Copyright © 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 1 CHAPTER 8 ICD-10-CM OUTPATIENT CODING AND REPORTING GUIDELINES

Copyright © 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 2 First-Listed Diagnosis I-10 Guidelines stateI-10 Guidelines state –Principal Dx = inpatient settings –First-Listed Dx = outpatient settings The primary reason for encounterThe primary reason for encounter Example: Pt with inguinal hernia presents with shortness of breathExample: Pt with inguinal hernia presents with shortness of breath –SOB is first-listed

Copyright © 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 3 Unconfirmed Diagnosis In outpatient setting, may take several encounters to confirm diagnosisIn outpatient setting, may take several encounters to confirm diagnosis Signs/Symptoms are reportedSigns/Symptoms are reported Example: Pt presents with complaint of frequent heartburnExample: Pt presents with complaint of frequent heartburn –Physician prescribes Prilosec for suspected GERD with patient returning in 10 days –Report: frequent heartburn

Copyright © 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 4 Outpatient Surgery Code the reason for the surgery firstCode the reason for the surgery first –Even if the surgery is not performed Followed by code to report reason procedure not carried out, such as Z53.09, procedure not carried out due to other complicationsFollowed by code to report reason procedure not carried out, such as Z53.09, procedure not carried out due to other complications

Copyright © 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 5 Z Codes Report circumstances other than disease or injuryReport circumstances other than disease or injury –Z codes are informative May be first- or additionally listedMay be first- or additionally listed –Depending on circumstances Z23 reports encounters for inoculations and vaccinationsZ23 reports encounters for inoculations and vaccinations –Procedure code identifies administration

Copyright © 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 6 External Cause Index Located before I-10Table of Drugs and ChemicalsLocated before I-10Table of Drugs and Chemicals Figure: 8.1 External Cause Index of the I-10. (From Buck CJ: 2010 ICD-10-CM Standard Edition DRAFT (Softbound), St. Louis, 2010, Saunders. )

Copyright © 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 7 External Cause Codes Never first-listed DxNever first-listed Dx Clarify injury or adverse effectsClarify injury or adverse effects Map to E codes in the I-9Map to E codes in the I-9

Copyright © 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 8 Observation Stay Categories Z03 and Z04Categories Z03 and Z04 Pt admitted to observation statusPt admitted to observation status –Report Z code as first-listed for DX stated as suspected /rule out conditions –If DX made, report DX as first-listed

Copyright © 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 9 Coexisting Conditions If condition are present and affect pt care or is treated—report as coexisting conditionIf condition are present and affect pt care or is treated—report as coexisting condition –Example, pt presents with SOB due to asthma. Physician prescribes nebulizer treatments. Pt is morbidly obese making examination and treatment more complex. –First-listed: (asthma); –Coexisting Condition: (obesity)

Copyright © 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 10 Uncertain DX Inpatient report uncertain DX as if existsInpatient report uncertain DX as if exists –Probable, suspected, questionable, rule out, working DX, etc. Outpatient report symptoms, signs, abnormal test results, or other reason for encounterOutpatient report symptoms, signs, abnormal test results, or other reason for encounter

Copyright © 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 11 Chronic Diseases Chronic conditions are treated on ongoing basisChronic conditions are treated on ongoing basis Report condition as many times as pt receives care or treatment for conditionReport condition as many times as pt receives care or treatment for condition Do not report conditions that were previously treated and no longer existDo not report conditions that were previously treated and no longer exist –Report history codes (Z80-Z87) as secondary DX is condition impacts current condition or affects treatment

Copyright © 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 12 Diagnostic Services Only diagnostic service provided, report first reason for serviceOnly diagnostic service provided, report first reason for service –Example: Pt presents for routine, periodic gynecological exam, report Z No signs, symptoms, or associated diagnosisNo signs, symptoms, or associated diagnosis –Example: Pt presents for diagnostic imaging for left, central breast mass, report N63, unspecified breast lump Later DX: Malignant neoplasm, report C50.112Later DX: Malignant neoplasm, report C50.112

Copyright © 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 13 Therapeutic Services Pt receiving only therapeutic service, report reason for encounterPt receiving only therapeutic service, report reason for encounter –Example: Outpatient chemotherapy for right breast cancer, report Z51.11 (chemo) and C (malignant neoplasm, right breast)

Copyright © 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 14 Preoperative Evaluation First-listed code is preop examFirst-listed code is preop exam –Subcategory Z01.81 code (encounter for pre-procedural exam) Z Preop cardiovascular examZ Preop cardiovascular exam Z Preop respiratory examZ Preop respiratory exam Z Preop labZ Preop lab Z Preop exam, NOS exam before chemoZ Preop exam, NOS exam before chemo Additional code, reason for surgeryAdditional code, reason for surgery

Copyright © 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 15 Pre/Postoperative DX Report most definitive DXReport most definitive DX Usually postoperative DXUsually postoperative DX

Copyright © 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 16 Prenatal Encounters Routine outpatient prenatal encounters with no complications, report category Z34, supervision of routine pregnancyRoutine outpatient prenatal encounters with no complications, report category Z34, supervision of routine pregnancy –Example: 19-year-old female presents for initial prenatal exam, first pregnancy, Z34.00 Prenatal encounters for high-risk patients report as first-listed a O09 (supervision of high-risk pregnancy)Prenatal encounters for high-risk patients report as first-listed a O09 (supervision of high-risk pregnancy) –Example: 29-year-old first trimester female patient presents for prenatal encounter with varicose veins of legs, O22.01

Copyright © 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 17 Conclusion CHAPTER 8 ICD-10-CM OUTPATIENT CODING AND REPORTING GUIDELINES