Using, Adding, and Editing Diagnosis Codes

Overview

Cerbo comes pre-loaded with the full ICD-10 Diagnostic Code database for entering your assessment in the SOAP Assessment box, or documenting the patient's past medical history. Some of the more commonly-used codes are pre-loaded into your preferred short list, and any codes that you assign to a patient will be added to your favorites.

NOTE: If you don't see a code, add a + to your search to expand your shortlist (details about this are below)

Details

Searching for Codes

To add a new diagnosis to an encounter note, type search terms associated with the diagnosis (including all or part of the diagnosis name, nickname(s), and ICD-10 code) in any order in the - Find DX to Assign - bar in the Assessment box.

When you search, the system will preferentially return results from your preferred short list. Add additional search terms OR add a + to your search to instead return results from the full ICD-10 database.

Shortlist results:

Expanded search results:
Note: Once you have used the code once, it is automatically added to your preferred short list.

Rearranging Diagnostic Codes

The double arrow icon allows you to rearrange the order of your dx codes. Click on the icon, and hover over a dx until you see the 4-sided cursor. Then click on the dx you'd like to move.

Different colors of ICD-10 codes (billable vs. non-billable)

The color difference indicates billable (dark blue) versus non-billable (gold/light brown) codes. For insurance reimbursement, choose the specific dark blue codes.

Working with Diagnostic Codes in the Encounter Note

Right-click any diagnosis that has been added to the note to:

Make it the primary diagnosis,
Add it to a patient's past medical history,
Remove it from the note, or
Manage the diagnosis definition (including adding nickname(s), a description, common workup, differential diagnoses, and patient education information).

If it is a diagnosis for which additional information has been added to the system, you can also use the right click menu to add to the note:

A description of the diagnosis,
Common workup,
Differential diagnoses, and
Patient education.

Diagnostic codes that are part of a note will automatically appear on any billing or insurance forms generated from the note. Once generated, billing and insurance forms can be manually edited. Unless specifically set otherwise, the diagnosis codes in the Assessment will also be included as part of the patient Encounter Summary.

Adding Custom Diagnostic Codes

You can add custom diagnosis codes under Admin > Manage > Diagnostic Codes, by clicking Add New. This can be useful, for example, for a provider who wants to add non-ICD diagnoses, for being able to trigger Health Maintenance trackers by custom "diagnoses," or otherwise. When adding the diagnosis, the code field is required, but you can enter your "code" or N/A, and then select non-ICD from the "What code-set is this from?" drop down.

Note: The list of dx codes in Admin > Manage > Diagnostic Codes shows only shortlisted codes and NOT the full ICD-10 database.

Automatically Setting Certain Codes to Add to PMH When Diagnosed

To always add certain diagnoses to a patient's Past Medical History when entered in the encounter note Assessment box, configure this in Admin > Manage > Diagnostic Codes. Options include: Do NOTHING (default), PROMPT ME to add to PMH, or AUTOMATICALLY ADD to PMH.