ICD-10-CM Outpatient Coding
Guidelines Exam 100% Correct
Answers
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.
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.
-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.
-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 the encounter), followed by codes for the
complications as secondary diagnoses
-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.
-Accurate reporting of ICD-10-CM diagnosis codes - -For accurate reporting
of ICD-10-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-10-
CM codes to describe all of these.
-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
Guidelines Exam 100% Correct
Answers
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.
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.
-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.
-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 the encounter), followed by codes for the
complications as secondary diagnoses
-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.
-Accurate reporting of ICD-10-CM diagnosis codes - -For accurate reporting
of ICD-10-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-10-
CM codes to describe all of these.
-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
