Outpatient Coding and Reporting
Guidelines Questions & Answers
first-listed - ANSWERS-"principal Dx" in inpatient settings (expectation of 24-hr
stay/care);
In outpatient settings and all ambulatory settings (sometimes called primary Dx);
-the *primary reason* for the encounter/visit (aka chief complaint)
*first-listed example*: pt with inguinal hernia presents w/SOB - ANSWERS-*SOB* is
first-listed (the pt didn't come in for the hernia, it was because of their SOB)
check for example in book - ANSWERS...
unconfirmed diagnosis in outpatient setting - ANSWERS-in outpatient setting,
confirming a diagnosis would take several visits;
-cannot code for diagnosis until a definitive diagnosis is made
*unconfirmed Dx example - outpatient*: pt presents with complaint of frequent heartburn
- ANSWERS-physician prescribes Priolsec for "suspected" GERD with pt returning in 10
days
-you cannot code a "suspected" Dx, instead you code for *frequent heartburn* (i.e. the
only thing that has been confirmed)
outpatient (ambulatory) surgery - ANSWERS-code the *reason* for the surgery 1st (this
is a guidline), even if the surgery is not performed;
-follow the "reason" code if surgery not done with a code that reports the reason (e.g.
Z53.09 ""procedure not carried out due to other contraindication)
Z codes - ANSWERS-encountering the healthcare services codes
-used to report circumstances other than disease or injury;
-Z codes are informative (i.e. prevention visits, well baby checks, pregnancy checks)
-may be "first-" or additionally listed, depending on circumstances
external cause Index - ANSWERS-located after I-10 Table of Drugs and Chemicals
