medical coding chapter 3. chapter 3 icd-9-cm outpatient coding and reporting guidelines

Medical Coding Chapter 3

CHAPTER 3CHAPTER 3ICD-9-CM OUTPATIENT CODING AND REPORTING GUIDELINES

Section IV Diagnostic CodingSection IV Diagnostic Coding

● Physician’s office● Hospital-based outpatient services● Part of Official Guidelines for Coding and Reporting,

Section IV

Section IV Diagnostic CodingSection 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

Diagnostic Coding Guideline ADiagnostic Coding Guideline A

● Term first-listed diagnosis, rather than principal diagnosis● Outpatient Surgery: Reason for surgery

– Even if surgery is cancelled due to contraindication

Diagnostic Coding Guideline ADiagnostic 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

Selection of First-Listed DiagnosisSelection 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

Diagnosis and ServicesDiagnosis and Services

● Diagnosis and procedure MUST correlate● Medical necessity must be established through

documentation● No correlation = No reimbursement

Symptoms, Signs, and Ill-Defined Conditions

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

Diagnostic Coding Guideline BDiagnostic Coding Guideline B

● Use codes 001.0 through V91.99 to code: – Diagnosis– Symptoms– Conditions– Problems– Complaints– Or other reason(s) for visit

Diagnostic Guideline CDiagnostic Guideline C

● Documentation should describe patient's condition, using terminology that includes:– Specific diagnoses – Symptoms– Problems– Reasons for encounter

Diagnostic Guideline DDiagnostic Guideline D

● Selection of codes 001.0 through 999.9 (Chapters 1-17) frequently used to describe reason for encounter

Diagnostic Guideline EDiagnostic 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

Diagnostic Guideline FDiagnostic 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 onV codes

Section I.C.18. Classification of Factors Influencing Health Status and Contact with Health Service

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

V CodesV Codes

● Located after 999.9 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

Uses of V CodesUses 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

Uses of V CodesUses 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

History V Code Categories in Tabular

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 conditionsCondition no longer present or treated

Diagnostic Guideline GDiagnostic Guideline G

● Codes have either 3, 4, or 5 digits● 4 and/or 5 digit codes provide greater

specificity (detail)

Diagnostic Guideline GDiagnostic 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!

Diagnostic Guideline HDiagnostic 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

Diagnostic Guideline IDiagnostic 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

Diagnostic Guideline JDiagnostic 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)

Diagnostic Guideline KDiagnostic 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

Diagnostic Guideline KDiagnostic Guideline K

● “History of” codes (V10-V19) may be used as secondary codes if:– Impacts current care or treatment

Special Note About “History of”

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

Diagnostic Guidelines L and MDiagnostic 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

Diagnostic Guidelines L and MDiagnostic 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

Diagnostic Guideline NDiagnostic 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

Diagnostic Guideline O, Ambulatory Surgery

Diagnostic Guideline O, Ambulatory Surgery

● Code diagnosis which required ambulatory surgery● Pre- and post-op diagnosis different

– Code the post-op diagnosis

Diagnostic Guideline PDiagnostic 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)

V91 Multiple Gestation Placenta StatusV91 Multiple Gestation Placenta Status

● New in 2011● Identifies twins, triplets, quadruplets, other multiples

ConclusionCHAPTER 3Conclusion

CHAPTER 3ICD-9-CM OUTPATIENT CODING AND REPORTING GUIDELINES