Hospital Outpatient and Physician OfficeCoding Guidelines Should Be Reviewed
Patricia Maccariella, RRA, CCS
Time is flying by, and hopefully those of you who are taking the certified coding specialist (CCS) or the CCS-P (physician-based) exam have been studying each month. As we get close to exam time, let us review the official coding guidelines for hospital outpatient and physician office coding.
Outpatient coding guidelines differ from the inpatient coding guidelines in many ways. It is a good idea to review both guidelines and note their differences.
A full description of the official outpatient coding guidelines can be found in The Official ICD-9-CM Guidelines For Coding and Reporting, which were developed by the four cooperating parties (American Hospital Association [AHA], the American Health Information Management Association [AHIMA], the Health Care Financing Administration [HCFA] and the National Center for Health Statistics [NCHS]). They are described in section 12. The official outpatient coding guidelines are also listed in Coding Clinic, fourth quarter, 1995, pages 42-53. The last official revision to the outpatient coding guidelines occurred on Oct. 1, 1995. Here are the basic coding guidelines for outpatient services:
A. The appropriate code or codes from 001.0 through V82.9 must be used to identify diagnoses, symptoms, conditions, problems, complaints or other reason(s) for the encounter/visit.
B. For accurate reporting of ICD-9-CM diagnosis codes, the documentation should describe the patient’s condition, using terminology that includes specific diagnoses as well as symptoms, problems or reasons for the encounter. There are ICD-9-CM codes to describe all of these.
C. The selection of codes 001.0 through 999.9 will frequently be used to describe the reason for the encounter. These codes are from the section of ICD-9-CM for the classification of diseases and injuries (e.g., infectious and parasitic diseases; neoplasms; symptoms, signs, and ill-defined conditions, etc.).
D. Codes that describe symptoms and signs, as opposed to diagnoses, are acceptable for reporting purposes when an established diagnosis has not been diagnosed (confirmed) by the physician. Chapter 16 of ICD-9-CM, Symptoms, Signs, and Ill-Defined Conditions (codes 780.0 799.9), contains many, but not all codes for symptoms.
E. ICD-9-CM provides codes to deal with encounters for circumstances other than a disease or injury. The Supplementary Classification of Factors Influencing Health Status and Contact with Health Services (V01.0-V82.9) is provided to deal with occasions when circumstances other than a disease or injury are recorded as diagnosis or problems.
F. ICD-9-CM is composed of codes with either three, four or five digits. Codes with three digits are included in ICD-9-CM as the heading of a category of codes that may be further subdivided by the use of fourth and/or fifth digits, which provide greater specificity. A three-digit code is to be used only if it is not further subdivided. Where fourth-digit subcategories and/or fifth-digit subclassifications are provided, they must be assigned. A code is invalid if it has not been coded to the full number of digits required for that code.
G. List first the ICD-9-CM code for the diagnosis, condition, problem or other reason for encounter/visit shown in the medical record to be chiefly responsible for the services provided. List additional codes that describe any coexisting conditions.
H. Do not code diagnoses documented as “probable,” “suspected,” “questionable,” “rule out” or working diagnosis. Rather, code the conditions(s) to the highest degree of certainty for that encounter/visit, such as symptoms, signs, abnormal test results or other reason for the visit. Please note: This is contrary to the coding practices used by hospitals and medical record departments for coding the diagnosis of hospital inpatients.
I. Chronic diseases treated on an ongoing basis may be coded and reported as many times as the patient receives treatment and care for the condition(s).
J. Code all documented conditions that coexist at the time of the encounter/visit 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 secondary codes if the historical condition or family history has an impact on current care or influences treatment.
K. For patients receiving diagnostic services only during an encounter/visit, 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.
L. For patients receiving therapeutic services only during an encounter/visit, 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 that for patients receiving chemotherapy, radiation therapy or rehabilitation, the appropriate V code for the service is listed first, and the diagnosis or problem for which the service is being performed is listed second.
M. For patients receiving preoperative evaluations only, sequence 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 related to the pre-op evaluation.
N. For ambulatory surgery, code the diagnosis for which the surgery was performed. If the postoperative diagnosis is known to be different from the preoperative diagnosis at the time the diagnosis is confirmed, select the postoperative diagnosis for coding because it is the most definitive.
The Coding Clinic, fourth quarter, 1995, page 43 lists these differences between the inpatient and outpatient guidelines:
* The Uniform Hospital Discharge Data Set (UHDDS) definition of principal diagnosis applies only to inpatients in acute, short-term, general hospitals.
* Coding guidelines for inconclusive diagnoses (probable, suspected, rule out, etc.) were developed for inpatient reporting and do not apply to outpatients. (This rule could be changing in the future.)
* Diagnoses often are not established at the time of the initial encounter/visit. It may take two or more visits before the diagnosis is confirmed.
Coding Clinic fourth quarter, 1995 pages 50-53 provides examples of outpatient guideline coding.
In addition, The Supplementary Classification of Factors Influencing Health Status and Contact with Health Services (V01.0 V82.9) should be reviewed extensively along with all corresponding Coding Clinic issues.
Now, test your skills. Code the following outpatient/physician office scenarios. Assign diagnoses codes only. Compare your answers with the answer key, which has the outpatient coding guidelines associated with the answer.
1. Patient is seen in the outpatient clinic area for follow-up examination. Patient previously had surgery for malignancy of the colon. No recurrence is found.
2. Patient presents for whole blood donation for sister who is having surgery in the next few days.
3. Patient is seen in the outpatient surgery area with chronic abdominal pain, to have esophagogastroduodenoscopy (EGD). Patient is found to have chronic gastritis. The patient is also under treatment for hypertension and is on daily medication.
4. Patient presents to the emergency room with bout of syncope. Physician states that this is probably due to either atrial fibrillation or orthostatic hypotension. Patient is sent home to follow up with family physician.
5. Patient presents to the physician’s office for treatment of hypertension. She is two months status post hysterectomy.
6. The patient presents to the internist’s office for a general overall preoperative clearance examination.
7. Same case as in #6 above; however, the patient is to have cholecystectomy for chronic cholecystitis with cholelithiasis. During the preoperative examination, the internist finds a large suspicious mole on skin of back and refers the patient to have biopsy of the mole while having cholecystectomy.
8. Patient presents with pleuritic mass and surgical removal. Pathology report reveals the mass is a lipoma.
Patricia Maccariella is manager of coding services at UASI, headquartered in Cincinnati.
Final coding is always de-pendent on physician documentation. We do not guarantee that the use of this material will prevent differences of opinion with Medicare or other third-party payers.