesheet. Instead, you'll need to use an evaluation.

1. Diagnoses can be documented on any evaluation form that includes the patient.diagnosis_code field type, like an initial Psych Evaluation or Bio-Psycho Social.
2. To add codes to an evaluation, type the first three letters or numbers of the code into the Diagnosis Code field and then select the correct option from the drop-down.
3. To delete a code, click on the x next to the one you want to remove.
4. Scroll to the bottom and click Sign and Submit to update the patient's record.
5. To view all updates to the patient's diagnosis, click the History button.
6. Each update is recorded here.

To allow the history to be accurately recorded, you must have an evaluation date added to the evaluation template (e.g., the field type evaluation_date, evaluation_datetime, or evaluation_start_and_end_time). This is true for any history field that allows you to view change history.

Managing Diagnosis Codes

• You can view the patient's diagnosis history from here by clicking the Hx button.
• The patient's most recent signed diagnoses appear in the patient header.
• When adding or editing diagnoses, the EMR pre-populates the patient's existing diagnoses from previous entries. Any modifications will be effective on the date or date/time of the evaluation once signed and completed.
• Previous documentation that has been finalized will not be modified.
• Diagnosis codes can also be viewed under patient's chart > Billing/Patient Ledger > Diagnosis Codes. Keep in mind that the Billing or Patient Ledger tab can be can be named something different based on your facility's preferences.