© 2012 Cengage Learning. All Rights Reserved. May not be scanned, copied, duplicated, or posted to a publicly accessible website, in whole or in part. Michelle Cranney, MBA, RHIT, CCS-P, CPC Chapter 6 ICD-9-CM and ICD-10-CM Outpatient and Physician Office Coding

© 2012 Cengage Learning. All Rights Reserved. May not be scanned, copied, duplicated, or posted to a publicly accessible website, in whole or in part. Outpatient Care (Ambulatory Care) Primary care Point of first contact Primary care provider

© 2012 Cengage Learning. All Rights Reserved. May not be scanned, copied, duplicated, or posted to a publicly accessible website, in whole or in part. Medical Specialties Allergy and immunology Anesthesiology Colon and rectal surgery Dermatology Family practice General surgery Gynecology

© 2012 Cengage Learning. All Rights Reserved. May not be scanned, copied, duplicated, or posted to a publicly accessible website, in whole or in part. Internal Medicine Sub-specialties –Adolescent medicine –Cardiovascular medicine –Critical care medicine –Electrophysiology –Endocrinology –Gastroenterology

© 2012 Cengage Learning. All Rights Reserved. May not be scanned, copied, duplicated, or posted to a publicly accessible website, in whole or in part. Internal Medicine Subspecialties Geriatrics Hematology Immunology Infectious disease Nephrology Oncology Pulmonary medicine Rheumatology Sports medicine

© 2012 Cengage Learning. All Rights Reserved. May not be scanned, copied, duplicated, or posted to a publicly accessible website, in whole or in part. Medical Specialties Medical genetics Neurology Obstetrics Ophthalmology Orthopedics Otorhinolaryngology Plastic and reconstructive surgery Psychiatry Radiology Thoracic surgery Urology

© 2012 Cengage Learning. All Rights Reserved. May not be scanned, copied, duplicated, or posted to a publicly accessible website, in whole or in part. Hospital Outpatient Services Ambulatory patients (outpatients) Ambulatory surgery patients Emergency care patients Observation patients

© 2012 Cengage Learning. All Rights Reserved. May not be scanned, copied, duplicated, or posted to a publicly accessible website, in whole or in part. Freestanding Ambulatory Care Facilities Ambulatory surgical center Cardiovascular center Clinical laboratory Imaging center Industrial health clinic Infusion center Neighborhood health center (continued)

© 2012 Cengage Learning. All Rights Reserved. May not be scanned, copied, duplicated, or posted to a publicly accessible website, in whole or in part. Freestanding Ambulatory Care Facilities Pain management center Physician office Primary care center Public health department Radiology center Rehabilitation facility

© 2012 Cengage Learning. All Rights Reserved. May not be scanned, copied, duplicated, or posted to a publicly accessible website, in whole or in part. Other Ambulatory Care Facilities Staff model health maintenance organization Student health center Urgent care center

© 2012 Cengage Learning. All Rights Reserved. May not be scanned, copied, duplicated, or posted to a publicly accessible website, in whole or in part. Hospital-Based Departments Ambulatory surgery Outpatient department Emergency department Partial hospitalization program

© 2012 Cengage Learning. All Rights Reserved. May not be scanned, copied, duplicated, or posted to a publicly accessible website, in whole or in part. Hospital-Owned Facilities Hospital-owned physician practice Satellite clinics

© 2012 Cengage Learning. All Rights Reserved. May not be scanned, copied, duplicated, or posted to a publicly accessible website, in whole or in part. Outpatient Coding and Reporting Guidelines Diagnostic Coding and Reporting Guidelines for Outpatient Services (Hospital-Based and Physician Office) –Selection of first-listed diagnosis –ICD-9-CM and ICD-10-CM Tabular List of Diseases ICD-9-CM: V89 ICD-10-CM: A00-T88, Z00-Z99 (continued)

© 2012 Cengage Learning. All Rights Reserved. May not be scanned, copied, duplicated, or posted to a publicly accessible website, in whole or in part. Outpatient Coding and Reporting Guidelines Diagnostic Coding and Reporting Guidelines for Outpatient Services (Hospital-Based and Physician Office) –Accurate reporting of ICD-9-CM and ICD-10-CM codes –Always code to greatest degree of accuracy and completeness

© 2012 Cengage Learning. All Rights Reserved. May not be scanned, copied, duplicated, or posted to a publicly accessible website, in whole or in part. Outpatient Coding Guidelines Reason for encounter –ICD-9-CM only Reporting signs and symptoms Factors influencing health status and contact with health services –ICD-9-CM: V codes –ICD-10-CM: Z00-Z99 (continued)

© 2012 Cengage Learning. All Rights Reserved. May not be scanned, copied, duplicated, or posted to a publicly accessible website, in whole or in part. Outpatient Coding Guidelines Level of detail in coding Sequencing diagnoses Reporting qualified diagnoses –e.g., suspected pneumonia; questionable Reporting chronic diseases Reporting coexisting conditions (continued)

© 2012 Cengage Learning. All Rights Reserved. May not be scanned, copied, duplicated, or posted to a publicly accessible website, in whole or in part. Outpatient Coding Guidelines Encounter for diagnostic services Encounter for therapeutic services Encounter for preoperative evaluations Ambulatory surgery Routine outpatient prenatal visits

© 2012 Cengage Learning. All Rights Reserved. May not be scanned, copied, duplicated, or posted to a publicly accessible website, in whole or in part. Outpatient Diagnostic Tests Determining first-listed diagnosis –e.g., due to signs and/or symptoms Instruction to determine reason for test Information unavailable from physician Incidental findings Always code to greatest degree of accuracy and completeness (continued)

© 2012 Cengage Learning. All Rights Reserved. May not be scanned, copied, duplicated, or posted to a publicly accessible website, in whole or in part. Outpatient Diagnostic Tests Unrelated/coexisting conditions Tests ordered in absence of signs and/or symptoms If order communicated via telephone, both treating provider and testing facility must document call

© 2012 Cengage Learning. All Rights Reserved. May not be scanned, copied, duplicated, or posted to a publicly accessible website, in whole or in part. Outpatient Surgery Code reason for surgery as first-listed diagnosis –Even if surgery cancelled due to contraindication