ICD-9-CM and ICD-10-CM Outpatient and Physician Office Coding Chapter 6 ICD-9-CM and ICD-10-CM Outpatient and Physician Office Coding

Outpatient Care (Ambulatory Care) Primary care Point of first contact Primary care provider

Medical Specialties Allergy and immunology Anesthesiology Colon and rectal surgery Dermatology Family practice General surgery Gynecology

Internal Medicine Sub-specialties Adolescent medicine Cardiovascular medicine Critical care medicine Electrophysiology Endocrinology Gastroenterology

Internal Medicine Subspecialties Geriatrics Hematology Immunology Infectious disease Nephrology Oncology Pulmonary medicine Rheumatology Sports medicine

Medical Specialties Medical genetics Neurology Obstetrics Ophthalmology Orthopedics Otorhinolaryngology Plastic and reconstructive surgery Psychiatry Radiology Thoracic surgery Urology

Hospital Outpatient Services Ambulatory patients (outpatients) Ambulatory surgery patients Emergency care patients Observation patients

Freestanding Ambulatory Care Facilities Ambulatory surgical center Cardiovascular center Clinical laboratory Imaging center Industrial health clinic Infusion center Neighborhood health center (continued)

Freestanding Ambulatory Care Facilities Pain management center Physician office Primary care center Public health department Radiology center Rehabilitation facility

Other Ambulatory Care Facilities Staff model health maintenance organization Student health center Urgent care center

Hospital-Based Departments Ambulatory surgery Outpatient department Emergency department Partial hospitalization program

Hospital-Owned Facilities Hospital-owned physician practice Satellite clinics

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)

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

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)

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)

Outpatient Coding Guidelines Encounter for diagnostic services Encounter for therapeutic services Encounter for preoperative evaluations Ambulatory surgery Routine outpatient prenatal visits

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)

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

Outpatient Surgery Code reason for surgery as first-listed diagnosis Even if surgery cancelled due to contraindication