How do I add ICD-10 diagnoses to a patient chart?

Properly record diagnoses for your patients without memorizing billing codes with Practice Fusion’s Code Assist for ICD-10. Please note that ICD-9 codes should be used for encounters with a date of service or date of delivery prior to October 1, and ICD-10 codes must be used for encounters with a date of service or delivery on or after October 1.

Adding diagnoses to the patient Summary

From the Summary tab of a  patient’s chart, you can either:

  • Search for a new diagnosis

  • Select a diagnosis from your My Dx list

  • Upgrade existing  ICD-9 codes to ICD-10 codes

Diagnosis display

You can choose to display patient diagnoses by term, ICD-9 code, or ICD-10 code.
  • Term - displays the diagnosis as it has been previously entered prior to 10/1, with the ICD-9 code and the term or description chosen when adding the diagnosis

  • ICD-9 code - displays the ICD-9 code and description

  • ICD-10 code - displays the ICD-10 code and description

Note: This display setting will apply to the Summary, encounter, and encounter diagnoses.

Searching for a new diagnosis

1.  On the patient Summary, select the + icon.

2.  Select a diagnosis from your My Dx list or search by description, ICD-9 code, or ICD-10 code and select a diagnosis from the drop-down menu. Note: An orange badge indicates that the diagnosis maps to multiple  ICD-10 codes and will require further refinement.

3. If the selected diagnosis matches only one ICD-10 code, simply click Save to add it to the chart or Save to My Dx list.

If the selected diagnosis needs further refinement, you will be presented with  a list of potential ICD-10 diagnoses. Use the refine search filters to narrow the list of diagnoses. Click ‘Show codes’ or ‘Hide codes’ to display or remove ICD-9 and ICD-10 codes.

Note: In some instances, a ICD-9 code may not map to any ICD-10 codes. If you have searched for a diagnosis by description and no ICD-10 codes are available, we recommend searching by the specific ICD-9 code.

4. Select the correct ICD-10 diagnosis, then enter the diagnosis details and click Add. Click Add another to continue adding diagnoses.

5. You also add the diagnosis your custom My Dx list for future use by selecting the arrow next to the Add button. For more information, see How do I create and update "My Dx list"?

Upgrading existing ICD-9 codes to ICD-10

1. Click on the ICD-9 diagnosis from the patient’s Summary to review the diagnosis details.

2. If the ICD-9 code maps to a single ICD-10 code, click the  1 diagnoses: Refine diagnosis link. Select the refined ICD-10 code,  then click Save to upgrade the diagnosis within the Summary.

3. If the ICD-9 code maps to multiple ICD-10 codes, click Refine diagnoses  to view a list of potential ICD-10 codes.

4. Click the refine search icon and use the filters to narrow the list of ICD-10 results.

5. Once you have selected the applicable ICD-10 code, click Save to upgrade the diagnosis or Save to My Dx list to add the diagnosis to your customized My Dx list.

Note: To display the updated ICD-10 code on the patient's Summary, adjust the display drop-down menu to show ICD-10.

Adding diagnosis codes during a patient encounter

Any diagnoses added from a patient encounter will be added to the patient's Summary. Diagnoses can be entered in an encounter in two locations:

  • The Diagnoses section

  • The Assessment section of a SOAP note

Adding a diagnosis through the Diagnoses section

1. Click on an existing diagnosis or click Record next to the Diagnoses header to add a new diagnosis.

2. A pane will open to the right where you can add specifics including start/end dates, acuity, medications associated with a diagnosis, and comments. This also links out to patient resources. To add the diagnosis to the encounter, check the box to Attach diagnosis to this encounter.

Adding diagnoses through the Assessment section

1. Select the Diagnoses tab from the fly-out panel in the Assessment section to record a new diagnosis, attach an existing diagnosis, or select from your list customized My Dx list.

2. If you select an ICD-10 code from the My Dx list or Patient Dx history, the ICD-10 code  will automatically be added to the encounter.

If you select an ICD-9 code that maps to one or more ICD-10 codes, an orange badge will alert you that further refinement is required.  Click on the diagnosis to begin upgrading to ICD-10.

3. Click Refine diagnosis to view a list of the related codes. Use the filters to further narrow the results.

4. Once you’ve selected the correct ICD-10 code, click Save to attach the upgraded code.

Creating customized diagnoses

Practice Fusion uses Health Language for ICD coding and our list is fairly robust. If you cannot locate a specific diagnosis, click "Add custom diagnosis for "...." after searching for the diagnosis. This will allow you enter a custom diagnosis for the particular patient.

Please note, custom diagnoses are not saved for all patients and will need to be entered new for each patient.  Additionally, custom diagnosis codes may not be accepted for billing purposes.

For additional information,  please review the video tutorial below:


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