1. Medical Coding
Chapter 3

2. ICD-9-CM OUTPATIENT CODING AND REPORTING GUIDELINES
CHAPTER 3
ICD-9-CM OUTPATIENT CODING AND REPORTING GUIDELINES
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3. Section IV Diagnostic Coding
Physician’s office
Hospital-based outpatient services
Part of Official Guidelines for Coding and Reporting, Section IV
Outpatient guidelines do not address specific sequencing or diseases as inpatient guidelines do.
Follow the inpatient coding guidelines in situations in which there are no clear outpatient coding guidelines.
In the outpatient setting, the term “first-listed diagnosis [primary]” is used instead of “principal diagnosis.”
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4. Section IV Diagnostic Coding
Guidelines do not address specific sequencing or diseases as inpatient do
Though not stated, if there is no outpatient guideline, follow inpatient guidelines
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5. Diagnostic Coding Guideline A
Term first-listed diagnosis, rather than principal diagnosis
Outpatient Surgery: Reason for surgery
Even if surgery is cancelled due to contraindication
Primary diagnosis is synonymous with first-listed diagnosis.
Either term can replace the term principle diagnosis.
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6. Diagnostic Coding Guideline A
Observation Stay: Medical condition that occasioned admission
Assign a code from medical condition
Observation Stay: Complications from outpatient surgery lead to observation report:
Reason for surgery as first reported diagnosis
Codes for complications necessitating observation
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7. Selection of First-Listed Diagnosis
Condition for encounter
Why patient presented, not necessarily most serious condition noted
Documented
Chiefly responsible for services provided
Also list co-existing conditions
In an outpatient setting, coders should indicate the main reason for the visit as the primary diagnosis, as well as subsequent diagnoses to substantiate other services provided, such as laboratory or radiology.
Sequence the primary diagnosis first.
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8. Diagnosis and Services
Diagnosis and procedure MUST correlate
Medical necessity must be established through documentation
No correlation = No reimbursement
What is the reason for the use of ICD-9 codes? (They establish medical necessity for the documentation.)
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9. Symptoms, Signs, and Ill-Defined Conditions
Can be the first-listed diagnosis if no more specific diagnosis available
Diagnoses often are not established at the time of the initial encounter/visit
Codes that describe symptoms and signs, as opposed to diagnoses, are acceptable for reporting purposes when the physician has not confirmed an established diagnosis.
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10. Diagnostic Coding Guideline B
Use codes through V91.99 to code:
Diagnosis
Symptoms
Conditions
Problems
Complaints
Or other reason(s) for visit
You will use all different codes from to V86.1.
Many clinics are specialized so you may use some codes more than others but it is important to be familiar with all.
If your facility is more specialized (cardiology), other than family practice, you may only use a minimum of diagnosis codes, but if you follow the guidelines, you would be able to properly code any diagnosis.
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11. Diagnostic Guideline C
Documentation should describe patient's condition, using terminology that includes:
Specific diagnoses
Symptoms
Problems
Reasons for encounter
There are ICD-9-CM codes to describe all of these items.
If no specific diagnosis is given by the physician what should you code as the diagnosis? (the symptoms the patient came in with or the reason for the encounter)
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12. Diagnostic Guideline D
Selection of codes through (Chapters 1-17) frequently used to describe reason for encounter
These codes are from the section of ICD-9-CM for the classification of disease and injuries.
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13. Diagnostic Guideline E
Codes that describe symptoms and signs, as opposed to diagnoses, acceptable for reporting purposes when
An established diagnosis has NOT been determined by physician
Chapter 16 contains many, but not all, codes for symptoms.
This is the chapter that you would refer to when there is no definitive diagnosis given.
These codes would still be referenced in the index prior to the tabular section of your coding book.
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14. Diagnostic Guideline F
V codes deal with encounters for circumstances other than disease or injury
Example: Well-baby checkup
See Section I.C.18 for information on V codes
Encounters for reasons other than a disease or injury.
These have been discussed earlier. What are some other encounters that would be coded with V codes? (postoperative visit, immunization only, birth control counseling)
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15. V01-V91 Assigned as first-listed diagnosis for:
Section I.C.18. Classification of Factors Influencing Health Status and Contact with Health Service
V01-V91
Assigned as first-listed diagnosis for:
Admissions for evaluation
Following an accident that would ordinarily result in health problem, BUT there is none
Car accident, driver hits head, no apparent injury, admit to R/O head trauma
Never a secondary diagnosis
There are four primary circumstances for the use of V codes:
When a person who is not sick obtains health services, such as vaccination, health screening, or testing to act as an organ donor.
When a person with a resolving disease or injury or a chronic condition requiring continuous care receives specific aftercare.
When circumstances or problems influence a person’s health status but are not in themselves a current illness or injury.
For newborns, to indicate birth status.
Can be a first-listed or a secondary code, depending on the circumstances of the encounter.
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16. Located after 999.9 in Tabular
V Codes
Located after in Tabular
Two digits before decimal (e.g., V10.1X)
Index for V codes is Alphabetic Index to Diseases
Main terms:
Contraception
Counseling
Dialysis
Status
Examination
V codes can be located in the Index, similar to any other code.
Where is the V code index listed? (The V codes are enclosed in the main index of CPT.)
Like other diagnosis codes you would find the main term that you are looking for in the Alphabetical Index.
What are some main terms of V codes? (Status (post), absence, history of, Counseling)
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17. Not sick BUT receives health care (e.g., vaccination)
Uses of V Codes
Not sick BUT receives health care (e.g., vaccination)
Services for known/resolving disease/injury (e.g., chemotherapy)
Codes for “aftercare” (e.g., surgery or fracture)
Indicate birth status/outcome of delivery
• There are four uses of V codes:
When a patient isn’t currently sick but needs to go to the doctor. What would be an example of this? (When a child goes in for immunizations only.)
A patient with a known disease who receives health services. What would be an example of this? (A patient who is receiving radiation therapy.)
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18. Section I.C.18.e. of Guidelines contains the V Code Table
Uses of V Codes
A circumstance/problem that influences patient’s health BUT NOT current illness/injury
Example: Organ transplant status
Example: Birth status and outcome of delivery (newborn)
Section I.C.18.e. of Guidelines contains the V Code Table
Identifies if V code can be listed as first, first/additional, additional only
When there is not a current illness or injury. What would be an example of this? (Patient is status post a procedure)
To indicate birth status or outcome of surgery. What would be an example of this? (Outcome of delivery)
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19. History V Code Categories in Tabular
V10 Personal history of malignant neoplasm
V11 Personal history of mental illness
V12 Personal history of certain other diseases
V13 Personal history of other diseases
V14 Personal history of allergy to medicinal agents
V15 Other personal history presenting hazards to health
V16 Family history of malignant neoplasm
V17 Family history of certain chronic disabling diseases
V18 Family history of certain other specific diseases
V19 Family history of other conditions
Condition no longer present or treated
“History of” codes are separated by whether it is personal history or family history.
Are there only “History of” neoplasm codes? (No)
What other “History of” codes are there? (ASHD, asthma, gout, mental disorders)
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20. Diagnostic Guideline G
Codes have either 3, 4, or 5 digits
4 and/or 5 digit codes provide greater specificity (detail)
Codes with three digits are included as the heading for a category of codes.
Never code a three digit code if it requires a fourth or fifth digit.
Why should you never code a three digit code if forth or fifth digits are required for that code? (You should always code to the greatest level of specificity. This would also, ultimately, be denied by the third party payer as an incorrect diagnosis and delay reimbursement.)
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21. Diagnostic Guideline G
3-digit code used ONLY if no 4 or 5 digit
Where 4 and/or 5 digits provided, must be assigned
Diagnoses NOT coded to full digits available invalid
Claims bounce!
A three-digit code is to be used only if it is not further subdivided.
A three-digit code has the heading of a category code (example: 462).
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22. Diagnostic Guideline H
List first code for diagnosis, condition, problem, or other reason for encounter/visit shown in medical record to be chiefly responsible for services provided
List additional codes that describe any coexisting conditions
Assign V72.5 and/or V72.6x for routine lab/radiology test ordered without signs, symptoms, or associated diagnosis
List first the reason for the encounter and then any coexisting conditions.
A patient comes into the clinic and his or her chief complaint is a severe cough for greater than a week. Associated signs and symptoms are extreme fatigue and sore throat. No definitive diagnosis is given. Which symptom would be the first coded, as it was the main reason the patient came into the clinic? (Cough) What would be the coexisting conditions? (fatigue and sore throat)
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23. Diagnostic Guideline I
Do NOT code diagnoses documented as probable, suspected, questionable, rule out, or working diagnoses
Rather, code condition(s) to suspected highest degree of certainty for that encounter/visit, such as symptoms, signs, abnormal test results, or other reason for visit
Note that this differs from the coding practices used by hospital medical record departments for coding the diagnosis of acute care, short-term hospital inpatients.
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24. Diagnostic Guideline J
Chronic diseases treated on an ongoing basis may be coded and reported as many times as patient receives treatment and care for condition(s)
A patient who has a chronic disease and is seen at the physician’s office multiple times, the same diagnosis can be used for each encounter.
What might be some examples of this? (Hypertension, Diabetes, Arteriosclerotic heart disease, Asthma, COPD)
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25. Diagnostic Guideline K
Code all documented conditions that coexist at time of visit, that require or affect patient care, treatment, or management
Do NOT code conditions previously treated, no longer existing
All diagnoses that co-exist with primary diagnosis should be coded.
If a patient was previously diagnosed with pneumonia, and now the patient comes into the clinic for an asthma check, and the physician lists in his assessment that they are status post pneumonia, but they no longer have symptoms or are being treated, would the pneumonia be coded out as a diagnosis? Why or why not? (No because even though pneumonia pertains to the lung and the patient is in for an asthma check, the patient no longer has pneumonia or is being treated for it so this should not be coded)
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26. Diagnostic Guideline K
“History of” codes (V10-V19) may be used as secondary codes if:
Impacts current care or treatment
What are some examples of situations that would require use of a history code? (Personal history of malignant neoplasm or Personal history of allergy. Family history of malignant neoplasm or Family history of certain chronic disabling diseases.)
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27. Special Note About “History of”
Index to Disease, MAIN term “History”
Entries between “family” and “visual loss V19.0” = “family history of” (FHO)
Entries before “family” and after “visual loss” = “personal history of” (PHO)
Personal history = V10-V15
Family history = V16-V19
If the patient record states that there is a “history of” a disease, such as diabetes, it does not mean that the patient no longer has the disease; but that the patient’s medical history includes the disease.
A V code is not assigned to indicate a previous history of diabetes; rather, the code for the current disease (250.0X) is used.
Ask students to use a highlighter and mark their Index where family history begins and ends.
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28. Diagnostic Guidelines L and M
For patients receiving diagnostic services ONLY
Sequence first
Diagnosis
Condition
Problem OR
Other reason shown in medical record to be chiefly responsible for encounter
Do not code related signs and symptoms as additional diagnoses.
How does this coding guideline differ from the inpatient guideline? (In the outpatient setting, related signs and symptoms are not coded as additional diagnoses. In the inpatient setting, abnormal findings on test results are coded.)
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29. Diagnostic Guidelines L and M
Codes for other diagnoses (e.g., chronic conditions)
May be sequenced as secondary diagnoses
Exception: Therapeutic Services
Patients receiving chemotherapy (V58.11), radiation therapy (V58.0), or rehabilitation (V57.0-V57.9)
V code first diagnosis and problem for which service being performed second
For outpatient encounters for diagnostic tests that have been interpreted by a physician with the final report available at the time of coding, code any documented confirmed or definitive diagnoses.
Diagnosis is listed second only when the patient is receiving chemotherapy, radiation therapy, or rehabilitation when the V code must be listed first.
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30. Diagnostic Guideline N
For patients receiving preoperative evaluations ONLY
Code from category V72.8 (Other specified examinations)
Assign secondary code for reason for surgery
Code also any findings related to preoperative evaluation
A patient receiving only a preoperative evaluation should first be coded with a code from the V72.8 category.
The secondary code would be the reason the patient is having the procedure or surgery.
If the patient was found to have a fever on the preoperative evaluation, should this be coded for this visit? (Yes, because it was found on evaluation and may require further looking into, or delay the procedure or surgery.)
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31. Diagnostic Guideline O, Ambulatory Surgery
Code diagnosis which required ambulatory surgery
Pre- and post-op diagnosis different
Code the post-op diagnosis
The postoperative diagnosis is the most definitive.
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32. Diagnostic Guideline P
Code routine prenatal visits with no complications:
V22.0 (Supervision of normal first pregnancy)
V22.1 (Supervision of other normal pregnancy)
DO NOT use these codes with pregnancy complication codes (Chapter 11, ICD-9-CM)
Routine outpatient prenatal visits with no complications are coded with V22.0.
A normal first pregnancy is V22.1.
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33. V91 Multiple Gestation Placenta Status
New in 2011
Identifies twins, triplets, quadruplets, other multiples

34. ICD-9-CM OUTPATIENT CODING AND REPORTING GUIDELINES
Conclusion CHAPTER 3
ICD-9-CM OUTPATIENT CODING AND REPORTING GUIDELINES