COC Outpatient Coding Guidelines 1

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

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.

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

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

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

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

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

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

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.

COC - Certified Outpatient Coder Practice Test

COC - Certified Outpatient Coder Practice Test

COC Outpatient Coding Guidelines 1