Adding diagnosis and treatment plans

This guide explains how to add, manage, sign, and share diagnoses and treatment plans for a client in SimplePractice.

Note: There’s no limit to how many diagnosis and treatment plans can be added.

In this guide, we’ll cover:

• Using ICD-10 codes for diagnoses
• Adding a diagnosis and treatment plan to a client's file
• Editing, printing, downloading, or deleting a diagnosis and treatment plan
• Signing and locking a diagnosis and treatment plan
• Sharing a diagnosis and treatment plan with a client for e-signature
• Unlocking a locked diagnosis and treatment plan

Using ICD-10 codes for diagnoses

SimplePractice uses ICD-10 codes for diagnoses. While you can find the ICD-10 codes available in your account in the DSM-5, you may find that the descriptions aren’t aligned, as we use the ICD-10 descriptions from CMS.gov.

Every year on October 1st, the list of billable ICD-10 codes is updated. To confirm a code’s current description and to check if it’s billable:

• Navigate to the ICD-10 database
• Search for the code
• Click the ICD-10 CM Diagnosis Code

• Confirm the code has the current year and is listed as a Billable/Specific Code

Adding a diagnosis and treatment plan to a client's file

To add a diagnosis and treatment plan to a client's file:

1. Navigate to the client's Overview page
2. Click New > Diagnosis and treatment plan

If you had already created a diagnosis and treatment plan for the client, you can click Load last plan to  populate with content from the previous treatment plan.

You can then edit the plan as needed, then click Save. This will allow you to update their treatment plan, while still retaining a copy of the original completed treatment plan.

If you need to create a new diagnosis and treatment plan from scratch, you can select a diagnosis:

1. Choose a Diagnosis code
   • You can adjust the diagnosis description by typing in the Description text box
2. Click the plus icon to add multiple diagnoses if needed
   • To add multiple diagnoses, first check that Include multiple Diagnosis Codes is checked in Settings > Client billing and insurance > Insurance billing
3. Click Save

To enter the treatment plan, select a treatment plan template to choose one of your existing treatment plan templates.

To use a Wiley Treatment Planner template, see Using Wiley Treatment Planners.

To add a template to your options, see:

• Adding a pre-built template or Creating a new template and accessing the template builder to add it to your template library
• Managing your template library to add it to available templates to use when you're creating documentation

Next, follow the steps below:

1. Enter the treatment plan information
   • Click Documentation history in the top right corner to view any past documentation for the client
     • For additional information, see Viewing documentation history
   • You can also add a Reminder to review plan, which will appear as a notification in your account
   • Use snippets to add frequently used text
     • For more information, see Using snippets
2. Click Complete and Save
3. Click Save

You can add and save a diagnosis without a treatment plan, or vice versa. The primary clinician will be noted as the provider within a client’s diagnosis and treatment plan.

The Date and time assigned to plan will default to the current date and time, and will only apply to appointments after that time. If you want to make sure a diagnosis shows up on superbills, claims, and notes for an appointment, you can edit the date and time to backdate it before that appointment. For more information, see Editing, printing, or deleting a diagnosis and treatment plan.

Note: If you only have one diagnosis added to a client’s file, it'll be applied to all of the client's appointments.

Editing, printing, downloading, or deleting a diagnosis and treatment plan

To edit, print, or delete a diagnosis and treatment plan:

1. Navigate to the client's Overview page
2. Hover over the Diagnosis and treatment plan and select from the following:
   • Edit to make changes
   • The printer icon to print
   • The trash can icon to delete

Note: If the diagnosis and treatment plan has been locked, it’ll need to be unlocked before it can be edited or deleted.

You can also edit, print, or delete a diagnosis and treatment plan by selecting it from the client’s Overview page. Click the pencil icon to edit the diagnosis, or select More for options to Print, Download, or Delete the diagnosis.

Important: After editing a diagnosis and treatment plan, make sure to click Update or Update Treatment Plan.

Signing and locking a diagnosis and treatment plan

You can sign and lock a client's diagnosis and treatment plan at any time. To do this:

1. Navigate to your client's Overview page
2. Click the Diagnosis and treatment plan you'd like to sign
3. Select Sign

After reviewing your name and credentials, click Sign and lock.

Once you sign a diagnosis and treatment plan, it’ll automatically be locked. If it hasn't been shared and signed by the client, it can be unlocked if you need to amend, correct, or clarify the plan. For more information, see Unlocking a diagnosis and treatment plan.

Sharing a diagnosis and treatment plan with a client for e-signature

After signing and locking a diagnosis and treatment plan, you can share it with a client or contact so they can electronically sign it. To do this:

1. Navigate to the client's Overview page
2. Click the Diagnosis and treatment plan you'd like to share
3. Choose Share in the upper right corner

4. Review the document being shared and click Continue to Email

5. Review the content of the email and click Continue to Review > Share & Send Now

Unlocking a locked diagnosis and treatment plan

Important: This feature should be used with care and in a manner that's consistent with HIPAA requirements and professional ethics. While this feature is built in a HIPAA-compliant way, you and your team members are ultimately responsible for safeguarding the information in your SimplePractice account. For more information on maintaining HIPAA compliance when unlocking documentation, see Unlocking a locked progress note.

To unlock the diagnosis and treatment plan:

1. Navigate to your client's Overview page
2. Click the Diagnosis and treatment plan you'd like to unlock
3. Choose Unlock

Note: If you're not seeing this option, you may need permission to unlock diagnosis and treatment plans. To be granted permission for this, see Updating a team member’s roles.

4. Enter the Reason for unlocking
5. Click Accept & Unlock