ICD-10-CM Outpatient Coding and Reporting Guidelines

Documented Conditions

Code conditions that coexist at the time of the encounter and for which the physician provides care, treatment, or management.

An established patient is seen for equal management of mild, intermittent, uncomplicated asthma and type 2 diabetes.

Codes: J45.20 Asthma, E11.9 Diabetes, type 2 (either code could be the first-listed)

Categories of Z Codes

Contact/Exposure, Inoculations and vaccinations

Code for patient having an MRI of the head to monitor the progression of brain tumor.

D49.6 brain tumor

________ code diagnoses documented as "probable", "suspected," "questionable," "rule out," or "working diagnosis" or other similar terms indicating uncertainty. Rather, code the condition(s) to the highest degree of certainty for that encounter/visit, such as symptoms, signs, abnormal test results, or other reason for the visit.

Do not

__________ hypertension is high blood pressure for which the cause is not known.

Essential

Encounters for routine health screenings

Factors influencing health status and contact with health services, Screening

Encounters for circumstances other than a disease or injury

ICD-10-CM provides codes to deal with encounters for circumstances other than a disease or injury. The Factors Influencing Health Status and Contact with Health Services codes (Z00-Z99) are provided to deal with occasions when circumstances other than a disease or injury are recorded as diagnosis or problems.

A status code is distinct from a ____________.

History code - indicates that the patient no longer has the condition.

A __________ is an acute type of heart attack that occurs when a coronary artery is totally blocked.

myocardial infarction

In an inpatient setting, uncertain diagnoses are reported, but in the outpatient setting these uncertain diagnoses are _________ as explained in the Section IV.H of the Guidelines.

not reported

___________ hypertension is a continuous, mild blood pressure elevation that can usually be controlled by medication.

Benign

For ambulatory surgery, code the diagnosis for which the surgery was performed. If the postoperative diagnosis is known to be different from the preoperative diagnosis at the time the diagnosis is confirmed, select the postoperative diagnosis for coding, since it is the most definitive.

True

For outpatient encounters for diagnostic tests that have been interpreted by a physician, and the final report is available at the time of coding, code any confirmed or definitive diagnosis(es) documented in the interpretation. Do not code related signs and symptoms as additional diagnoses.

True

For patients receiving diagnostic services only during an encounter/visit, sequence first the diagnosis, condition, problem, or other reason for encounter/visit shown in the medical record to be chiefly responsible for the outpatient services provided during the encounter/ visit. Codes for other diagnoses (e.g., chronic conditions) may be sequenced as additional diagnoses.

True

For routine outpatient prenatal visits when no complications are present, a code from category Z34, Encounter for supervision of normal pregnancy, should be used as the first-listed diagnosis. These codes should not be used in conjunction with chapter 15 codes.

True

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.

True

In determining the first-listed diagnosis the coding conventions of ICD-10-CM

True

NSTEMI is a type of heart attack. Sometimes an NSTEMI is known as a non-STEMI.

True

The Guidelines instruct you to assume that there is a cause-and-effect relationship between hypertension and chronic kidney disease reported with N18.-. The physician might not indicate that the hypertension and chronic kidney disease are related, but the coder is to assume this relationship.

True

When a diagnostic service is provided to a patient during an encounter, the reason for the service is the diagnosis stated in the medical record, or when no diagnostic statement is available, report the primary reason the patient presented for the service.

True

When a patient presents for outpatient surgery, code the reason for the surgery as the first-listed diagnosis, even if the surgery is not performed due to a contraindication.

True

____________ hypertension has not been specified in the medical record as either benign or malignant

Unspecified

Factors influencing health status and contact with health services (Z00-Z99)

Use of Z codes in any healthcare setting, Z Codes indicate a reason for an encounter,

________ are most often assigned in the outpatient settings, that is, ambulatory care centers, physicians' offices, and outpatient departments of hospitals.

Z codes

Code for patient encounter for blood typing prior to outpatient surgery tomorrow

Z01.83 encounter for blood typing

Code for patient without any symptoms had a CBC (complete blood count).

Z01.89 laboratory examination without any sign or symptom documented.

Two categories of Z codes that report observation are ______ and _____.

Z03 and Z04.

Category I21 STEMI includes the following infarctions:

cardiac infarction coronary artery embolism coronary artery occlusion coronary artery rupture coronary artery thrombosis infarction of heart - myocardium or ventricle

Most physicians will document the __________ of the patient for each encounter in the medical record.

chief complaint

The Uniform Hospital Discharge Data Set (UHDDS) definition of principal diagnosis does not apply to hospital-based outpatient services and provider-based office visits.

does not apply to hospital-based outpatient services and provider-based office visits.

Code for patient who was seen for shortness of breath and fever with a negative x-ray. Patient returned the next day for a CT of chest, which confirmed the presence of pneumonia.

J18.9 pneumonia.

____________ hypertension is also known as accelerated hypertension

Malignant

An ___________ is a non-ST segment acute heart attack

NSTEMI

__________ stands for Non-ST-elevation myocardial infarction.

NSTEMI

Codes ____________ report observation and evaluation of newborns for suspected conditions that are not found.

P00-P04 These codes are only reported when a healthy newborn is evaluated for a condition that is suspected, but after a study has determined the condition not to be present.

___________ hypertension may be controlled (benign) or uncontrolled (malignant, untreated, not responding to treatment) and both types are reported with I10.

Primary

Codes from A00.0 through T88.9, Z00-Z99

The appropriate code(s) from A00.0 through T88.9, Z00-Z99 must be used to identify diagnoses, symptoms, conditions, problems, complaints, or other reason(s) for the encounter/visit.

.9 is an unspecified code.

True

Code all documented conditions that coexist at the time of the encounter/visit, and require or affect patient care treatment or management.

True

Codes from category O09, Supervision of high-risk pregnancy, are intended for use only during the prenatal period. If there are no complications during the labor or delivery episode, assign code O80, Encounter for full-term uncomplicated delivery.

True

Codes that describe symptoms and signs

are acceptable for reporting purposes when a related definitive diagnosis has not been established by the provider.

In the outpatient setting, the term first-listed diagnosis is used __________

in lieu of principal diagnosis.

Accurate reporting of ICD-10-CM diagnosis codes

the documentation should describe the patient's condition, using terminology which includes specific diagnoses as well as symptoms, problems, or reasons for the encounter.

A _________ is informative, because the status may affect the course of treatment and its outcome.

status code

A ___________ is assigned to indicate that a patient has a residual of a past disease or condition or is a current carrier of a disease.

status code