COC Outpatient Coding Guidelines

Question 1

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

Accepted Answer

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

Answer

The most chronic condition present

Answer

The reason the patient called to make the appointment

Answer

The diagnosis with the highest RVU

Question 2

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

Accepted Answer

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

Answer

Code the qualified diagnosis as if confirmed

Answer

Query the physician before coding

Answer

Leave the diagnosis field blank

Question 3

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

Accepted Answer

The postoperative (confirmed) diagnosis

Answer

The preoperative diagnosis

Answer

Both diagnoses with equal sequencing

Answer

The diagnosis with the higher severity weight

Question 4

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

Accepted Answer

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

Answer

Only once per fiscal year

Answer

Only when it is the primary reason for the visit

Answer

Only if it changed during this encounter

Question 5

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

Accepted Answer

Code the abnormal finding directly using the appropriate code

Answer

Wait for the physician to query before coding

Answer

Code as 'examination, unspecified'

Answer

Do not code until a definitive diagnosis exists

Question 6

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

Accepted Answer

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

Answer

Code the condition requiring surgery as the principal diagnosis

Answer

Code only the examination; omit the condition

Answer

Code status codes only