OUTPATIENTS CODING AND REPORTING
GUIDELINES TEST
first-listed - ANSWER -"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 - ANSWER -
*SOB* is first-listed (the pt didn't come in for the hernia, it was because of their
SOB)
check for example in book - ANSWER ...
unconfirmed diagnosis in outpatient setting - ANSWER -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 - ANSWER -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 - ANSWER -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 - ANSWER -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
