Diagnosis codes (ICD-10) are the most-used triggers for Document Skeletons (DS). Because ICD-10 codes are very specific to a patient's complaint, linking DS to diagnosis codes means that once a provider has assigned a code or codes to an encounter he will be presented with a very targeted set of DS to choose from to document the encounter. A DS can have any number of diagnosis codes associated with it.
To link a diagnosis code to trigger a document skeleton, follow these steps:
- On the Edit Document Skeleton page, check Diagnosis in the Trigger Type dropdown field and click the Save button. This will ensure that the Diagnosis tab appears in the area at the top of the screen. NOTE: If the Diagnosis box is not checked in the Trigger Type field, the Diagnosis tab will NOT show with the other tabs at the top of the page.
- Select the Diagnosis tab at the top of the page. This opens the Diagnosis page of the document skeleton you are currently working on.
- Make sure that the Current ICD-10's radio button is selected and click New.
- In the Create ICD-10 Diagnosis Range popup window, you can search for and enter a single diagnosis code or a range of codes. You can search this field by either entering the actual ICD-10 code or by using key words from the code description. To add the code to the field, select from the displayed search results. Note that any codes highlighted in RED in the results are not billable
codes. Click Save when you have completed the From and To fields.
NOTE: If you are unable to locate the code you are searching for, clicking on the search icon to the right of the search fields will open a new browser window to allow you to do an Internet search.
- You will now see a list of all Current ICD-10 codes associated with this document skeleton.
Choosing the Historical ICD-10's radio button will allow you to add diagnosis codes that will associate a patient's historical diagnosis with an encounter.
- Select Historical ICD-10's and click New. This opens the Create ICD-10 Diagnosis Range popup window.
- Enter any historical code or codes you want to associate with this document skeleton.
- You can also add a Look Back in Time parameter that defines how far back in the patient's record it will search.
- Click 'Save' when complete and the vital sign range will be added to the Historical ICD-10 list.
When this Document Skeleton is used by the Provider, any historical diagnosis code in the patient's records that meets the specifications set here will now be brought to the forefront of the encounter documentation.
The Clone to Historical ICD-10's button allows you to add codes from the Current list to the Historical list.