Copyright © 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. CHAPTER 3 OUTPATIENT CODING AND REPORTING GUIDELINES

2 Copyright © 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Section IV Diagnostic Coding Physician’s officePhysician’s office Hospital-based outpatient servicesHospital-based outpatient services Part of Official Guidelines for Coding and Reporting, Section IVPart of Official Guidelines for Coding and Reporting, Section IV

3 Copyright © 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Section IV Diagnostic Coding Guidelines do not address specific sequencing or diseases as inpatient doGuidelines do not address specific sequencing or diseases as inpatient do Though not stated, if there is no outpatient guideline, follow inpatient guidelinesThough not stated, if there is no outpatient guideline, follow inpatient guidelines

4 Copyright © 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Diagnostic Coding Guideline A Term first-listed diagnosis, rather than principal diagnosisTerm first-listed diagnosis, rather than principal diagnosis Outpatient Surgery: Reason for surgeryOutpatient Surgery: Reason for surgery –Even if surgery is cancelled due to contraindication

5 Copyright © 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Diagnostic Coding Guideline A Observation Stay: Medical condition that occasioned admissionObservation Stay: Medical condition that occasioned admission –Assign a code from medical condition Observation Stay: Complications from outpatient surgery lead to observation report:Observation Stay: Complications from outpatient surgery lead to observation report: Reason for surgery as first reported diagnosisReason for surgery as first reported diagnosis Codes for complications necessitating observationCodes for complications necessitating observation

6 Copyright © 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Selection of First-Listed Diagnosis Condition for encounterCondition for encounter –Why patient presented, not necessarily most serious condition noted DocumentedDocumented Chiefly responsible for services providedChiefly responsible for services provided Also list co-existing conditionsAlso list co-existing conditions

7 Copyright © 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Diagnosis and Services Diagnosis and procedure MUST correlateDiagnosis and procedure MUST correlate Medical necessity must be established through documentationMedical necessity must be established through documentation No correlation = No reimbursementNo correlation = No reimbursement

8 Copyright © 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Symptoms, Signs, and Ill- Defined Conditions Can be the first-listed diagnosis if no more specific diagnosis availableCan be the first-listed diagnosis if no more specific diagnosis available Diagnoses often are not established at the time of the initial encounter/visitDiagnoses often are not established at the time of the initial encounter/visit

9 Copyright © 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Diagnostic Coding Guideline B Use codes through V89.09 to code:Use codes through V89.09 to code: –Diagnosis –Symptoms –Conditions –Problems –Complaints –Or other reason(s) for visit

10 Copyright © 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Diagnostic Guideline C Documentation should describe patient's condition, using terminology that includes:Documentation should describe patient's condition, using terminology that includes: –Specific diagnoses –Symptoms –Problems –Reasons for encounter

11 Copyright © 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Diagnostic Guideline D Selection of codes through (Chapters 1-17) frequently used to describe reason for encounterSelection of codes through (Chapters 1-17) frequently used to describe reason for encounter

12 Copyright © 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Diagnostic Guideline E Codes that describe symptoms and signs, as opposed to diagnoses, acceptable for reporting purposes whenCodes that describe symptoms and signs, as opposed to diagnoses, acceptable for reporting purposes when –An established diagnosis has NOT been determined by physician

13 Copyright © 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Diagnostic Guideline F V codes deal with encounters for circumstances other than disease or injuryV codes deal with encounters for circumstances other than disease or injury –Example: Well-baby checkup See Section I.C.18 for information on V codesSee Section I.C.18 for information on V codes

14 Copyright © 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Section I.C.18. Classification of Factors Influencing Health Status and Contact with Health Service V01-V89.09V01-V89.09 –Assigned as first-listed diagnosis for: Admissions for evaluationAdmissions for evaluation Following an accident that would ordinarily result in health problem, BUT there is noneFollowing 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

15 Copyright © 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. V Codes Located after in TabularLocated after in Tabular Two digits before decimal (e.g., V10.1X)Two digits before decimal (e.g., V10.1X) Index for V codes is Alphabetic Index to DiseasesIndex for V codes is Alphabetic Index to Diseases Main terms:Main terms: –Contraception –Counseling –Dialysis –Status –Examination

16 Copyright © 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Uses of V Codes Not sick BUT receives health care (e.g., vaccination)Not sick BUT receives health care (e.g., vaccination) Services for known/resolving disease/injury (e.g., chemotherapy)Services for known/resolving disease/injury (e.g., chemotherapy) Codes for “aftercare” (e.g., surgery or fracture)Codes for “aftercare” (e.g., surgery or fracture) Indicate birth status/outcome of deliveryIndicate birth status/outcome of delivery(Cont’d…)

17 Copyright © 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Uses of V Codes (…Cont’d) A circumstance/problem that influences patient’s health BUT NOT current illness/injuryA 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.18.e. of Guidelines contains the V Code TableSection I.18.e. of Guidelines contains the V Code Table –Identifies if V code can be listed as first, first/additional, additional only

18 Copyright © 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. History V Code Categories in Tabular V10 Personal history of malignant neoplasmV10 Personal history of malignant neoplasm V12 Personal history of certain other diseasesV12 Personal history of certain other diseases V13 Personal history of other diseasesV13 Personal history of other diseases V14 Personal history of allergy to medicinal agentsV14 Personal history of allergy to medicinal agents V15 Other personal history presenting hazards to healthV15 Other personal history presenting hazards to health V16 Family history of malignant neoplasmV16 Family history of malignant neoplasm V17 Family history of certain chronic disabling diseasesV17 Family history of certain chronic disabling diseases V18 Family history of certain other specific diseasesV18 Family history of certain other specific diseases V19 Family history of other conditionsV19 Family history of other conditions Condition no longer present or treated

19 Copyright © 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Diagnostic Guideline G Codes have either 3, 4, or 5 digitsCodes have either 3, 4, or 5 digits 4 and/or 5 digit codes provide greater specificity (detail)4 and/or 5 digit codes provide greater specificity (detail)(Cont’d…)

20 Copyright © 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Diagnostic Guideline G (…Cont’d) 3-digit code used ONLY if no 4 or 5 digit3-digit code used ONLY if no 4 or 5 digit Where 4 and/or 5 digits provided, must be assignedWhere 4 and/or 5 digits provided, must be assigned Diagnoses NOT coded to full digits available invalidDiagnoses NOT coded to full digits available invalid Claims bounce!Claims bounce!

21 Copyright © 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. 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 providedList 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 conditionsList 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 diagnosisAssign V72.5 and/or V72.6x for routine lab/radiology test ordered without signs, symptoms, or associated diagnosis

22 Copyright © 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Diagnostic Guideline I Do NOT code diagnoses documented as probable, suspected, questionable, rule out, or working diagnosesDo 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 visitRather, 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

23 Copyright © 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. 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)Chronic diseases treated on an ongoing basis may be coded and reported as many times as patient receives treatment and care for condition(s)

24 Copyright © 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Diagnostic Guideline K Code all documented conditions that coexist at time of visit, that require or affect patient care, treatment, or managementCode 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 existingDo NOT code conditions previously treated, no longer existing(Cont’d…)

25 Copyright © 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Diagnostic Guideline K (…Cont’d) “History of” codes (V10-V19) may be used as secondary codes if:“History of” codes (V10-V19) may be used as secondary codes if: –Impacts current care or treatment

26 Copyright © 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Special Note About “History of” Special Note About “History of” Index to Disease, MAIN term “History”Index to Disease, MAIN term “History” Entries between “family” and “visual loss V19.0” = “family history of” (FHO)Entries between “family” and “visual loss V19.0” = “family history of” (FHO) Entries before “family” and after “visual loss” = “personal history of” (PHO)Entries before “family” and after “visual loss” = “personal history of” (PHO) Personal history = V10-V15Personal history = V10-V15 Family history = V16 –V19Family history = V16 –V19

27 Copyright © 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Diagnostic Guidelines L and M For patients receiving diagnostic services ONLYFor patients receiving diagnostic services ONLY Sequence firstSequence first –Diagnosis –Condition –Problem OR –Other reason shown in medical record to be chiefly responsible for encounter (…Cont’d)

28 Copyright © 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Diagnostic Guidelines L and M (…Cont’d) Codes for other diagnoses (e.g., chronic conditions)Codes for other diagnoses (e.g., chronic conditions) –May be sequenced as secondary diagnoses Exception: Therapeutic ServicesException: 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

29 Copyright © 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Diagnostic Guideline N For patients receiving preoperative evaluations ONLYFor 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

30 Copyright © 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Diagnostic Guideline O, Ambulatory Surgery Code diagnosis which required ambulatory surgeryCode diagnosis which required ambulatory surgery Pre- and post-op diagnosis differentPre- and post-op diagnosis different –Code the post-op diagnosis

31 Copyright © 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Diagnostic Guideline P Code routine prenatal visits with no complications: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)

Copyright © 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Conclusion CHAPTER 3 OUTPATIENT CODING AND REPORTING GUIDELINES