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Review of the Official Outpatient ICD-9-CM Coding & Reporting Guidelines

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My past seven years researching regulations and guidelines to answer various coding inquiries has provided me with a great deal of expertise spanning a 20-year career in health information management (HIM). Amid arenas of great change and dynamic processes, at least one area has remained largely unchanged and static. For many of the coding guidelines such as observation and surgical services, outpatient coding guidelines are a dependable source of standards and rules tried and true in the outpatient arena. So why are we still getting so many questions from coders on individual outpatient cases? I think the answer lies in language interpretation.

As with the inpatient guidelines, the coding guidelines for outpatient diagnoses have also been developed and approved by the four cooperating parties for ICD-9-CM, which include the American Hospital Association (AHA), American Health Information Management Association (AHIMA), Centers for Medicare and Medicaid Services (CMS) and National Center for Health Statistics (NCHS). These guidelines are for use by hospitals/providers coding and reporting hospital-based outpatient services and provider-based office visits. This may be part of the problem - so many coders doing multi-disciplinary coding and having to switch their thought process from one set of fundamentally different guidelines to another.

Although the conventions and general guidelines apply to all provider settings, coding guidelines for outpatient/provider reporting, especially for diagnoses, are different in a number of instances. The Uniform Hospital Discharge Data Set (UHDDS) definition of principal diagnosis (originally developed in 1985) applies only to inpatients in acute, short-term, long-term care and psychiatric hospitals. This is due to length of stay parameters. Rules for inconclusive diagnoses, such as "probable," "suspected," "rule out," "working diagnosis," or other similar terms indicating uncertainty were developed for inpatient reporting only and do NOT apply to outpatient visits. In the outpatient setting, it is important to code the condition(s) to the highest degree of certainty documented by the provider for a single encounter/visit. This could be definitive in nature, if known, or symptoms, signs, abnormal test results, or other documented reasons for further diagnostics or treatment. The terms "encounter" and "visit" are often used interchangeably in describing outpatient services, and once again are predicated on the length of time the provider has to ascertain the patient's condition. The outpatient guidelines use the term for reporting the reason for admission as the "first-listed."

First-Listed Diagnosis

The term first-listed diagnosis/condition is used in the outpatient setting in lieu of principal diagnosis, once again because of the timing. Often, diagnoses are not established at the time of the initial encounter in the outpatient setting and it may take two or more visits prior to a confirmed diagnosis. The documentation to support the reason for the visit should describe the patient's condition, using terminology that includes either specific diagnoses and/or symptoms, problems, or reasons for the encounter. In the instance where a discrepancy is discovered, determining the first-listed diagnosis per the coding conventions of ICD-9-CM, as well as the general and disease-specific guidelines within ICD-9-CM, will have precedence over the outpatient guidelines.

  • In the outpatient setting, code all documented conditions that coexist at the time of the encounter AND require or affect patient care treatment or management. Do NOT code conditions that were previously treated and no longer exist. However, history codes (V10-V19) may be used as additional codes if the historical condition or family history has an impact on current care or influences treatment. Codes for other diagnoses (e.g., chronic conditions the patient receives treatment for, including medication management) and care should be sequenced as additional diagnoses.
  • For visits in the outpatient setting for routine laboratory/radiology testing in the absence of any signs, symptoms or associated diagnosis, assign V72.5 and/or a code from subcategory V72.6. If routine testing is performed during the same encounter as a test to evaluate a sign, symptom or diagnosis, it is appropriate to assign both the V code and the code describing the reason for the non-routine test. Please review individual coding policies at your facility for guidance on using these generic codes.
  • Reporting visits in the outpatient setting for diagnostic tests that have been interpreted by a physician where the final report is available at the time of coding should be coded with any confirmed or definitive diagnoses documented in the interpretation. It is NOT appropriate to code related signs and symptoms of the diagnosis as additional codes.
  • For patients receiving therapeutic services only during an encounter/visit, the coders should sequence first the diagnosis, condition, problem or other reason for encounter/visit shown in the medical record to be chiefly responsible for the outpatient services provided during the encounter/visit. Codes for other diagnoses (e.g., chronic conditions) may be sequenced as additional diagnoses. The only exception to this rule is when the primary reason for the admission/encounter is chemotherapy, radiation therapy or rehabilitation. For these services, the appropriate V code for the service is listed first, and the diagnosis or problem for which the service is being performed listed second.
  • For encounters for preoperative evaluations only, the coder should sequence first a code from category V72.8, other specified examinations, to describe the pre-op consultations. Assign a code for the condition to describe the reason for the surgery as an additional diagnosis. Code also any findings documented during the pre-op evaluation that are available at the time of code assignment.
  • Outpatient surgery encounter rules are to assign the diagnosis code as first-listed for the condition that the surgery was performed. However, if the postoperative diagnosis is known to be different from the preoperative diagnosis at the time the diagnosis is confirmed, select the postoperative diagnosis or condition, as this would be the most definitive diagnosis. This is an important point: The first-listed diagnosis or condition is still governed by circumstances of admission, which must reflect the reason the patient is here for care. Coding a subsequent contraindication or physician/patient determination to postpone the surgery occurs after the patient has been admitted for the surgery, thus the surgery remains as the first-listed.
  • For visits for routine outpatient prenatal visits when no complications are present, the coder should use V22.0, Supervision of normal first pregnancy, or V22.1, Supervision of other normal pregnancy, as the first-listed diagnosis. These codes should not be used in conjunction with chapter 11 codes. Check your individual facility policies on these codes for guidance.

The External Causes of Injury and Poisoning codes (categories E000 and E800-E999) are intended to provide data for injury research and prevention, and they play a large role in how the right type of insurance payment is going to be selected. Worker Comp, Liability Insurance (Including Self-Insurance) and No-Fault Insurance are some of the choices. E codes capture how the injury, poisoning or adverse effect happened (cause), the intent (unintentional or accidental; or intentional, such as suicide or assault), the person's status (e.g. civilian, military), the associated activity and the place where the event occurred. E-codes should never be assigned as a first-listed diagnosis, and are assigned most frequently in the emergency department setting.

The Supplementary Classification of Factors Influencing Health Status and Contact with Health Services (V01.0 - V91.99) are available for occasions when circumstances other than a disease or injury (codes 001-999) are recorded as a diagnosis or problem. V codes can be used in any healthcare setting; however, they are much more common in the outpatient setting as compared to inpatient. While V codes may be used as either a first-listed or as additional diagnosis, depending on the circumstances of the encounter/visit, certain V codes may only be used as first-listed, and others only as additional code (see coding guidelines for a list of codes that may only be used as first-listed codes).

The official coding guidelines should be consulted for all coding and sequencing decisions made when the ICD-9-CM conventions do not provide specific directions. A copy of the current 2012 ICD-9-CM Official Coding Guidelines for Coding and Reporting can be downloaded at http://www.cdc.gov/nchs/data/icd10/10cmguidelines2012.pdf

For the expert coding professional, I hope this article will provide confirmation of what you know to be correct and right. As for the novice, my recommendation would be to commit these guidelines to memory as soon as possible. When doing multidisciplinary coding, make it a part of your routine to scan the face sheet for each encounter to ensure you have changed your mental automatic guideline application to the correct setting.

This month's column has been prepared by Jennifer Gamache, RHIT, CCS, ICD-10-CM/PCS trainer, manager of PrecyseAssist, Precyse (www.precyse.com), a leader in health information management (HIM) services and technologies. With products ranging from integrated transcription and coding platforms with advanced speech recognition, expert workflow technologies, Natural Language ComprehensionTM to HIM consulting services, Precyse's flexible software can be delivered standalone or complemented by a professional staff of more than 1,200 experts.

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Review of the Official Outpatient ICD-9-CM Coding & Reporting Guidelines

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