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Add a Diagnosis Code

Diagnosis codes (ICD-10, DSM-5) link clinical findings to billing and documentation. Adding them accurately to a client's record ensures insurance claims are supported, clinical notes are complete, and care continuity is maintained across providers.

How to Add a Diagnosis Code​

  1. Open the client's record.
  2. Navigate to the Overview or Diagnoses section.
  3. Click Add Diagnosis.
  4. Search for the diagnosis by name or code (e.g., "F32.1" for Major Depressive Disorder, moderate).
  5. Select the correct code from the results.
  6. Set the diagnosis status — Active, Historical, or Resolved.
  7. Click Save.

Tips​

  • Always use the most specific code available to support accurate billing and reduce claim denials.
  • Review and update diagnosis statuses regularly to keep the client's active problem list current.
  • Diagnosis codes added here can be pulled automatically into clinical notes and invoices.