You can connect clinical codes (ICD-10, CPT, HCPCS, and custom codes) to form and template fields so they automatically populate billing information while you complete your clinical note.
Clinical codes can be added to the following field types:
Before building your form, review Best Practices for Building Custom Forms to get the most out of the clinical notes feature.
Getting Started
To begin adding clinical codes to a form field:
- Go to Clinical > Form Tools > Clinical Form Management
- Select the form you would like to use from the Form List.
- Add the desired fields from the Form Tools
- Use the pencil icon to edit the form field > select the Code Attachment tab.
- Click + Add Code to select the type of code you want to add (ICD-10, CPT, HCPCS, or Custom).
- Search for the code by keyword, number, or by entering it directly into the field.
Billing Code Attachment tab
Do not use both a Billing Profile and individual Clinical Codes on the same field. Using both can cause billing errors.
- Billing Profile – attach a billing profile (allows use of modifiers).
- Clinical Code – attach individual clinical codes directly (no modifiers).
Adding Codes to Yes / No Fields
Codes associated with either the Yes or No option will also appear in the billing section of the form once the field is completed in a clinical note.
With Yes / No fields, you can assign specific codes to trigger when Yes is selected and different codes when No is selected. This allows billing to reflect the clinical outcome documented.
- After selecting the codes, use the Option column to tie each code to either Yes or No.
- Click Update Field to save your changes.
Adding Codes to Switches
With a Switch field, you can tie multiple codes that will all populate at once when the switch is activated in the note. When the switch is turned off, those codes are automatically removed from billing.
- Click + Add New, then select the code type and search for the desired code.
- Repeat for all codes you want linked to the switch.
- Click Update Field when finished.
Once activated in the clinical note, the switch will populate all linked codes in the billing section. Deactivating the switch removes them.
Adding Codes to Single and Multiple Select Fields
Codes populated by Single Select and Multiple Select fields will also appear in the billing section of the form when those options are selected during a clinical note.
The process for adding clinical codes to Single Select and Multiple Select fields is the same.
The difference is in how many codes can be triggered at once:
- Single Select: one answer can be chosen, triggering one set of associated codes.
- Multiple Select: more than one answer can be chosen, triggering codes for each selected option.
- Add your Allowed Values (the answer options) to the field.
- In the Clinical Codes section, add all codes relevant to this field using + Add New.
- Use the Options dropdown next to each code to connect it to the correct Allowed Value.
- Click Update Field when finished.