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CHAPTER 3

CHAPTER 3. ICD-10-CM OUTPATIENT CODING AND REPORTING GUIDELINES. 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

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CHAPTER 3

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  1. CHAPTER 3 ICD-10-CM OUTPATIENT CODING AND REPORTING GUIDELINES

  2. 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

  3. 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: frequentheartburn

  4. 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 complications

  5. 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

  6. External Cause Index Located after I-10 Table of Drugs and Chemicals Figure: 3.1 External Cause Index of the I-10. (From Buck CJ: 2010 ICD-10-CM Standard Edition DRAFT (Softbound), St. Louis, 2010, Saunders. )

  7. External Cause Codes Never first-listed Dx Clarify injury or adverse effects Map to E codes in the I-9

  8. 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

  9. 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)

  10. 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

  11. 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

  12. 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, central breast mass, report N63, unspecified breast lump Later DX: Malignant neoplasm, report C50.112

  13. 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)

  14. Preoperative Evaluation First-listed code is preop exam Subcategory Z01.81 code (encounter for pre-procedural 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

  15. Pre/Postoperative DX Report most definitive DX Usually postoperative DX

  16. 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

  17. ConclusionCHAPTER 3 ICD-10-CM OUTPATIENT CODING AND REPORTING GUIDELINES

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