Coding Guidelines Flashcards

What should you code first in an outpatient encounter?

Answer: The reason for the encounter or visit

In outpatient settings, the first-listed diagnosis is the condition chiefly responsible for the services provided during the encounter.

When should you use an acute and chronic code together?

Answer: When a condition has both an acute exacerbation and an underlying chronic condition, code both with the acute code first

When a patient has both acute and chronic forms of a condition, both should be coded, with the acute condition sequenced first.

What is the 'code first' convention?

Answer: Certain codes must be sequenced before others; the underlying condition is coded first followed by the manifestation

The 'code first' note indicates a manifestation code that requires the underlying disease to be coded first, establishing the etiology/manifestation relationship.

Can you code a suspected or probable diagnosis in outpatient settings?

Answer: No, code only confirmed conditions or the signs/symptoms in outpatient settings

In outpatient settings, do not code suspected, probable, or rule-out diagnoses. Instead, code the signs, symptoms, or conditions to the highest degree of certainty.

What is sequencing in ICD-10-CM?

Answer: The order in which diagnosis codes are listed, with the principal/first-listed diagnosis sequenced first

Sequencing determines which diagnosis is listed first (principal diagnosis for inpatient, first-listed for outpatient) followed by additional diagnoses in order of relevance.

What does 'code also' mean in ICD-10-CM?

Answer: An instruction that two codes may be needed together to fully describe a condition, with either code potentially sequenced first

'Code also' indicates that both codes should be reported. Unlike 'code first,' sequencing depends on the circumstances of the encounter.