Diagnosis Details in Client Profile & Charting

For ease of documentation and creating Superbills or CMS 1500 claims, client's diagnosis or CPT codes can be documented, and auto-populated into a claim form. This can be done through charting and/or manually added to the client's profile. 

Document Diagnosis & Billing Items in Charting 

Healthie's form builder can be used to add key fields relevant to billing within a charting template including: 

  • Diagnosis 
  • Billing Items (CPT code, units, fee per unit) 

From the form builder, locate the diagnosis field in the Question Bank > Client Info. Drag the field(s) onto your Charting template. 

When charting on a client, this template will be available for you to choose when starting your note. The diagnosis and/or billing field(s) you added to your template will render as drop-downs, making it easy for you to search & select the appropriate choice. 

Once added, this information will auto-fill into a claim form or Superbill

Add Diagnosis Details to Client Profile 

If you add a diagnosis to a client's claim form or Superbill, or you collected the information in a charting note, the details will automatically populate into the Client's Profile. 

This information can be found in the Client Profile > Actions > Client Info > Diagnoses

Alternatively, you can manually search-for and add the details. You can remove a diagnosis as needed and/or adjust the Onset Date. The First Symptom Date is generally required for submitting CMS 1500 claims to insurance. 

1. The Diagnosis field in the Client's Profile contains the following: 

  • ICD-10 search field 
  • Active checkbox
  • Onset Date (First Symptom Date) 
  • End Date

2. When a diagnosis is set to active, the end date field is automatically disabled.

3. Providers can dynamically add more diagnosis codes by clicking "Add Diagnosis"  

4. Pressing the "X" will remove the diagnosis from the client's profile. 

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