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

To add the Diagnosis List module to a charting template:

• Navigate to Forms > Create new form or select an existing form to edit
• Locate the Diagnosis List field in the Question Bank > Client Info
• Drag the field onto your Charting template
• Click on the "..." for the Diagnosis List module > Edit
• Within the Edit field view, there is the option to "Hide inactive diagnoses in Chart note". This will hide inactive diagnoses in the charting edit view and signed/locked chart notes. Checking the box will turn the setting on for that specific charting template, and for any user that has access to that charting template.

While charting, this template will be available for you to choose when starting your note. The Diagnosis List field will render as an editable table, automatically pulling any diagnoses from the client's profile. You can search & select new diagnoses with ICD-10 Favorites listed first in the dropdown, update statuses, and modify dates directly in the table. While additions and updates made in the chart note note will sync to the Client Profile, deleting a diagnosis from the table only removes it from the note and does not delete it from the Client Profile.

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. 

• The Diagnosis field in the Client's Profile contains the following: 
  • ICD-10 search field 
  • Active checkbox
  • Onset Date (First Symptom Date) 
  • End Date
• When a diagnosis is set to active, the end date field is automatically disabled.
• Providers can dynamically add more diagnosis codes by clicking "Add Diagnosis"  
• Pressing the trash can icon will remove the diagnosis from the client's profile.