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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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