Write the note and add the diagnosis
Every claim needs a session note and at least one ICD-10 diagnosis. AI Scribe can draft the note, but you'll always add the diagnosis yourself.
- The session has taken place, and its appointment has the correct service (Lesson 6.2)
- You've set up AI Scribe with your template if you'd like it to draft the note (Lesson 3.4)
Draft the note with AI Scribe
During a Carepatron Telehealth call, AI Scribe can transcribe the session and draft the note when the call ends. For an in person session, open the client's record in Clients → New note → Start transcribing, then select Generate note to use your template.
You can see the full process in Lesson 3.4. For an insurance claim, always read the draft and correct it. A payer could audit this record later, so make sure it's accurate.
Add the ICD-10 diagnosis
- Open the note and go to its Medical coding tab.
- Search for and add one or more ICD-10 codes. You can also reuse the codes from the client's last appointment.
- Check the codes are listed in the order you want, with the main diagnosis first.
Diagnosis codes are saved against the note's appointment, which is where the claim picks them up. If the note isn't linked to an appointment, set it from the date and time above the note.
Find the diagnosis in other places
- You can also add diagnosis codes on the appointment: open its Billing tab → Edit services → Diagnosis.
- You can save an ongoing diagnosis as a Condition on the client's record under profile Overview → Conditions. This makes it easy to choose again at the next session. Set it to Inactive when it no longer applies.
Tick these off in your own workspace before moving on.
Will AI Scribe add the diagnosis for me?
No. AI Scribe drafts the written note from the transcript, but the diagnosis is a clinical decision. You'll add it yourself in the note's Medical coding tab.
Can I add more than one diagnosis to a note?
Yes, you can add every diagnosis that applies. Put the main diagnosis first.
What happens if I don't add a diagnosis?
The claim won't have a diagnosis, and a payer will reject it. Add the diagnosis before you create the claim.
Do I have to use AI Scribe?
No. You can type the note yourself and use it in exactly the same way. AI Scribe simply gives you a draft to review.