Allied Coding Module 3

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outpatient setting

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* a patient who receives services in an ambulatory health care facility and is currently not an inpatient.

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Outpatient Coding and Reporting Guidelines

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* are used for physician offices, hospital-based outpatient services, or any outpatient setting.
* Although these Guidelines form the basis of diagnostic coding in an outpatient setting, the outpatient coder also uses many of Section I-III Guidelines.

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Section IV.A. Selection of first-listed condition

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* When a patient presents to the physician's office with complaints, but there is no specific or confirmed diagnosis, the signs or symptoms are reported.
* For example, a patient presents with fatigue, the physician orders a laboratory workup to diagnose the reason for the fatigue. The coder reports the fatigue as the first-list diagnosis.
* In the outpatient setting, the term first-listed diagnosis is used in lieu of principal diagnosis.

* In determining the first-listed diagnosis the coding conventions of ICD-10-CM, as well as the general and disease specific guidelines take precedence over the outpatient guidelines.

* Diagnoses often are not established at the time of the initial encounter/visit. It may take two or more visits before the diagnosis is confirmed.

* The most critical rule involves beginning the search for the correct code assignment through the Alphabetic Index. Never begin searching initially in the Tabular List as this will lead to coding errors.

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Section IV.A.1. Outpatient Surgery

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* When a patient presents for outpatient surgery, but the surgery is cancelled due to a contraindication, the first-listed diagnosis would be the reason for the surgery. List the contraindication code as the secondary diagnosis.
* When a patient presents for outpatient surgery (same day surgery), code the reason for the surgery as the first-listed diagnosis (reason for the encounter), even if the surgery is not performed due to a contraindication.

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Unconfirmed Diagnosis:

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* Often times, it may take several encounters before a diagnosis is confirmed. In these instances, report the symptoms and signs.

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Additional Diagnoses

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Additional Diagnoses are reported in some cases, to describe complications, reasons for canceled procedures, and other coexisting conditions

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Section IV.B. - D.

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B. 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.

C. Accurate reporting of ICD-10-CM diagnosis codes
For 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. There are ICD-10-CM codes to describe all of these.

D. Codes that describe symptoms and signs
Codes that describe symptoms and signs, as opposed to diagnoses, are acceptable for reporting purposes when a diagnosis has not been established (confirmed) by the provider. Chapter 18 of ICD-10-CM, Symptoms, Signs, and Abnormal Clinical and Laboratory Findings Not Elsewhere Classified (codes R00-R99) contain many, but not all codes for symptoms.