Outpatient Coding Guidelines Flashcards

According to the UHDDS/OGCR, what is the principal diagnosis for outpatient coding?

Answer: The condition established after study to be chiefly responsible for occasioning the visit

For outpatient coding, the principal diagnosis is the condition established after study to be chiefly responsible for the visit, as defined in the Uniform Hospital Discharge Data Set.

For outpatient encounters, when a diagnosis is qualified as 'probable' or 'suspected,' the coder should:

Answer: Code the sign, symptom, or abnormal finding — NOT the unconfirmed diagnosis

Unlike inpatient coding, outpatient guidelines prohibit coding uncertain diagnoses ('probable,' 'suspected'); instead, code the presenting sign, symptom, or test result.

When coding an outpatient surgery visit, if the postoperative diagnosis differs from the preoperative diagnosis, the coder should code:

Answer: The postoperative (confirmed) diagnosis

Per outpatient coding guidelines, the postoperative diagnosis is coded because it represents the most definitive diagnosis established after the procedure.

In outpatient coding, a 'chronic condition' may be coded:

Answer: As many times as applicable to the encounter when it affects care

Chronic conditions are coded whenever they are relevant to and affect the management of the patient during the encounter.

For an outpatient encounter, how should an abnormal diagnostic test result be coded when no diagnosis has been confirmed?

Answer: Code the abnormal finding directly using the appropriate code

If a definitive diagnosis has not been confirmed, the abnormal finding or sign/symptom should be coded directly using the appropriate ICD-10-CM code.

Which coding guideline applies when a patient is seen for a pre-operative physical examination?

Answer: Code the pre-op examination code plus the condition requiring surgery

For pre-operative physicals, code the encounter for pre-op exam (Z01.810–Z01.818) along with the condition that necessitates the surgery.