1. 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

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

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

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

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

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

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

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

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

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

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

12. Hospital-Owned Facilities
Hospital-owned physician practice
Satellite clinics

13. 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: V89
ICD-10-CM: A00-T88, Z00-Z99
(continued)

14. 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

15. 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)

16. 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)

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

18. 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)

19. 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

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