2 LEARNING OUTCOMES After studying this chapter, you should be able to: 5-2LEARNING OUTCOMESAfter studying this chapter, you should be able to:1. Define the outpatient settings to which Section IV of the Official Guidelinesapplies.2. Define the term first-listed diagnosis as it relates to the outpatient setting.3. Apply diagnosis code sequencing rules for a variety of outpatientencounters, such as outpatient procedures/ambulatory surgeries,observation stays, and encounters for circumstances other than diseaseor injury.4. Compare and contrast coding for uncertain conditions in the outpatientand inpatient setting.5. Understand how chronic diseases are coded in the outpatient setting.
3 LEARNING OUTCOMES (cont’d) 5-3LEARNING OUTCOMES (cont’d)6. Apply ICD-9-CM coding guidelines to outpatient visits when patientsreceive only diagnostic services, therapeutic services, or preoperativeexaminations.7. Apply outpatient coding guidelines for emergency rooms visits.8. Understand the coding and sequencing guidelines for routine outpatientprenatal visits.9. Understand guidelines regarding reporting of additional diagnoses and Ecodes in the outpatient setting.Based on diagnostic statements, correctly assign diagnosis codes forthe outpatient setting.
4 KEY TERMS Ambulatory Payment Classifications (APC) ambulatory surgery 5-4KEY TERMSAmbulatory Payment Classifications (APC)ambulatory surgerycoexisting conditioncontraindicationfirst-listed diagnosisfreestanding facilityhistory codeshospital-based outpatient serviceshospital-based facilityOPPS APC status indicatorsoutpatient procedureOutpatient Prospective Payment System (OPPS)Patient’s Reason for Visittherapeutic servicesunscheduled outpatient visitvisit
5 Basic Coding Guidelines for Outpatient Settings 5-5Basic Coding Guidelines for Outpatient SettingsOutpatient diagnostic coding differs from inpatient coding in two ways:the definition of principal diagnosisthe coding of inconclusive diagnosesThe definition of principal diagnosis –the diagnosis arrived at after study – in the UHDDS does not apply in any outpatient setting.Inconclusive conditions – those that are documented as possible, probable, or suspected – are not assigned codes in outpatient settings.
6 DEFINITION OF OUTPATIENT VISITS 5-6DEFINITION OF OUTPATIENT VISITSSection IV Official Guidelines apply only to outpatient visits; it is important to understand that an outpatient visit or encounter – the terms are used interchangeably – is one in which the patient is not formally admitted to a facility.
7 DEFINITION OF OUTPATIENT VISITS (cont’d) 5-7DEFINITION OF OUTPATIENT VISITS (cont’d)Hospital-based facility outpatient services are the responsibility of the hospital-based facilityThey take place in the ER, ambulatory surgery units, observation units, clinics (a distinct part of a facility or a separate facility used only for outpatient physician services), specialized physical therapy units, cardiac cath unitsFreestanding facility provides services to an outpatient who is not the responsibility of the hospital.Such as doctors’ offices, public health clinics, and urgent care centers
8 DEFINITION OF OUTPATIENT VISITS (cont’d) 5-8DEFINITION OF OUTPATIENT VISITS (cont’d)IMPORTANT!Do not use ICD-9-CM Volume 3 for Outpatient CodingHIPPA mandates the use of CPT codes, rather than ICD-9-CM Volume 3 codes, for procedural reporting in the outpatient setting
9 GUIDELINES FOR CODE SELECTION 5-9GUIDELINES FOR CODE SELECTIONOutpatient Code Assignment Flow ChartStep 1: Review the complete outpatient documentationStep 2: Abstract the confirmed diagnoses to be codedbased on documentationStep 3: Assign the correct ICD-9-CM diagnosis codes,following the ICD-9-CM rules and conventions.Step 4: Sequence the codes based on Section IV of theICD-9-CM Official Guidelines.
10 SELECTION OF FIRST-LISTED DIAGNOSIS 5-10SELECTION OF FIRST-LISTED DIAGNOSISIf just one diagnosis is provided, the code for that condition is reported.If a definite condition is not documented, the code for the patient’s chief complaint is reported.If multiple diagnoses can be assigned as the reasons for the encounter, all are coded.
11 SELECTION OF FIRST-LISTED DIAGNOSIS 5-11SELECTION OF FIRST-LISTED DIAGNOSISSpecific Guidelines apply for determining first-listed diagnosis codes for the following outpatient services: Outpatient procedures and ambulatory surgery; observation services; diagnostic services; therapeutic services, preoperative evaluations; routine outpatient prenatal care; uncertain diagnosis; emergency department visits.
12 SELECTION OF FIRST-LISTED DIAGNOSIS (cont’d) 5-12SELECTION OF FIRST-LISTED DIAGNOSIS (cont’d)Outpatient Procedures and Ambulatory SurgeryWhen a patient presents for an outpatient procedure or ambulatory surgery, the reason for the procedure or surgery is the first-listed diagnosis, unless the preoperative diagnosis and the postoperative diagnosis are different. If this happens, then the postoperative diagnosis is coded.Observation StayGuidelines state that when a patient is admitted for observation due to a medical condition, a code for that medical condition should be the first-listed diagnosis.
13 SELECTION OF FIRST-LISTED DIAGNOSIS (cont’d) 5-13SELECTION OF FIRST-LISTED DIAGNOSIS (cont’d)Outpatient Procedures and Ambulatory Surgery Flow ChartStep 1: Review documentation for pre/post-operativediagnoses.Step 2: Code the definitive diagnosis.Step 3: Determine if procedure/surgery was completedYES = Go to Step 4NO = Go to Step 3aStep 3a: Assign additional code(s) for (1) reason forcancellation, and (2) contraindication/complicationStep 4: Code any coexisting or chronic conditions that affect care during the visit.
14 SELECTION OF FIRST-LISTED DIAGNOSIS (cont’d) 5-14SELECTION OF FIRST-LISTED DIAGNOSIS (cont’d)Diagnostic ServicesFor diagnostic services, the first-listed code is the diagnosis, condition, problem, or other reason shown in the medical record to be chiefly responsible for the diagnostic services provided during the encounter. Codes for other diagnoses may be sequenced as additional codes.Therapeutic ServicesPatients may receive only therapeutic services – the many procedures done to treat conditions and injuries – during outpatient visits. For these visits, as for diagnostic services, the ICD-9-CM code reported first represents the diagnosis, condition, problem, or other reason for the encounter that the medical record shows is chiefly responsible for the outpatient services provided.
15 SELECTION OF FIRST-LISTED DIAGNOSIS (cont’d) 5-15SELECTION OF FIRST-LISTED DIAGNOSIS (cont’d)Preoperative EvaluationsWhen a patient receives a preoperative evaluation only, a code from category V72.8 (other specified examinations) is sequenced first.Routine Outpatient Prenatal VisitsThe guideline for prenatal visits applies when the prenatal visit occurs and the patient has no complications present. Under these circumstances, the first-listed diagnosis is reported V22.0, supervision of normal first pregnancy, or V22.1, supervision of other normal pregnancy; for complication of pregnancy, the above codes are not reported.
16 SELECTION OF FIRST-LISTED DIAGNOSIS (cont’d) 5-16SELECTION OF FIRST-LISTED DIAGNOSIS (cont’d)Uncertain DiagnosesIn the outpatient setting, uncertain diagnoses – those documented as probable, suspected, questionable, rule out, or working diagnoses – are not coded. Only the condition to the highest degree of certainty for that visit is assigned a code. The code may represent a symptom, sign, abnormal test result, or other reason for the visit.Emergency Department VisitsThe guidelines for first-listed diagnosis apply to ED visits. The first-listed diagnosis is the diagnosis, condition, problem, or other reason for the encounter shown in the medical record to be chiefly responsible for the services provided. However, ED visits are unscheduled outpatient visits.
17 Reporting Secondary Diagnoses and E Codes in Outpatient Settings 5-17Reporting Secondary Diagnoses and E Codes in Outpatient SettingsNot only must the coder identify the first-listed diagnosis for an outpatient visit, but other diagnoses (secondary diagnoses) should also be reported as appropriate.Chronic DiseasesChronic diseases that are treated on an ongoing basis may be coded and reported as many times as the patient received treatment and care for them.Coexisting ConditionsAll documented conditions that coexist at the time of the encounter and require or affect patient care, treatment, or management should be coded. Conditions that were previously treated and not longer exist or no longer affect treatment or patient management should not be reported.
18 5-18Reporting Secondary Diagnoses and E Codes in Outpatient Settings (cont’d)E CodesIn the facility outpatient setting E Codes are strongly suggest; if the situation involves adverse effect of drugs and medicines in therapeutic use, they are mandatory.
19 Table 5.2 Comparison of Coding, Billing, and Payment Schedule 5-19Table 5.2 Comparison of Coding, Billing, and Payment ScheduleHospital InpatientHospital OutpatientAll Physician ServicesDiagnosis CodesICD-9-CME CodesRequiredOptionalProcedure CodesCPT/HCPCSBilling Form8371 or UB-04837P or CMS-1500Medicare PaymentDiagnosis Related Group (DRG)Ambulatory Payment Classification (APC)Resource Based Relative Value Scale (RBRVS)