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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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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