Outpatient Coding



Outpatient Coding



Learning Objectives



1. Explain terminology as related to the outpatient setting


2. Identify major differences between ICD-9-CM and ICD-10-CM related to outpatient conditions


3. Describe the difference between inpatient coding guidelines and outpatient coding guidelines


4. Describe what CPT coding is, when it is used, and the official guideline source


5. Apply Diagnostic Coding and Reporting Guidelines for Outpatient Services


6. Assign ICD-9-CM codes for outpatient services


7. Explain the purpose and use of APCs



Abbreviations/Acronyms



















CPT only copyright © 2011. Current Procedural Terminology, 2012, 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:



These outpatient services are called visits or encounters. Encounters may require hospital services and/or professional services (services rendered by a physician or a nonphysician 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-9-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-9-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.



In the outpatient setting, the first-listed diagnosis is the reason for the encounter. The first-listed diagnosis may often be a symptom.



Example


Patient presents to physician’s office with complaints of headache and slurred speech. Physician suspects that this patient is experiencing a transient ischemic attack (TIA) or a cerebrovascular accident (CVA). The patient is sent directly to the hospital. The first-listed diagnosis for the physician office visit is 784.59 (R51), headache, with a secondary diagnosis of 784.5 (R47.81), slurred speech.




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 Supplementary Classification of Factors Influencing Health Status and Contact with Health Services (V codes) may often be the most appropriate code. Refer to Chapter 8 for greater detail on assigning V codes.



Example


A child presents to his physician’s office for a required camp physical, V70.3 (Z02.89).


To locate this code in the Alphabetic Index, look under the main term “Admission for, exam.”



Example


A healthcare worker is stuck by a needle used on a patient with acquired immunodeficiency syndrome (AIDS), V01.79 (Z20.6).


To locate this code in the Alphabetic Index, look under the main term “Exposure to.”



Example


A patient is visiting her oncologist’s office for her yearly visit 5 years status post left mastectomy for breast cancer, V67.09, V10.3, V45.71 (Z08, Z90.12, Z85.3).


This code is located in the Alphabetic Index under “Admission for follow-up exam—surgery” and “History, malignant neoplasms, breast.” Coding Clinic (1984 M-J:p10)1 instructs coding of follow-up visits for cancer patients treated with surgery, who currently have no evidence of cancer, to code V67.09, follow-up exam following other surgery.



Example


A patient presents to her physician’s office with a strong family history of breast cancer. She is interested in prophylactic removal of both breasts, V16.3 (Z80.3).


This code is located in the Alphabetic Index under “History, family, malignant neoplasm.”







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.



Example


A patient reports to the outpatient surgery department for an arthroscopic meniscectomy for a torn meniscus on the right knee. The patient injured her meniscus when she tripped over the cat. The patient is administered anesthesia and is found to be in atrial fibrillation. The surgeon decides that it is best not to proceed with the procedure but wishes to consult with a cardiologist and reschedule. The primary diagnosis is the torn meniscus; atrial fibrillation is coded secondarily along with canceled surgery and the E code for the accident, 836.2, 427.31, V64.1, E885.9 (S83.206A, I48.91, Z53.09, W01.0xxA).


2. Observation Stay


    When a patient is admitted for observation for a medical condition, assign a code for the medical condition as the first-listed diagnosis.


    When a patient presents for outpatient surgery and develops complications requiring admission to observation, code the reason for the surgery as the first reported diagnosis (reason for encounter), followed by codes for the complications as secondary diagnoses.



Example


A patient is admitted to outpatient surgery with cholelithiasis and is scheduled for a laparoscopic cholecystectomy. The surgery proceeds uneventfully. In the recovery room, the patient is found to have hypotension. The surgeon decides to admit the patient for observation, 574.20, 458.9 (K80.20, I95.9).


B Codes from 001.0 through V89


    The appropriate code or codes from 001.0 through V89 must be used to identify diagnoses, symptoms, conditions, problems, complaints, or other reason(s) for the encounter/visit.



Example


When presenting to a doctor’s office, a patient often presents with symptoms such as cough or leg pain. At the end of the visit, the physician may not know the cause of the leg pain and therefore may make the assessment that leg pain is probably the result of muscle strain. Therefore, in this case, the code would be 729.5 (M79.606) for leg pain.


C Accurate reporting of ICD-9-CM diagnosis codes


    For accurate reporting of ICD-9-CM diagnosis codes, the documentation should describe the patient’s condition, using terminology which includes specific diagnoses as well as symptoms, problems, or reasons for the encounter. There are ICD-9-CM codes to describe all of these.



Example


A patient is scheduled for cataract surgery and has congestive heart failure. The surgeon asks the patient’s cardiologist for a preoperative consult, V72.81, 428.0, 366.9 (Z01.810, I50.9, H26.9).


D Selection of codes 001.0 through 999.9


    The selection of codes 001.0 through 999.9 will frequently be used to describe the reason for the encounter. These codes are from the section of ICD-9-CM for the classification of diseases and injuries (e.g., infectious and parasitic diseases; neoplasms; symptoms, signs, and ill-defined conditions, etc.).


E Codes that describe symptoms and signs


    Codes that describe symptoms and signs, as opposed to diagnoses, are acceptable for reporting purposes when a diagnosis has not been established (confirmed) by the provider. Chapter 16 of ICD-9-CM, Symptoms, Signs, and Ill-defined conditions (codes 780.0-799.9) contain many, but not all codes for symptoms.



Example


When a patient is seen in a physician’s office for a problem-oriented visit, it is often a symptom that will be reported as the first-listed diagnosis. A patient may come to the office with abdominal pain, and the physician suspects it is due to diverticulitis. The patient is sent for testing. The first-listed diagnosis for this encounter is 789.00 (R10.9).


On the return visit, test results reveal that the patient does indeed have diverticulitis; therefore, the follow-up visit code would be 562.11 (K57.92).


F Encounters for circumstances other than a disease or injury


    ICD-9-CM provides codes to deal with encounters for circumstances other than a disease or injury. The Supplementary Classification of factors Influencing Health Status and Contact with Health Services (V01.0-V91.99) is provided to deal with occasions when circumstances other than a disease or injury are recorded as diagnosis or problems. See Section I.C.18 for information on V-codes.



Example


A patient is planning on donating an organ and is seen by his family physician. The patient must be examined so it can be determined whether he can qualify as a donor, V70.8 (Z00.5).



Example


A patient who is on Coumadin therapy for history of DVT is required to visit a Coumadin clinic weekly until the levels of medication are adjusted, V58.83, V58.61, V12.51 (Z51.81, Z79.01, Z86.718).

Related posts:

  1. Diseases of the Digestive System: (ICD-9-CM Chapter 9, Codes 520-579, and ICD-10-CM Chapter 11, Codes K00-K95)
  2. Diseases of the Blood and Blood-Forming Organs: (ICD-9-CM Chapter 4, Codes 280-289, and ICD-10-CM Chapter 3, Codes D50-D89)
  3. Diseases of the Circulatory System: (ICD-9-CM Chapter 7, Codes 390-459, and ICD-10-CM Chapter 9, Codes I00-I99)
  4. Introduction to ICD-10-PCS

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Jun 14, 2017 | Posted by in GENERAL SURGERY | Comments Off on Outpatient Coding

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