Chapter 3 Outpatient Coding and Reporting Guidelines
For patients receiving diagnostic services only during an encounter/ visit sequence indicated in the medical record.
True
When a final diagnosis has not been established by the provider, it is acceptable to report codes for the presenting signs and symptoms.
True
Status code should not be used with a ______ from one of the body systems chapters.
diagnosis code
When a diagnostic service is provided to a patient during an encounter, the reason for the service is the ________, _______, ______
diagnosis stated in medical record, or when no diagnostic statement is available, report the primary reason the patient presented for the service
Report the ______, _____, _____, or other reason for the encounter when a patient presents for a therapeutic service
diagnosis, condition, problem
You would not assign a Z code to indicate a previous history of diabetes mellitus but instead would assign the code for the current _____.
disease of diabetes mellitus (E11.9)
Codes the condition to the
highest degree of certainty for that encounter/visit such as symptoms, signs, abnormal test results, or other reason for the visit
Often, the patient record states that there is a "_______" a disease
history of
Follow- up office visit for a 28- year- old male with recent colonoscopy with biopsy and small bowel x-rays. The biopsy and small bowel x-rays confirmed that the patient had ulcerative colitis and the patient started on sulfasalazine.
Code: K51.90 ( Colitis, Ulcerative colitis)
Initial office visit for a 28- year- old male with persistent abdominal pain and bloody diarrhea. Patient was scheduled for small- bowel x-rays and colonoscopy and will be seen in office following those outpatient procedures.
Codes: R10.9, K92.1 (Blood in feces)
Additional diagnoses would be reported to _______,______,and _______.
Describe complications, reasons for canceled procedures, and other coexisting conditions
Accident to watercraft causing other injury; occupant of small powered boat injured due to collision, initial encounter
External cause code: V91.83XA
A patient with primary lung cancer with metastasis to spine presents for radiation treatment of the spine. The first- listed diagnosis reported is the primary lung cancer.
False
External Cause codes are located in the Alphabetic Index for Diseases under External Causes.
False
For patients receiving preoperative evaluations, sequence first a code from the subcategory Z01.81, Encounter for preprocedural examinations, followed by findings related to the preoperative evaluation.
False
Report all conditions that coexist, even if they are not addressed or do not affect management/ treatment during that encounter.
False
Section IV Diagnostic Coding and Reporting Guidelines for Outpatient services take precedence over the general and disease- specific guidelines
False
The External Cause codes can be reported as a first- listed diagnosis.
False
The codes from A00 through Z99 are always reported as first- listed diagnoses.
False
When a patient is admitted to observation for a complication following outpatient surgery, report the complication as the first- listed diagnosis.
False
When a patient presents for outpatient surgery and the surgery is canceled, report the reason why the surgery was canceled as first-listed diagnosis.
False
A male patient was admitted as an outpatient for transurethral prostatic resection for symptomatic benign prostatic hypertrophy.
First- listed diagnosis: Benign prostatic hypertrophy
A female patient was admitted as an outpatient for elective bilateral tubal ligation. The patient was noted to be wheezing during the nurse's assessment. She was seen by her physician and her surgery was canceled because of an exacerbation of her asthma.
First- listed diagnosis: Bilateral tubal ligation
Initial office visit for patient requiring equal management of COPD and CHF.
First- listed diagnosis: COPD and CHF
Established patient presented to clinic with exacerbation of Crohn's disease. Patient's rheumatoid arthritis is stable and no medication changes were made.
First- listed diagnosis: Exacerbation of Crohn's disease
A patient was admitted as an outpatient for a cystoscopy for hematuria. The procedure was performed without complications. No abnormality or explanation for the hematuria was found.
First- listed diagnosis: Hematuria
Established patient seen for cough, fever, and shortness of breath. Chest x-ray confirmed physician's diagnosis of pneumonia and patient was sent home on antibiotics.
First- listed diagnosis: Pneumonia
Initial office visit for sprained left knee. Patient has a history of hypertension and asthma, both stable at this time.
First- listed diagnosis: Sprained left knee
Established patient complaining of painful urination and frequency. Patient is a type 2 diabetic. Lab work revealed a urinary tract infection and blood glucose was within normal limits.
First- listed diagnosis: Urinary tract infection
Z codes are used more frequently in the ________.
outpatient setting
Do not code diagnoses documented as
"probable," "suspected," "questionable," "rule out," or "working diagnosis." or other similar terms indicating uncertainty
How many chapters are in Volume 1, Tabular List, of the I-10?
22
Most common Index terms for locating Z codes
Admission Dialysis Observation Aftercare Donor Problem Attention (to) Examination Replacement Procedure(surgical) Prophylactic Screening Care (of) Fitting (and adjustment) (of) Carrier Healthy Status Supervision (of) Checking History Test Transplant Contraception Maintenance Unavailability (of) Counseling Maladjustment Vaccination
The most critical rule involves beginning the search for the correct code assignment through the _____
Alphabetic index
Follow- up office visit for 55-year-old male with jaundice and fatigue. Diagnostic tests confirm that the patient has hepatitis C. He will be treated with interferon therapy.
B19.20 (Hepatitis C viral)
Heart transplant status code Z94.1 should not be reported with a code from subcategory T86.2, Complications of heart transplant.
True
Routine prenatal outpatient visits for high- risk patients are reported with a first- listed diagnosis from category 009, Supervision of high- risk pregnancy.
True
When reporting a routine prenatal visit with no complications, a code from category Z34 should be the first-listed diagnosis
True
When reporting the first- listed diagnosis, the coding conventions and specific guidelines of ICD- 10- CM take precedence over the outpatient guidelines.
True
Z codes may be reported as a principal diagnosis in the hospital setting.
True
When the only service is a preoperative examination, report the appropriate ______ along with any codes that may indicate significant conditions
Z code
When the primary care provider reports the diagnosis for visit, the first-listed diagnosis will be appropriate ______ to indicate the encounter is for preop clearance; then the ______ is reported followed by _______.
Z code, reason for the upcoming surgery, the condition requiring the clearance
What codes are reported only as first-listed diagnosis for medical observation, suspected conditions, and conditions ruled out?
Z03 & Z04
The two categories of Z codes that report observation are _____ and ____.
Z03, Z04
Codes ______ report observation and evaluation of newborns during the neonatal period for suspected conditions that are not found.
Z05.0- Z05.9
What codes are only reported when a healthy newborn is evaluated for a condition that is suspected without signs or symptoms?
Z05.0- Z05.9
Status codes indicate that a patient is either a _____ or has the ______ or
carrier of a disease; sequelae or residual of a past disease or condition
Codes from _______, Supervision of high-risk pregnancy, are intended for use only during the prenatal period
category O09
For routine outpatient prenatal visits when no complications are present, report a code from _____
category Z34
Most physicians will document the "_______" of the patient for each encounter in the medical record
chief complaint
Code all the documented conditions that
coexist at the time of an encounter/visit and require or affect patient care, treatment, or management
When abstracting information from the medical record as the basis for code assignment, the intent is to ________ of the patient encounter.
communicate the story
According to Guidelines D, its is acceptable for symptoms and signs to be reported if no ________ has been established by the provider.
definitive diagnosis
In the outpatient setting, the term ______ is used in lieu of principal diagnosis.
first- listed diagnoses
The External Cause codes are never reported as a ______.
first-listed diagnosis
Sometimes the Z code will be the ______ code, and _____ code
first-listed, supplemental
A status code may affect the course of ____ and its ____.
treatment, outcome
The Z codes are assigned to report ______ and ______ accurately.
types of encounters, capture the story
In an inpatient setting, uncertain diagnoses are reported, but in the outpatient setting these ________ are not reported as explained in Section IV.
uncertain diagnoses
Initial office visit for 55-year-old male with fatigue and jaundice. Laboratory tests were ordered and patient will return in 1 week for the results.
Codes: R53.83 (Fatigue) R17 (Jaundice yellow)
In the preceding guidelines and exercises, we were concerned primarily with the _______ of the first-listed diagnosis.
Identification
The Guidelines state that is acceptable to use any code throughout the entire Tabular List to _______ for an outpatient visit including the use of ______.
Identify the reason, Z codes
Most groups of codes have _____ or _____ notes that provide further detail about assigning the codes.
Includes, Excludes
External cause codes have their own index, and not listed in the _____.
Index to Diseases
Motor vehicle traffic accident due to tire blowout; driver of the car was injured, initial encounter
Injured person code: V48.5XXA
Horse being ridden, rider injured, and non-motor vehicle collision, initial encounter
Injured person code: V80.790A
Driver of an ATV (off-road vehicle) is injured when he collides with a fence
Injured person code: V86.59XA
The majority of services that a physician will provide are _________ .
Outpatient services
Railway accident involving derailment without antecedent collision, injuring a porter
Place of occurrence code: Y92.815
Z codes are located at the end of the _________
Tabular
Never begin searching initially in the ______ as this will lead to coding errors.
Tabular list
Codes may be reported in addition to the observation code but only when __________
That condition or conditions are unrelated to the reason for the observation codes
Always begin the search for the correct code assignment in the Alphabetic Index.
True
Category O09 codes only intended for use when reporting for prenatal period
True
The main terms in code index usually represent the type of ______ or ____, with the specific agent or the circumstances listed below the main term.
accident, violence
The index classifies environment events (tornadoes, floods), circumstances, and other conditions as the cause of injury and other adverse effects ______.
alphabetically
Sometimes, important information contributing to the care of the patient is not an ______.
illness
When a external code is reported, it is reported _____ to an injury code from the Tabular List of the I-10.
in addition
Diagnoses often are not established at the time of the ______/______. It may take two or more visits before the diagnosis is confirmed.
initial encounter/ visit
Each chapter represent a different _____ or ______.
organ system, type of disease
Do not code conditions that were
previously treated and no longer exist
If a patient has a chronic condition that is treated on an ongoing basis you can
report the condition as many times as the patient receives care or treatment for the condition
History codes ( categories Z80-Z87) may be used as _______ if the historical condition or family history has an impact on current care or influences treatment
secondary codes
If the newborn has signs or symptoms of a suspected problem, you would report the _____ or _____ and not a code from Z05.0- Z05.9 observation codes.
signs, symptoms
Often, it may take several encounters before the diagnosis is confirmed. In these instances, report the ______ or _____ that occasioned the encounter.
symptoms, signs
