Joan E. Wolfgang, MAEd, CPC, CPC-H, CPC-I, CHCA Codes that describe symptoms and signs. Online Lesson 1, Screens 7-8 QUICK CHECK 3-1 Codes from this category indicate a patients continuous use of a prescribed drug (including such things as aspirin therapy) for the long-term treatment of a condition or for prophylactic use. In some cases, additional diagnoses would be reported to describe complications, reasons for canceled procedures, and other coexisting conditions. Initial office visit, 30-year-old woman complains of fatigue, abnormal weight gain, and constipation. Status post administration of tPA (rtPA) in a different facility within the last 24 hours prior to admission to current facility. This includes such things as the presence of prosthetic or mechanical devices resulting from past treatment. Describe code assignment for outpatient surgery. It may take two or more visits before the diagnosis is confirmed. Illustrate reporting of preoperative evaluations. This guideline applies even if the patient is still receiving the tPA at the time they are received into the current facility. Illustrate reporting of preoperative evaluations.
For accurate reporting of ICD-10-CM diagnosis codes, the documentation should describe the patients condition, using terminology which includes specific diagnoses as well as symptoms, problems, or reasons for the encounter. These codes are for patients who do not show any sign or symptom of a disease but are suspected to have been exposed to it by close personal contact with an infected individual or are in an area where a disease is epidemic. Report Plagiarism.
Coding guidelines for inconclusive diagnoses (probable, suspected, rule out, etc.) Code Z92.82 is only applicable to the receiving facility record and not to the transferring facility record. Other postprocedural states Z18 Review of systems identified unexplained weight loss. Patient also received a prescription for a refill of medication for hypertension. Understand assignment of codes for chronic diseases. Transplanted organ and tissue status 1. Apr 17, 2017 | Posted by admin in NURSING | Comments Off on ICD-10-CM outpatient coding and reporting guidelines, The ICD-10-CM implementation will provide the ability to report more specific information regarding patient conditions and circumstances. 4. Codes that describe symptoms and signs, as opposed to diagnoses, are acceptable for reporting purposes when a diagnosis has not been established (confirmed) by the provider. Encounters for routine health screenings. When a patient presents for outpatient surgery (same day surgery), code the reason for the surgery as the first-listed diagnosis (reason for the encounter), even if the surgery is not performed due to a contraindication. Z codes can only be used in the outpatient setting? NOTE: The 2012 ICD-10-CM DRAFT was used in this text. Examples Z97 Never begin searching initially in the Tabular List as this will lead to coding errors. ASelection of first-listed condition Code Z78.1, Physical restraint status, may be used when it is documented by the provider that a patient has been put in restraints during the current encounter. were developed for inpatient reporting and do not apply to outpatients. This guideline applies even if the patient is still receiving the tPA at the time they are received into the current facility. Patient also received a prescription for a refill of medication for hypertension. Diagnoses often are not established at the time of the initial encounter/visit. This guideline assures data integrity by promoting accurate I-10 diagnosis codes that are supported by documentation in the health record. She will be maintained on her current dose. Following assessment of the patient by the nurse, it was discovered that the patient had breakfast and the surgery was canceled and will be rescheduled for next week. Information about the use of certain abbreviations, punctuation, symbols, and other conventions used in the ICD-10-CM Tabular List (code numbers and titles), can be found in Section IA of these guidelines, under Conventions Used in the Tabular List. Information about the correct sequence to use in finding a code is also described in Section I. It is important to code all the conditions or problems that are being managed during an encounter. Outpatient surgery A status code is informative, because the status may affect the course of treatment and its outcome. Lab studies including thyroid function test were ordered. Apply the Official Guidelines for Coding and Reporting. Carrier of infectious disease Allergy status to drugs, medicaments and biological substances, Except: Z88.9, Allergy status to unspecified drugs, medicaments and biological substances status, Acquired absence of organs, not elsewhere classified, Allergy status, other than to drugs and biological substances. Asymptomatic HIV infection status In these instances, report the symptoms or signs that occasioned the encounter. The history code indicates that the patient no longer has the condition. The Guidelines state that it is acceptable to use any of the codes throughout the entire Tabular List to identify the reason(s) for an outpatient visit including the use of Z codes. This code is a secondary code only for use when the pregnancy is in no way complicating the reason for visit. She will have repeat thyroid function studies on her next visit. 1. ________________ This code indicates that a patient has a condition that is resistant to antimicrobial drug treatment. After completing this chapter you should be able to NOTE: The 2012 ICD-10-CM DRAFT was used in this text. Z codes are for use in any healthcare setting. A corresponding procedure code must accompany a Z code to describe any procedure performed. Complete the following in Chapter 3 of your ICD-10-CM Online Training Modules: CPT is a registered trademarks of American Medical Association. The ICD-10-CM implementation will provide the ability to report more specific information regarding patient conditions and circumstances. Outpatient surgery that has been canceled In this case the only reportable diagnoses are symptom codes as no specific diagnosis has been confirmed during this visit. Outpatient surgery Identify a first-listed diagnosis. First-Listed Diagnosis SECTION IV. SECTION IV.D. 3. ICD-10-CM provides codes to deal with encounters for circumstances other than a disease or injury. Log In or Register to continue Outline assignment of additional diagnoses. Do not assign a code from category Z79 for medication being administered for a brief period of time to treat an acute illness or injury (such as a course of antibiotics to treat acute bronchitis). Chapter-specific guidelines (ICD-10-CM chapters 1-10), Chapter-specific guidelines (ICD-10-CM chapters 15-21), Chapter-specific guidelines (ICD-10-CM chapters 11-14), Case study of a patient with tuberculosis. Z74.01 Otherwise, a code from the obstetric chapter is required. Contact/exposure codes may be used as a first-listed code to explain an encounter for testing, or, more commonly, as a secondary code to identify a potential risk. Carrier status indicates that a person harbors the specific organisms of a disease without manifest symptoms and is capable of transmitting the infection. ICD-10 OFFICIAL GUIDELINES FOR CODING AND REPORTING See Section I.C.21. Apply the Official Guidelines for Coding and Reporting. Complete the following in Chapter 3 of your ICD-10-CM Online Training Modules:. In the preceding guidelines and exercises, we were concerned primarily with the identification of the first-listed diagnosis. It is not for use for patients who have addictions to drugs. The status code does not provide additional information. Note: The chapter specific guidelines provide additional information about the use of Z codes for specified encounters. Never begin searching initially in the Tabular List as this will lead to coding errors. Codes: R53.83 fatigue, R63.5 abnormal weight gain, and K59.00 constipation. Z15 See Section I.C.21. Patient with a history of asthma presents for an outpatient T&A due to chronic tonsillitis. The appropriate code(s) from A00.0 through T88.9, Z00-Z99 must be used to identify diagnoses, symptoms, conditions, problems, complaints, or other reason(s) for the encounter/visit. 2. Z93 7. Follow-up office visit, 30-year-old woman is seen following her repeat thyroid function studies and her hypothyroidism has responded to the Synthroid. Define observation stay. No additional treatment was directed at the patients symptoms. Z21 Understand assignment of codes for chronic diseases. The Uniform Hospital Discharge Data Set (UHDDS) definition of principal diagnosis applies only to inpatients in acute, short-term, long-term care, and psychiatric hospitals. Additional diagnoses Blood type Patient has hypertension and blood pressure is above baseline on this visit. Online Lesson 1, Screens 1-4 8. ICD-10 OFFICIAL GUIDELINES FOR CODING AND REPORTING Allergy status, other than to drugs and biological substances Z14 3. The terms encounter and visit are often used interchangeably in describing outpatient service contacts and, therefore, appear together in these guidelines without distinguishing one from the other. Z codes are used more frequently in the outpatient setting. The status code does not provide additional information. Lab studies including thyroid function test were ordered. It is important to code all the conditions or problems that are being managed during an encounter. ICD-10 OFFICIAL GUIDELINES FOR CODING AND REPORTING This web site is not endorsed by, directly affiliated with, maintained, authorized, or sponsored by any coding organization including, but not limited to, QPro, AHIMA, AAPC, or PMI. Delineate the differences between first-listed and coexisting conditions. Understand assignment of codes for chronic diseases. Use of Z codes in any healthcare setting. Outpatient Surgery This subcategory is not for use of medications for detoxification or maintenance programs to prevent withdrawal symptoms in patients with drug dependence (e.g., methadone maintenance for opiate dependence). A status code is assigned to indicate that a patient has a sequelae or residual of a past disease or condition or is a current carrier of a disease. Chapter topics Lab results confirm that patient has hypothyroidism and she was started on Synthroid. Observation Stay ________________, According to the Guidelines, this category is referenced when reporting suspected exposure to a communicable disease: ________________. b. 2)Inoculations and vaccinations Z78 Genetic carrier status indicates that a person carries a gene, associated with a particular disease, which may be passed to offspring who may develop that disease. Chapter 18 of ICD-10-CM, Symptoms, Signs, and Abnormal Clinical and Laboratory Findings Not Elsewhere Classified (codes R00-R99) contain many, but not all codes for symptoms. It may take two or more visits before the diagnosis is confirmed. The majority of the services that a physician will provide are outpatient services, so this chapter will start with assigning I-10 diagnosis codes for outpatient services in accordance with the I-10. 9. Explain prenatal visits. Z codes are used more frequently in the outpatient setting. When a patient presents for outpatient surgery (same day surgery), code the reason for the surgery as the first-listed diagnosis (reason for the encounter), even if the surgery is not performed due to a contraindication. Awaiting organ transplant status Learning objectives ________________, 2. This subcategory is not for use of medications for detoxification or maintenance programs to prevent withdrawal symptoms in patients with drug dependence (e.g., methadone maintenance for opiate dependence). Z codes may be used as either a first-listed (principal diagnosis code in the inpatient setting) or secondary code, depending on the circumstances of the encounter. 3. The appropriate code for the condition for which the tPA was administered (such as cerebrovascular disease or myocardial infarction) should be assigned first. If the purpose of the encounter is genetic counseling associated with procreative management, code Z31.5, Encounter for genetic counseling, should be assigned as the first-listed code, followed by a code from category Z15. Presence of cardiac and vascular implants and grafts
