How to Add an ICD-10 Code to a Service Before the Clinician Completes the Assessment and Diagnosis

CalAIM allows for billing for services prior to an official diagnosis being given. However, an ICD-10 code must always be added to a claim (service) in order to be billed. Since Non-LPHAs cannot create a diagnosis, these are the steps in order to add an ICD-10 code to a service to make it billable.

  1. Write your service note as usual. DO NOT SIGN your note until the following steps are completed:
  2. Click on the Billing Diagnosis tab in the service note screen.
  3. This will show any diagnoses that have been created for this program. If there aren’t any, click the “ICD-10” button.
  1. This will bring up a popup window. Search for the ICD-10 code you want to add. We recommend searching by the code, not the description, as this will better limit the search results. After entering the code or description, click Search.
  1. This will bring up search results. Select the code you want to add.
  2. Scroll down using the right hand scroll bar.
  1. Click OK to add this code to the claim.
  1. This takes you back to the Billing Diagnosis tab on the service note. Select 1 from the dropdown to indicate the order in which these codes should be billed. You only need 1 code, but if you choose to enter more than 1, repeat steps 3-7 and make sure to number each of these.
  1. Click Sign to finish your note.

Video Walkthrough

Updated 9/13/23