ICD-10-CM outpatient coding and reporting guidelines

CHAPTER 3


ICD-10-CM outpatient coding and reporting guidelines




Learning objectives


After completing this chapter you should be able to


1. Identify a first-listed diagnosis.


2. Define assignment of codes for unconfirmed diagnosis.


3. Describe code assignment for outpatient surgery.


4. Outline assignment of additional diagnoses.


5. Describe Z code reporting.


6. Define observation stay.


7. Delineate the differences between first-listed and coexisting conditions.


8. Explain uncertain diagnosis.


9. Understand assignment of codes for chronic diseases.


10. Recognize diagnostic services.


11. Recognize therapeutic services.


12. Illustrate reporting of preoperative evaluations.


13. Explain prenatal visits.


14. Apply the Official Guidelines for Coding and Reporting.


NOTE: The 2012 ICD-10-CM DRAFT was used in this text.



First-listed diagnosis


The majority of the services that a physician will provide are outpatient services, so this chapter will start with assigning I-10 diagnosis codes for outpatient services in accordance with the I-10 Official Guidelines for Coding and Reporting, Section IV.



ICD-10 OFFICIAL GUIDELINES FOR CODING AND REPORTING



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.




Examples




imageEXERCISE 3-1   First-Listed Diagnosis


Complete the following in Chapter 3 of your “ICD-10-CM Online Training Modules:”


Online Lesson 1, Screens 1-4



Unconfirmed diagnosis


Often, it may take several encounters before the diagnosis is confirmed. In these instances, report the symptoms or signs that occasioned the encounter.



Examples


Two or more visits before a diagnosis is confirmed




1. Initial office visit, 30-year-old woman complains of fatigue, abnormal weight gain, and constipation. Lab studies including thyroid function test were ordered. Patient will return in two weeks.



2. Follow-up office visit, 30-year-old woman with continued complaints of fatigue, weight gain, and constipation. Lab results confirm that patient has hypothyroidism and she was started on Synthroid. She will have repeat thyroid function studies on her next visit.



3. Follow-up office visit, 30-year-old woman is seen following her repeat thyroid function studies and her hypothyroidism has responded to the Synthroid. She will be maintained on her current dose.




imageEXERCISE 3-2   Unconfirmed Diagnosis


Complete the following in Chapter 3 of your “ICD-10-CM Online Training Modules:”


Online Lesson 1, Screens 5-6



Outpatient surgery



ICD-10 OFFICIAL GUIDELINES FOR CODING AND REPORTING


SECTION IV.A. 1. Outpatient surgery


When a patient presents for outpatient surgery (same day 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.




Examples





imageEXERCISE 3-3   Outpatient Surgery


Complete the following in Chapter 3 of your “ICD-10-CM Online Training Modules:”


Online Lesson 1, Screens 7-8



Additional diagnoses


In the preceding guidelines and exercises, we were concerned primarily with the identification of the first-listed diagnosis. In some cases, additional diagnoses would be reported to describe complications, reasons for canceled procedures, and other coexisting conditions.



ICD-10 OFFICIAL GUIDELINES FOR CODING AND REPORTING


SECTION IV.B. Codes from a00.0 through t88.9, z00-z99


The appropriate code(s) from A00.0 through T88.9, Z00-Z99 must be used to identify diagnoses, symptoms, conditions, problems, complaints, or other reason(s) for the encounter/visit.


The Guidelines state that it is acceptable to use any of the codes throughout the entire Tabular List to identify the reason(s) for an outpatient visit including the use of Z codes. Z codes are used more frequently in the outpatient setting.


This guideline assures data integrity by promoting accurate I-10 diagnosis codes that are supported by documentation in the health record. It is important to code all the conditions or problems that are being managed during an encounter.



ICD-10 OFFICIAL GUIDELINES FOR CODING AND REPORTING



According to Guideline D, it is acceptable for symptoms and signs to be reported if no definitive diagnosis has been established by the provider. Chapter 18 of the I-10 contains codes (R00-R99) for most of these symptom or sign codes, but there are other such codes throughout the I-10.



ICD-10 OFFICIAL GUIDELINES FOR CODING AND REPORTING




Z codes


There are 21 chapters in Volume 1, Tabular List, of the I-10. Each of the chapters represents a different organ system or type of disease. You will review each of the chapters, but first, there are some special codes that you need to know about—Z codes. Read the following Guidelines about assignment of codes in the Z00-Z99 range:



ICD-10 OFFICIAL GUIDELINES FOR CODING AND REPORTING




SECTION IV.Q. Encounters for routine health screenings


See Section I.C.21. Factors influencing health status and contact with health services, Screening.



SECTION I.C.21. Factors influencing health status and contact with health services (z00-z99)


Note: The chapter specific guidelines provide additional information about the use of Z codes for specified encounters.



a. Use of Z codes in any healthcare setting



b. Z Codes indicate a reason for an encounter



c. Categories of Z Codes



1) Contact/Exposure



2) Inoculations and vaccinations




QUICK CHECK 3-1image





Status code


A status code is assigned to indicate that a patient has a sequelae or residual of a past disease or condition or is a current carrier of a disease. There are codes and categories of Z codes assigned to report a status.



ICD-10 OFFICIAL GUIDELINES FOR CODING AND REPORTING



SECTION I.C.21. 3) Status


Status codes indicate that a patient is either a carrier of a disease or has the sequelae or residual of a past disease or condition. This includes such things as the presence of prosthetic or mechanical devices resulting from past treatment. A status code is informative, because the status may affect the course of treatment and its outcome. A status code is distinct from a history code. The history code indicates that the patient no longer has the condition.


A status code should not be used with a diagnosis code from one of the body system chapters, if the diagnosis code includes the information provided by the status code. For example, code Z94.1, Heart transplant status, should not be used with a code from subcategory T86.2, Complications of heart transplant. The status code does not provide additional information. The complication code indicates that the patient is a heart transplant patient.


For encounters for weaning from a mechanical ventilator, assign a code from subcategory J96.1, Chronic respiratory failure, followed by code Z99.11, Dependence on respirator [ventilator] status.


The status Z codes/categories are:

















































































































































Z14 Genetic carrier
  Genetic carrier status indicates that a person carries a gene, associated with a particular disease, which may be passed to offspring who may develop that disease. The person does not have the disease and is not at risk of developing the disease.
Z15 Genetic susceptibility to disease
  Genetic susceptibility indicates that a person has a gene that increases the risk of that person developing the disease.
  Codes from category Z15 should not be used as principal or first-listed codes. If the patient has the condition to which he/she is susceptible, and that condition is the reason for the encounter, the code for the current condition should be sequenced first. If the patient is being seen for follow-up after completed treatment for this condition, and the condition no longer exists, a follow-up code should be sequenced first, followed by the appropriate personal history and genetic susceptibility codes. If the purpose of the encounter is genetic counseling associated with procreative management, code Z31.5, Encounter for genetic counseling, should be assigned as the first-listed code, followed by a code from category Z15. Additional codes should be assigned for any applicable family or personal history.
Z16 Resistance to antimicrobial drugs
  This code indicates that a patient has a condition that is resistant to antimicrobial drug treatment. Sequence the infection code first.
Z17 Estrogen receptor status
Z18 Retained foreign body fragments
Z21 Asymptomatic HIV infection status
  This code indicates that a patient has tested positive for HIV but has manifested no signs or symptoms of the disease.
Z22 Carrier of infectious disease
  Carrier status indicates that a person harbors the specific organisms of a disease without manifest symptoms and is capable of transmitting the infection.
Z28.3 Underimmunization status
Z33.1 Pregnant state, incidental
  This code is a secondary code only for use when the pregnancy is in no way complicating the reason for visit. Otherwise, a code from the obstetric chapter is required.
Z66 Do not resuscitate
  This code may be used when it is documented by the provider that a patient is on do not resuscitate status at any time during the stay.
Z67 Blood type
Z68 Body mass index (BMI)
Z74.01 Bed confinement status
Z76.82 Awaiting organ transplant status
Z78 Other specified health status
  Code Z78.1, Physical restraint status, may be used when it is documented by the provider that a patient has been put in restraints during the current encounter. Please note that this code should not be reported when it is documented by the provider that a patient is temporarily restrained during a procedure.
Z79 Long-term (current) drug therapy
  Codes from this category indicate a patient’s continuous use of a prescribed drug (including such things as aspirin therapy) for the long-term treatment of a condition or for prophylactic use. It is not for use for patients who have addictions to drugs. This subcategory is not for use of medications for detoxification or maintenance programs to prevent withdrawal symptoms in patients with drug dependence (e.g., methadone maintenance for opiate dependence). Assign the appropriate code for the drug dependence instead.
  Assign a code from Z79 if the patient is receiving a medication for an extended period as a prophylactic measure (such as for the prevention of deep vein thrombosis) or as treatment of a chronic condition (such as arthritis) or a disease requiring a lengthy course of treatment (such as cancer). Do not assign a code from category Z79 for medication being administered for a brief period of time to treat an acute illness or injury (such as a course of antibiotics to treat acute bronchitis).
Z88 Allergy status to drugs, medicaments and biological substances
  Except: Z88.9, Allergy status to unspecified drugs, medicaments and biological substances status
Z89 Acquired absence of limb
Z90 Acquired absence of organs, not elsewhere classified
Z91.0- Allergy status, other than to drugs and biological substances
Z92.82 Status post administration of tPA (rtPA) in a different facility within the last 24 hours prior to admission to current facility.
  Assign code Z92.82, Status post administration of tPA (rtPA) in a different facility within the last 24 hours prior to admission to current facility, as a secondary diagnosis when a patient is received by transfer into a facility and documentation indicates they were administered tissue plasminogen activator (tPA) within the last 24 hours prior to admission to the current facility.
  This guideline applies even if the patient is still receiving the tPA at the time they are received into the current facility.
  The appropriate code for the condition for which the tPA was administered (such as cerebrovascular disease or myocardial infarction) should be assigned first.
  Code Z92.82 is only applicable to the receiving facility record and not to the transferring facility record.
Z93 Artificial opening status
Z94 Transplanted organ and tissue status
Z95 Presence of cardiac and vascular implants and grafts
Z96 Presence of other functional implants
Z97 Presence of other devices
Z98 Other postprocedural states
  Assign code Z98.85, Transplanted organ removal status, to indicate that a transplanted organ has been previously removed. This code should not be assigned for the encounter in which the transplanted organ is removed. The complication necessitating removal of the transplant organ should be assigned for that encounter.
  See section 1.C.19.g.3 for information on the coding of organ transplant complications
Z99 Dependence on enabling machines and devices, not elsewhere classified
  Note: Categories Z89-Z90 and Z93-Z99 are for use only if there are no complications or malfunctions of the organ or tissue replaced, the amputation site or the equipment on which the patient is dependent.

Related posts:

  1. An overview of ICD-10-CM
  2. Using ICD-10-CM
  3. Chapter-specific guidelines (ICD-10-CM chapters 15-21)
  4. Chapter-specific guidelines (ICD-10-CM chapters 1-10)

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Apr 17, 2017 | Posted by in NURSING | Comments Off on ICD-10-CM outpatient coding and reporting guidelines

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