AAPC CPC CODING GUIDELINES
Questions and Answers
1.Finding main dx term--try reading dx right to left:
Answer EX: COPD (chronic obstruc- tive pulmonary disease) can be
found under "disease" as well as "obstruction" Ex2: URI (upper
respiratory infection) can be found under "infection"
2.Always code to the highest degree of specificity
Answer Ex: aged related Osteoporo- sis with current fracture of left
shoulder, follow up visit;
M80.012D:
M80 (osteoporosis with current fracture)
+ M80.0 (age related) +
M80.012 (age related w/current fracture of left shoulder +
M80.012D (subsequent visit)
3.Outpatient visits--SUSPECTED Dx NEVER coded.
If a definitive Dx has not been reported then code:
1--Signs
2--Sx
3--Abnormal Test results:
Answer Terms of suspected Dx:
Probable
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9
, Suspected
Questionable
Rule Out
Differential
Working
4.Inpatient Visits--SUSPECTED Dx MAY BE CODED, with exception to
HIV. HIV Dx must be confirmed before coding
Answer
5.Sx that are an INTEGRAL part of a disease do NOT need to be coded
Answer Ex: Pt presents w/severe AB pain, nausea, vomiting. Diagnosed
w/acute appendicitis. Code only acute appendicitis K35.80.
6.Sx that are NOT INTEGRAL part to a disease DO NEED TO BE CODED
Answer Ex: Patient presents with runny nose & cough as well as Rt
shoulder pain. Physician diagnoses URI. Code URI as well as Sx of Rt
Shoulder pain.
URI--J06.9
Rt Shldr Pn--M25.511
7.MULTIPLE CODING FOR A SINGLE CONDITION--
Some Diseases require multiple Dx codes and will indicate ETIOLOGY &
MANIFESTATION. It will appear in the alphabetic index as one code followed
by another code in brackets
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9
Questions and Answers
1.Finding main dx term--try reading dx right to left:
Answer EX: COPD (chronic obstruc- tive pulmonary disease) can be
found under "disease" as well as "obstruction" Ex2: URI (upper
respiratory infection) can be found under "infection"
2.Always code to the highest degree of specificity
Answer Ex: aged related Osteoporo- sis with current fracture of left
shoulder, follow up visit;
M80.012D:
M80 (osteoporosis with current fracture)
+ M80.0 (age related) +
M80.012 (age related w/current fracture of left shoulder +
M80.012D (subsequent visit)
3.Outpatient visits--SUSPECTED Dx NEVER coded.
If a definitive Dx has not been reported then code:
1--Signs
2--Sx
3--Abnormal Test results:
Answer Terms of suspected Dx:
Probable
1/
9
, Suspected
Questionable
Rule Out
Differential
Working
4.Inpatient Visits--SUSPECTED Dx MAY BE CODED, with exception to
HIV. HIV Dx must be confirmed before coding
Answer
5.Sx that are an INTEGRAL part of a disease do NOT need to be coded
Answer Ex: Pt presents w/severe AB pain, nausea, vomiting. Diagnosed
w/acute appendicitis. Code only acute appendicitis K35.80.
6.Sx that are NOT INTEGRAL part to a disease DO NEED TO BE CODED
Answer Ex: Patient presents with runny nose & cough as well as Rt
shoulder pain. Physician diagnoses URI. Code URI as well as Sx of Rt
Shoulder pain.
URI--J06.9
Rt Shldr Pn--M25.511
7.MULTIPLE CODING FOR A SINGLE CONDITION--
Some Diseases require multiple Dx codes and will indicate ETIOLOGY &
MANIFESTATION. It will appear in the alphabetic index as one code followed
by another code in brackets
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9
