Chapter_0031.pptx

    CHAPTER 3

    ICD-10-CM OUTPATIENT CODING AND REPORTING GUIDELINES

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    First-Listed Diagnosis

    I-10 Guidelines state

    Principal Dx = inpatient settings

    First-Listed Dx = outpatient settings

    The primary reason for encounter

    Example: Pt with inguinal hernia presents with shortness of breath

    SOB is first-listed

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    Assign I-10 codes for outpatient services in accordance with the I-10 Official Guidelines for Coding and Reporting.

    In the outpatient setting, the term “first-listed diagnosis [primary]” is used instead of “principal diagnosis.”

    Unconfirmed Diagnosis

    In outpatient setting, may take several encounters to confirm diagnosis

    Signs/Symptoms are reported

    Example: Pt presents with complaint of frequent heartburn

    Physician prescribes Prilosec for suspected GERD with patient returning in 10 days

    Report: frequent heartburn

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    3

    Outpatient Surgery

    Code the reason for the surgery first

    Even if the surgery is not performed

    Followed by code to report reason procedure not carried out, such as Z53.09, procedure not carried out due to other contraindication

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    Report the reason for the surgery as the first-listed diagnosis (reason for the encounter).

    Z Codes

    Report circumstances other than disease or injury

    Z codes are informative

    May be first- or additionally listed

    Depending on circumstances

    Z23 reports encounters for inoculations and vaccinations

    Procedure code identifies administration

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    External Cause Index

    Located after I-10 Table of Drugs and Chemicals

    Figure 3.1

    External Cause Index of the I-10. (From Elsevier: 2022 ICD-10-CM for Hospitals, St. Louis, 2022, Elsevier.)

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    External Cause Codes

    Never first-listed Dx

    Clarify injury or adverse effects

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    Code terms describe the external circumstances under which an accident, injury, or act of violence occurred.

    External Cause codes have their own Index in I-10.

    Observation Stay

    Categories Z03 and Z04

    Pt admitted to observation status

    Report Z code as first-listed for Dx stated as suspected/rule out conditions

    If Dx made, report Dx as first-listed

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    Other codes may be reported in addition to observation codes.

    Coexisting Conditions

    If coexisting conditions are present and affect pt care or is treated—report as coexisting condition

    Example, pt presents with SOB due to asthma. Physician prescribes nebulizer treatments. Pt is morbidly obese making examination and treatment more complex.

    First-listed: (asthma);

    Coexisting Condition: (obesity)

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    Uncertain Dx

    Inpatient report uncertain Dx as if exists

    Probable, suspected, questionable, rule out, working Dx, etc.

    Outpatient report symptoms, signs, abnormal test results, or other reason for encounter

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    Code the condition to the highest degree of certainty, such as symptoms, signs, abnormal results, or reason for encounter.

    Chronic Diseases

    Chronic conditions are treated on ongoing basis

    Report condition as many times as pt receives care or treatment for condition

    Do not report conditions that were previously treated and no longer exist

    Report history codes (Z80-Z87) as secondary Dx if condition impacts current condition or affects treatment

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    Diagnostic Services

    Only diagnostic service provided, report first reason for service

    Example: Pt presents for routine, periodic gynecological exam, report Z01.419

    No signs, symptoms, or associated diagnosis

    Example: Pt presents for diagnostic imaging for left breast mass, subareolar. Report N63.42, unspecified lump in left breast, subareolar

    Later Dx: Malignant neoplasm, report C50.112

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    Therapeutic Services

    Pt receiving only therapeutic service, report reason for encounter

    Example: Outpatient chemotherapy for right breast cancer, report Z51.11 (chemo) and C50.911 (malignant neoplasm, right breast)

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    Preoperative Evaluation

    First-listed code is preop exam

    Subcategory Z01.81 code (encounter for preprocedural exam)

    Z01.810 Preop cardiovascular exam

    Z01.811 Preop respiratory exam

    Z01.812 Preop lab

    Z01.818 Preop exam, NOS exam before chemo

    Additional code, reason for surgery

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    Also code any additional findings related to the preop evaluation.

    Pre/Postoperative Dx

    Report most definitive Dx

    Usually postoperative Dx

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    When the report indicates a different pre- and postoperative diagnosis, which would you report? (Postoperative)

    Prenatal Encounters

    Routine outpatient prenatal encounters with no complications, report category Z34, supervision of routine pregnancy

    Example: 19-year-old female presents for initial prenatal exam, first pregnancy, Z34.00

    Prenatal encounters for high-risk patients report as first-listed, O09 (supervision of high-risk pregnancy)

    Example: 29-year-old first trimester female patient presents for prenatal encounter with varicose veins of legs, O22.01

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    ConclusionCHAPTER 3

    ICD-10-CM OUTPATIENT CODING AND REPORTING GUIDELINES

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