Adding Diagnosis Codes for a Patient

Cases allow you to create more than one set of diagnosis codes for your client.  

For example, you may be seeing a client/patient for more than one injury and you need to have a different set of diagnosis codes show up on the claim form depending on the injury you are working on.

Adding diagnosis codes (cases) for a client

You can add/edit your diagnosis codes and cases for a client on the add/edit client form. When adding or editing a client, the diagnosis codes are displayed on the bottom right of the Demographics & Ins screen of the add/edit client form (see image to the right, lower corner, diagnosis codes circled in red).

1. Click the blue pencil graphic in the Default Case box to display the Edit Case form (see image to the right, lower corner), to enter the default diagnosis codes (you can enter up to 12).
2. Then enter diagnosis codes into the 12 diagnosis code text boxes. You must enter diagnosis codes in order.  The primary diagnosis should go into text box 1.  Do not enter a diagnosis into text box 2, without first entering a diagnosis code in text box 1.  If this is the only set of diagnosis codes needed for this client, then you can stop there.
3. Click the update button at the bottom of the form to save the diagnosis codes for this case. Those will be the default diagnosis codes and will always show up on the CMS-1500 claim form as the diagnosis codes.

ICD-9 and ICD-10 Codes

For now, you are still able to add either ICD-9 Codes, ICD-10 codes, or both. For more information about the ICD-10 codes, see Dual ICD-9 & ICD-10 Diagnosis Codes. You can also click on the text This changed. Help!! above the box containing the diagnosis case(s) list.

Additional Cases

If you need to add additional sets of diagnosis codes, then click the Add Case button at the top right of the diagnosis codes.  A form will appear asking you to give the case a name and to enter another diagnosis setup with up to 12 diagnosis codes.  Give a (very) brief description of the case (i.e. Knee injury) in the case name text box.  Enter at least one diagnosis code and then click the Update button. You will now see that the diagnosis code list has changed to display a list of your cases.  

Edit or Delete Cases

You can edit a case by clicking the edit icon next to the case listed.  You can delete a case by clicking the delete icon next to the case.  IMPORTANT:  You cannot delete a case that has active sessions in your schedule assigned to it.

Assigning sessions to a case

The add/edit session form has a place for you to select the case from a drop-down menu.  This drop-down menu is labeled Diagnosis case and the options available in the drop-down menu will show the name of each of the cases set up for this client.  

From the drop-down menu, choose the case that the session belongs to.  By selecting a case, Therabill will know which set of diagnosis codes to use on the claim form when creating a claim for this session.

NOTE:  If you have only entered a single diagnosis code set for the client, then the diagnosis case drop-down menu on the add/edit session form will only have one entry labeled Default case.