CHAPTER 9
ICD-9-CM OUTPATIENT CODING
AND REPORTING GUIDELINES
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Slide 1
Section IV. Diagnostic Coding
• Physician’s office
• Hospital-based outpatient services
• Part of Official Guidelines for Coding and
Reporting, Section IV
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Slide 2
Section IV. Diagnostic Coding
• Guidelines do not address specific
sequencing or diseases as inpatient do
• Though not stated, if there is no outpatient
guideline, follow inpatient guidelines
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Slide 3
Diagnostic Coding Guideline A
• Term first-listed diagnosis, rather than
principal diagnosis
• Outpatient Surgery: Reason for surgery
– Even if surgery is canceled due to
contraindication
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Slide 4
Diagnostic Coding Guideline A
• Observation Stay: Medical condition that
occasioned admission
– Assign a code from medical condition
• Observation Stay: Complications from
outpatient surgery lead to observation
report:
• Reason for surgery as first reported diagnosis
• Codes for complications necessitating observation
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Slide 5
Selection of First-Listed
Diagnosis
• Condition for encounter
– Why patient presented, not necessarily most
serious condition noted
• Documented
• Chiefly responsible for services provided
• Also list co-existing conditions
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Slide 6
Diagnosis and Services
• Diagnosis and procedure MUST correlate
• Medical necessity must be established
through documentation
• No correlation = No reimbursement
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Slide 7
Symptoms, Signs, and IllDefined Conditions
• Can be the first-listed diagnosis if no more
specific diagnosis available
• Diagnoses often are not established at the
time of the initial encounter/visit
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Slide 8
Diagnostic Coding Guideline B
• Use codes 001.0 through V91.99 to code:
– Diagnosis
– Symptoms
– Conditions
– Problems
– Complaints
– Or other reason(s) for visit
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Slide 9
Diagnostic Guideline C
• Documentation should describe patient's
condition, using terminology that includes:
– Specific diagnoses
– Symptoms
– Problems
– Reasons for encounter
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Slide 10
Diagnostic Guideline D
• Selection of codes 001.0 through 999.9
(Chapters 1-17) frequently used to
describe reason for encounter
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Slide 11
Diagnostic Guideline E
• Codes that describe symptoms and signs,
as opposed to diagnoses, acceptable for
reporting purposes when
– An established diagnosis has NOT been
determined by physician
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Slide 12
Diagnostic Guideline F
• V codes deal with encounters for
circumstances other than disease or injury
– Example: Well-baby checkup
• See Section I.C.18. for information on
V codes
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Slide 13
Section I.C.18. Classification of Factors
Influencing Health Status and Contact
with Health Service
• V01-V91
– Assigned as first-listed diagnosis for:
• Admissions for evaluation
• Following an accident that would ordinarily result in
health problem, BUT there is none
– Car accident, driver hits head, no apparent
injury, admit to R/O head trauma
– Never a secondary diagnosis
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Slide 14
V Codes
• Located after 999.9 in Tabular
• Two digits before decimal (e.g., V10.1X)
• Index for V codes is Alphabetic Index
to Diseases
• Main terms:
– Contraception
– Counseling
– Dialysis
– Status
– Examination
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Slide 15
Uses of V Codes
• Not sick BUT receives health care
(e.g., vaccination)
• Services for known/resolving disease/injury
(e.g., chemotherapy)
• Codes for “aftercare” (e.g., surgery or fracture)
• Indicate birth status/outcome of delivery
(Cont’d…)
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Slide 16
Uses of V Codes
(…Cont’d)
• A circumstance/problem that influences patient’s
health BUT NOT current illness/injury
– Example: Organ transplant status
– Example: Birth status and outcome of delivery
(newborn)
• Section I.C.18.e. of Guidelines contains the V
Code Table
– Identifies if V code can be listed as first,
first/additional, additional only
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Slide 17
History V Code Categories
in Tabular
• V10 Personal history of malignant neoplasm
• V11 Personal history of mental illness
• V12 Personal history of certain other diseases
• V13 Personal history of other diseases
• V14 Personal history of allergy to medicinal agents
• V15 Other personal history presenting hazards to health
• V16 Family history of malignant neoplasm
• V17 Family history of certain chronic disabling diseases
• V18 Family history of certain other specific diseases
• V19 Family history of other conditions
Condition no longer present or treated
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Slide 18
Diagnostic Guideline G
• Codes have either 3, 4, or 5 digits
• 4 and/or 5 digit codes provide greater
specificity (detail)
(Cont’d…)
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Slide 19
Diagnostic Guideline G
(…Cont’d)
• 3-digit code used ONLY if no 4 or 5 digit
• Where 4 and/or 5 digits provided, must be
assigned
• Diagnoses NOT coded to full digits
available invalid
• Claims bounce!
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Slide 20
Diagnostic Guideline H
• List first code for diagnosis, condition,
problem, or other reason for encounter/visit
shown in medical record to be chiefly
responsible for services provided
• List additional codes that describe any
coexisting conditions
• Assign V72.5 and V72.6X for routine
lab/radiology test ordered without signs,
symptoms, or associated diagnosis
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Slide 21
Diagnostic Guideline I
• Do NOT code diagnoses documented as
probable, suspected, questionable, rule
out, or working diagnoses
• Rather, code condition(s) to suspected
highest degree of certainty for that
encounter/visit, such as symptoms, signs,
abnormal test results, or other reason for
visit
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Slide 22
Diagnostic Guideline J
• Chronic diseases treated on an ongoing
basis may be coded and reported as many
times as patient receives treatment and care
for condition(s)
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Slide 23
Diagnostic Guideline K
• Code all documented conditions that
coexist at time of visit, that require or
affect patient care, treatment, or
management
• Do NOT code conditions previously
treated, no longer existing
(Cont’d…)
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Slide 24
Diagnostic Guideline K
(…Cont’d)
• “History of” codes (V10-V19) may be used
as secondary codes if:
– Impacts current care or treatment
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Slide 25
Special Note About
“History of”
• Index to Disease, MAIN term “History”
• Entries between “family” and “visual loss
V19.0” = “family history of” (FHO)
• Entries before “family” and after
“visual loss” = “personal history of” (PHO)
• Personal history = V10-V15
• Family history = V16-V19
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Slide 26
Diagnostic Guidelines L and M
• For patients receiving diagnostic services
ONLY
• Sequence first
– Diagnosis
– Condition
– Problem
OR
– Other reason shown in medical record to be
chiefly responsible for encounter
(…Cont’d)
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Slide 27
Diagnostic Guidelines L and M
(…Cont’d)
• Codes for other diagnoses
(e.g., chronic conditions)
– May be sequenced as secondary diagnoses
• Exception: Therapeutic Services
– Patients receiving chemotherapy (V58.11), radiation
therapy (V58.0), or rehabilitation (V57.0-V57.9)
– V code first diagnosis and problem for which service
being performed second
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Slide 28
Diagnostic Guideline N
• For patients receiving preoperative
evaluations ONLY
– Code from category V72.8 (Other specified
examinations)
– Assign secondary code for reason for surgery
– Code also any findings related to preoperative
evaluation
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Slide 29
Diagnostic Guideline O,
Ambulatory Surgery
• Code diagnosis which required ambulatory
surgery
• Pre- and post-op diagnosis different
– Code the post-op diagnosis
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Slide 30
Diagnostic Guideline P
• Code routine prenatal visits with no
complications:
– V22.0 (Supervision of normal first pregnancy)
– V22.1(Supervision of other normal pregnancy)
– DO NOT use these codes with pregnancy
complication codes (Chapter 11,
ICD-9-CM)
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Slide 31
V91 Multiple Gestation Placenta
Status
• New in 2011
• Identifies number of placentas and
amniotic sacs for twins, triplets,
quadruplets, other multiples
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Slide 32
Conclusion
CHAPTER 9
ICD-9-CM OUTPATIENT CODING
AND REPORTING GUIDELINES
Copyright © 2012, 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc.
Slide 33