The Problem List tab on the Clinical screen allows you to enter and track a patient’s chronic diagnoses, conditions, and symptoms. Based on your settings, the problem list can have ICD-9, ICD-10 and Snomed codes added to the patient's account. Navigate to the Coding Preferences under the MacPractice menu to see your Problem List selection. I will use ICD-10 as this is currently the industry standard.
Clicking the green plus in the problem list will add a new diagnosis to the patient's account. You will notice that you can manually type the problem into the search box at the top of the screen. The bottom portion of the screen will show you the hierarchy of the codes. Double clicking on a folder will take you one level deeper in the hierarchy. You will know that a code can be added to the patient's account when you see start of life symbol rather than a folder to the left of the codes.
If you go too deep in the hierarchy, simply click on the links near the top of the screen to take you back to where you need to go. As you start working in the practice you will find codes that you would consider your favorite. Simply double click on the start at the right of the window to add this code to your favorites. Double click the code to add it to the patient’s account.
You will see the code, alias, and description for the diagnosis reference displayed below. you can specify the onset date, and a resolved date if applicable as well as the type and the status. You can also enter the date the patient’s problems were last checked. Check the No Problems checkbox to document that you have verified that the patient has no problems.
The Regularly Treated checkbox allows you to specify whether you would like to use this diagnosis code in the patient’s Ledger on new charges. If the condition is a chronic condition that you always need to submit to insurance, you will probably want to have this checkbox checked. If this is not a diagnosis that you will submit to insurance or you rarely submit it on insurance claims you should uncheck the use in procedures checkbox.
Be sure to save your changes using the Edit menu or with the keyboard shortcut Command S.
After saving, add a second diagnosis to the patient’s account by clicking the green plus. Using the tabs in the left corner will allow you to look for a diagnosis code from a specific list. Every billable code will be shown under all. The Patient tab will display all the diagnosis codes that have been associated with the current patient. Once a code has been started, it will be added into your favorites list to be quickly accessed. The tab for Top 50 will show your 50 most used codes within MacPractice.
Since ICD-10 is so new to the industry, MacPractice is equipped with an ICD9 Helper. Checking this box in the top right corner will switch your codeset to ICD-9. As you navigate through the hierarchy or manually select your ICD-9 code, MacPractice will suggest corresponding ICD-10 codes. This will help during the transition stages to ICD-10.