Outpatient Coding
Learning Objectives
1. Explain terminology as related to the outpatient setting
2. Describe the difference between inpatient coding guidelines and outpatient coding guidelines
3. Describe what CPT coding is, when it is used, and the official guideline source
4. Apply Diagnostic Coding and Reporting Guidelines for Outpatient Services
5. Assign ICD-10-CM codes for outpatient services
Abbreviations/Acronyms
AICD automatic implantable cardioverter-defibrillator
AMA American Medical Association
APC Ambulatory Payment Classification
COPD chronic obstructive pulmonary disease
CPT Current Procedural Terminology
DEXA dual-energy x-ray absorptiometry
HCPCS Healthcare Common Procedure Coding System
ICD-9-CM International Classification of Diseases, 9th Revision, Clinical Modification
ICD-10-CM International Classification of Diseases, 10th Revision, Clinical Modification
ICD-10-PCS International Classification of Diseases, 10th Revision, Procedure Coding System
MRI magnetic resonance imaging
MS-DRG Medicare Severity diagnosis-related group
OPPS Outpatient Prospective Payment System
CPT only copyright © 2012. Current Procedural Terminology, 2013, American Medical Association. All Rights Reserved.
Outpatient Terminology
Terminology in the outpatient setting is often confusing. Outpatient services may be provided in a variety of settings:
Clinic, free standing or facility based
Observation unit (a unit to which unstable patients are admitted for a stay of less than 48 hours)
These outpatient services are called visits or encounters. Encounters may require hospital services and/or professional services (services rendered by a physician or a non-physician practitioner). For example, a patient receiving a chest x-ray in a hospital setting will have a hospital bill for the chest x-ray and a professional service bill from the radiologist for the reading of the x-ray.
The term “principal diagnosis” as used in the inpatient setting does not apply in the outpatient setting. The outpatient term that is synonymous with “principal diagnosis” is “first-listed diagnosis” or “primary diagnosis.”
ICD-10-CM Official Guidelines for Coding and Reporting
Please refer to the companion Evolve website for the most current guidelines.
Section IV. Diagnostic Coding and Reporting Guidelines for Outpatient Services
These coding guidelines for outpatient diagnoses have been approved for use by hospitals/ providers in coding and reporting hospital-based outpatient services and provider-based office visits.
Information about the use of certain abbreviations, punctuation, symbols, and other conventions used in the ICD-10-CM Tabular List (code numbers and titles), can be found in Section IA of these guidelines, under “Conventions Used in the Tabular List.” Information about the correct sequence to use in finding a code is also described in Section I.
The terms encounter and visit are often used interchangeably in describing outpatient service contacts and, therefore, appear together in these guidelines without distinguishing one from the other.
Though the conventions and general guidelines apply to all settings, coding guidelines for outpatient and provider reporting of diagnoses will vary in a number of instances from those for inpatient diagnoses, recognizing that:
The Uniform Hospital Discharge Data Set (UHDDS) definition of principal diagnosis applies only to inpatients in acute, short-term, long-term care and psychiatric hospitals.
Coding guidelines for inconclusive diagnoses (probable, suspected, rule out, etc.) were developed for inpatient reporting and do not apply to outpatients.
A. Selection of first-listed condition
In the outpatient setting, the term first-listed diagnosis is used in lieu of principal diagnosis.
In determining the first-listed diagnosis the coding conventions of ICD-10-CM, as well as the general and disease specific guidelines take precedence over the outpatient guidelines.
In the outpatient setting, the first-listed diagnosis is the reason for the encounter. The first-listed diagnosis may often be a symptom.
Diagnoses often are not established at the time of the initial encounter/visit. It may take two or more visits before the diagnosis is confirmed.
The most critical rule involves beginning the search for the correct code assignment through the Alphabetic Index. Never begin searching initially in the Tabular List as this will lead to coding errors.
It is common in the outpatient setting for a patient to present to a physician’s office with symptoms, for administrative reasons, for follow-up on conditions that no longer exist, or with abnormal findings. A code from the Chapter 21, Factors Influencing Health Status and Contact with Health Services (Z codes) may often be the most appropriate code. Refer to Chapter 8 for greater detail on assigning Z codes.
1. Outpatient Surgery
When a patient presents for outpatient surgery, code the reason for the surgery as the first-listed diagnosis (reason for the encounter), even if the surgery is not performed due to a contraindication.
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