Diagnosis codes are the translation of written descriptions of diseases, illnesses, and injuries into codes from a particular classification. Diagnosis codes are used as part of the clinical coding process alongside procedure codes. The Diagnosis Code Search screen can be accessed by opening the Setup portal and clicking on Diagnosis Codes under Billing Setup. A user can then search for a diagnosis code and open the Diagnosis Codes Setup screen. The Diagnosis Codes Setup screen can be used to:
Add New Codes
Edit Existing Codes
Diagnosis Code Search Window Buttons
- New: Clicking the New button allows the user to Add New Codes
- More: Clicking the More button gives the user the options to open the Advanced Search Screen or run the Diagnosis Usage Reports
- Search (Magnifying Glass): Clicking the Search button opens a search box to allow the user to search for and open a diagnosis code
Diagnosis Codes Setup Screen
Summary
The Diagnosis Codes Setup Screen opens to the Summary tab. The Summary allows you to see all of the settings quickly that have been configured on the other tabs. You can switch to the other tabs by clicking on the section of the summary you wish to go to or by clicking on the tab name on the left side.
Code
The Code tab allows the user to be able to enter information specific to the code regardless of the payer. This includes effective dates, code type, short description, and problem description.
Rules
The Rules tab allows the user to enter information about how the selected diagnosis code is used, reported on, and billed. This tab also allows the user to enter default values to be used when the diagnosis code is selected. This includes procedure codes, diagnosis codes and modifiers.
The Advanced Diagnosis Search screen can be accessed from multiple locations.
- Setup > Diagnosis Codes > More
- Billing Portal > Setup Screens option on toolbar > Dx Codes
Fields
- Code: The code value associated with the diagnosis code.
- Code Type: The code type associated with the diagnosis code.
- Billing Code: The code that will be used on claims for the associated diagnosis code.
- Description: The description of the associated diagnosis code.
- Problem: The problem description of the associated diagnosis code.
- Start Date: The start date associated with the diagnosis code.
- End Date: The end date associated with the diagnosis code.
Additional Field Options
- Create Date: The creation date of the associated diagnosis code.
- User Id: The user id that created the associated diagnosis code.
- Gender: The gender requirement for the associated diagnosis code.
- Problem List Ind: Indicates the associated diagnosis code to appear on the problem list.
- Active: The active status of the associated diagnosis code.
- Billable: Indicates if the associated code is to appear on claims.
- Included in IHS: Indicates if the associated code is to be included in the IHS process.
- Included in CCM: Indicates if the associated code is to be included in the CCM process.
The Rules tab allows customization to include or exclude modifiers, procedures and diagnoses for claim validation.
The Diagnosis screen can be accessed from multiple locations.
- Setup > Billing Setup> Diagnosis Codes
- Billing Portal > Setup Screens option on toolbar > Diagnosis
With the diagnosis code open, navigate to the Rules tab.
Code Validations
Providers - Select one of the following options:
- N/A (by Default)
- Rendering and Referring must be the same
- Rendering and Referring cannot be the same
The remaining validators can be utilized as needed by checking the associated box and entering the appropriate modifier, procedure or diagnosis.
- Check the box next to the Code Validation to begin setup
- Select the blue text to the right to add the appropriate qualifier (modifier, procedure, diagnosis)
When adding a modifier users will type in the modifier then select Update. Modifiers aren't searchable.
Procedure and Diagnosis codes are searchable by clicking the magnifying glass.
Company Settings
There are Company Settings that run claim validations for these Diagnosis Code Rules. These will need to be set to "Yes" in order to enable the setting within the Diagnosis Code setup and enable the diagnosis code rule validation on the claim.
- Check diagnosis rendering/referring provider - If checked, check claim diagnoses rendering/referring provider combination
- Check diagnosis required diagnoses - If checked, check claim diagnoses for required diagnoses
- Check diagnosis required modifiers - If checked, check claim diagnoses for required modifiers
- Check diagnosis required primary diagnoses - If checked, check claim diagnoses for required primary diagnoses
- Check diagnosis required procedures - If checked, check claim diagnoses for required procedures
- Check diagnosis restricted diagnoses - If checked, check claim diagnoses for restricted diagnoses
- Check diagnosis restricted modifiers - If checked, check claim diagnoses for restricted modifiers
- Check diagnosis restricted primary diagnoses - If checked, check claim diagnoses for restricted primary diagnoses
- Check diagnosis restricted procedures - If checked, check claim diagnoses for restricted procedures
Override options for rules on a Payer, Financial Class, Rendering Provider and Service Location level are available under More > Diagnosis Code Rules Override. This can be used to override any Diagnosis Code Rules that have been setup but need to follow a different logic for a specific one off scenario.
The Advanced Diagnosis Search screen can be accessed from multiple locations.
- Setup > Diagnosis Codes > More
- Billing Portal > Setup Screens option on toolbar > Dx Codes
With the diagnosis code open, navigate to the More button on the toolbar and select Diagnosis Codes Rules Override.
Override Screen
- Financial Class: The financial class to override
- Payer Name: Payer to override
- Rendering Provider: The rendering provider to override
- Service Location: Service location to override
Once the above items are added, select save. Click on the line to make further selections, "Remove" to delete changes or "New" to add additional overrides for the selected Diagnosis Code.
The Rules screen will then be presented for setup.
