Slide 1ICD-10-CM OUTPATIENT CODING AND REPORTING GUIDELINES
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I-10 Guidelines state
Example: Pt with inguinal hernia presents with shortness of breath
SOB is first-listed
Example 2: Pt with CHF presents for urinary frequency issues
Urinary frequency 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.
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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
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
Example pt presents for hernia surgery, malignant hypertension causes surgery to be cancelled.
Code Z53.09 first, then hypertension
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Report circumstances other than disease or injury
Z codes are informative
Depending on circumstances
Procedure code identifies administration
Located after I-10 Table of Drugs and Chemicals
Figure: 3.1
External Cause Index of the I-10. (From Buck CJ: 2013 ICD-10-CM Standard Edition DRAFT (Softbound), St. Louis, 2013, Saunders. )
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Never first-listed Dx
Map to E codes in the I-9
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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.
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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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Copyright © 2013 by Saunders, an imprint of Elsevier Inc.
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);
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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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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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
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Example: Outpatient chemotherapy for right breast cancer, report Z51.11 (chemo) and C50.911 (malignant neoplasm, right breast)
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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
Additional code, reason for surgery
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Report most definitive DX
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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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ICD-10-CM OUTPATIENT CODING AND REPORTING GUIDELINES
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