Official Outpatient Coding Guidelines (Hospital-Based and Physician Office)

Official Outpatient Coding Guidelines (Hospital-Based and Physician Office)

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CCS prep!

Official Outpatient Coding Guidelines (Hospital-Based and Physician Office)

Last month, CCS Prep! featured an introduction to the inpatient official coding guidelines. In this month’s column, we will be discussing the importance of the Official Outpatient ICD-9-CM Guidelines for Coding and Reporting. For those newer to coding, the distinction between the inpatient and outpatient guidelines is important. The outpatient guidelines were last revised Oct. 1, 1995. This document is approved by the four cooperating parties, which include: the American Hospital Association (AHA), American Health Information Management Association (AHIMA), Health Care Financing Administration (HCFA) and National Center for Health Statistics (NCHS).

The official guidelines should be the basis on which all coding and sequencing decisions are made when the codebooks do not provide specific direction through the use of various conventions and notes. These guidelines were approved for use by hospitals/physicians in coding and outpatient services. The outpatient guidelines address diagnosis coding only. The terms “visit” and “encounter” are both used to describe outpatient service in the guidelines.

In future issues of CCS Prep!, we will discuss CPT procedure coding for outpatient and physician services.

Although all of the official outpatient guidelines are equally important, we will expand upon just a few of the outpatient guidelines in this segment. The remaining guidelines are listed here by main heading. For a copy of the official coding guidelines, see

Outpatient Coding Guidelines
12. A. Appropriate codes for outpatient reporting. Assign from the range of codes 001.0 through V82.9 to identify the diagnosis, symptom, problem or other reason for the encounter. V codes can be used as the first listed diagnosis as long as the code itself is not prohibitive. For example, code V66.7, encounter for palliative care, is to be used as a secondary only. See Coding Clinic, 2000 4Q pp. 57-60. This list is invaluable for determining whether V codes are appropriate as first, secondary, or either designation. Pay particular attention to screening codes.

12. B. For accurate reporting of ICD-9-CM diagnosis codes, the documentation should describe the patient’s condition, using terminology which includes specific diagnoses as well as symptoms, problems, or reasons for the encounter. Look at the referring physician’s order for the reason for tests. Many times these reflect symptoms, but at times, rule-out conditions are listed (see 12 H). At other times, diagnoses are confirmed. Refer to Coding Clinic, 2000 1Q pp. 3-6 for detailed advice regarding the coding of outpatient diagnoses in several scenarios.

12. 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.

12. D. Symptoms and signs permissible. Codes that describe symptoms and signs are acceptable for outpatient reporting purposes when an established diagnosis has not been diagnosed (confirmed). For example, a patient is admitted with rapid heartbeat. An EKG is performed without a conclusive diagnosis. Tachycardia, symptom code 785.0, is acceptable as the final diagnosis in this case. Chapter 16, including codes 780.0-799.9, contains many, but not all, of the symptom codes.

12. E. V codes are provided to deal with occasions when circumstances other than a disease or injury are recorded as diagnosis or problems. (V01.0-V82.9) See advice given in 12 A above.

12. F. Use three-digit codes only if it is not further subdivided. Where fourth-digit or fifth-digit subclassifications are provided, they must be used.

12. G. Additional diagnoses. The first listed diagnosis on the outpatient claim should be for the diagnosis, condition, problem or other reason for the encounter/visit, documented in the record to be chiefly responsible for the services provided. Additional documented diagnoses are listed secondly. For example, a patient is seen in the outpatient clinic for chronic urinary tract infection (UTI). Antibiotics are changed to treat the UTI. The physician also documents that the patient has asthma, controlled by inhaler, and adjusts the dose. Assign code 599.0, UTI first, followed by code 493.90 for asthma.

12. H. Probable diagnoses. Do not code diagnoses documented as “probable,” “suspected,” “questionable,” “rule-out,” or working diagnosis. Rather, code the condition to the highest degree of certainty. This would include symptoms, signs, abnormal test results or other reasons. For example, a patient is admitted for chest X-ray. The physician documents lung mass, probable abscess. Assign code 786.6, mass in chest. Had the physician documented “lung mass due to lung abscess,” then code 513.0, abscess of lung would be assigned. Remember, this is contrary to instructional notes of the inpatient guidelines. This can be confusing to many new coders and to physicians as well!

12. I. Chronic diseases. Any chronic, ongoing diseases, which are documented and treated, are reported as many times as patient receives treatment. If a patient is treated in the outpatient area five different times for insulin dependent diabetes mellitus, then 250.01 may be used as the diagnosis for each encounter. Chronic conditions under treatment should be reported to accurately reflect the severity of illness for outpatients.

12. J. Other diagnoses. Code all of the documented conditions that coexist at the time of the encounter and require or affect patient care treatment or management. Do not, however, code conditions that were previously treated and no longer exist. History codes (V10-V19) can be used if the historical condition impacts current care. For example, a patient presents at the clinic for hematemesis. A family history of stomach carcinoma is documented. The patient has a history of a musculoskeletal disorder and currently has anemia. Appropriate codes for this outpatient visit are 578.0, 285.9, and V16.0. The history of musculoskeletal disorder would not be coded, as it has no bearing on this visit. Be sure to follow these guidelines and to omit hospital-specific guidelines on the examinations.

12. K, L. Additional chronic conditions. When patients are receiving diagnostic or therapeutic services only during a visit, list that condition first (except for a patient receiving chemotherapy, radiation therapy or rehabilitation, in which case the V code is assigned). Codes for other diagnoses, such as chronic conditions, may be sequenced as secondary diagnoses. For example, a patient is brought to the outpatient clinic for chemotherapy for colon carcinoma. The physician also documents that the patient is currently on FeSol for anemia and bronchial inhaler for asthma. Assign V58.1 followed by 153.9, 285.9 and 493.90. Many facilities fail to code secondary diagnoses, which may impact future ambulatory payment classification (APC) reimbursements.

The official outpatient guidelines skip the letter M.

12. N. Preoperative evaluations. For pa-tients receiving preoperative evaluations only, sequence a code from category V72.8, other specified examinations, to describe pre-op consultations. For example, a patient scheduled to have inguinal hernia repair later in the month is seen for a preoperative cardiovascular examination in the outpatient clinic. No problems are identified, other than the inguinal hernia. Code V72.81, preoperative cardiovascular examination followed by 550.90 for the inguinal hernia. Remember, do not apply payer specific requests and coding in- struction when taking the CCS and CCS-P examinations.

12. O. Surgery Diagnosis. For ambulatory surgery, code the diagnosis for which the surgery is performed. If the preoperative and postoperative diagnoses are different, code the postoperative diagnosis because it is the most definitive. For example, if a patient is sent for outpatient skin biopsy, and the preoperative diagnosis is “skin lesion” and the postoperative diagnosis is “solar keratosis,” assign code 702.0 for the solar keratosis.

We have reviewed most of the official outpatient guidelines in some detail. We suggest that you review all of the guidelines in depth. Take this quick quiz to test your knowledge:

1. An outpatient reports for diagnostic X-rays because of chronic upper right abdominal pain. The doctor writes “RUQ abd pain, rule out cholecystitis. The X-rays confirm that the patient has chronic cholecystitis. The correct code(s) for the diagnosis (es) are:

  1. 789.01, 575.11
  2. 575.11
  3. 789.01

2. A surgeon discontinues an outpatient surgery after the administration of anesthesia. What modifier is utilized with the surgical CPT code for Medicare Part A hospital billing?

  1. -53
  2. -74
  3. -52

3. A patient presents for a screening mammogram. The diagnosis code is:

  1. V76.12
  2. 611.72
  3. V82.9

4. A physician’s office patient is diagnosed by the attending physician with “elevated blood pressure, possible hypertension.” Assign code:

  1. 796.2
  2. 401.9
  3. V81.1

5. An outpatient presents with uncontrolled hypertension. The patient also has a history of asthma. In addition to the hypertension, the asthma should also be coded.

  1. True
  2. False

6. A patient complains of fever and urinary frequency. Urinalysis is done and report reveals culture greater than 100,000 colonies per milliliter of urine of E. Coli. Assign diagnosis code(s)

  1. 599.0, 788.41, 780.6, 041.4
  2. 599.0
  3. 788.41, 780.6
  4. 599.0, 041.4

Patricia Maccariella-Hafey is manager of coding review services at United Audit Systems Inc. (UASI), a national consulting company offering multifaceted HIM and business office management services, headquartered in Cincinnati.


Answers to CCS Prep

1. b (OCG 12D), 2. b, 3. a (See “screening, mammogram” in the ICD index.), 4. a , 5. b (False, the asthma is not mentioned as currently being managed, only the past history is noted.), 6. c (A UTI was not diagnosed by a physician. The Urinalysis simply indicates probable UTI clinically. Query MD to add documentation of diagnosis of E. Coli UTI before coding as such. Lab results or other ancillary reports should not be used to code from without MD documentation.)

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