1. © 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

2. © 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

3. © 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

4. © 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

5. © 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

6. © 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

7. © 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

8. © 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)

9. © 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

10. © 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

11. © 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

12. © 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

13. © 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: 001.0-V89 ICD-10-CM: A00-T88, Z00-Z99 (continued)

14. © 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

15. © 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)

16. © 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)

17. © 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

18. © 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)

19. © 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

20. © 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