ICD-10-CM OUTPATIENT

CODING AND REPORTING

GUIDELINES

Copyright 2013 by Saunders, an imprint of Elsevier Inc.

I-10 Guidelines state

Principal Dx = inpatient settings
First-Listed Dx = outpatient settings

The primary reason for encounter

Example: Pt with inguinal hernia presents
with shortness of breath

SOB is first-listed
Example 2: Pt with CHF presents for urinary

frequency issues
Urinary frequency is first-listed

Copyright 2013 by Saunders, an imprint of Elsevier Inc.

Slide 2

In outpatient setting, may take several

encounters to confirm diagnosis
Signs/Symptoms are reported
Example: Pt presents with complaint of
frequent heartburn
Physician prescribes Prilosec for suspected
GERD with patient returning in 10 days
Report: frequent heartburn

Copyright 2013 by Saunders, an imprint of Elsevier Inc.

Slide 3

Code the reason for the surgery first

Even if the surgery is not performed

Followed by code to report reason procedure not

carried out, such as Z53.09, procedure not

carried out due to other contraindication
Example pt presents for hernia surgery,
malignant hypertension causes surgery to be
cancelled.
Code Z53.09 first, then hypertension

Copyright 2013 by Saunders, an imprint of Elsevier Inc.

Slide 4

Report circumstances other than disease

or injury

May be first- or additionally listed

Z codes are informative

Depending on circumstances

Z23 reports encounters for inoculations

and vaccinations

Procedure code identifies administration

Copyright 2013 by Saunders, an imprint of Elsevier Inc.

Slide 5

Located after I-10 Table of Drugs and

Chemicals

Figure: 3.1
External Cause Index of the I-10. (From Buck CJ: 2013 ICD-10-CM Standard Edition
DRAFT (Softbound), St. Louis, 2013, Saunders. )
Copyright 2013 by Saunders, an imprint of Elsevier Inc.

Slide 6

Never first-listed Dx
Clarify injury or adverse effects
Map to E codes in the I-9

Copyright 2013 by Saunders, an imprint of Elsevier Inc.

Slide 7

Categories Z03 and Z04

Pt admitted to observation status
Report Z code as first-listed for DX stated as
suspected /rule out conditions
If DX made, report DX as first-listed

Copyright 2013 by Saunders, an imprint of Elsevier Inc.

Slide 8

If coexisting conditions are present and

affect pt care or is treatedreport as
coexisting condition
Example, pt presents with SOB due to asthma.
Physician prescribes nebulizer treatments. Pt
is morbidly obese making examination and
treatment more complex.
First-listed: (asthma);
Coexisting Condition: (obesity)

Copyright 2013 by Saunders, an imprint of Elsevier Inc.

Slide 9

Inpatient report uncertain DX as if exists

Probable, suspected, questionable, rule out,

working DX, etc.

Outpatient report symptoms, signs,

abnormal test results, or other reason for
encounter

Copyright 2013 by Saunders, an imprint of Elsevier Inc.

Slide 10

Chronic conditions are treated on ongoing

basis
Report condition as many times as pt
receives care or treatment for condition
Do not report conditions that were
previously treated and no longer exist

Report history codes (Z80-Z87) as secondary

DX if condition impacts current condition or
affects treatment

Copyright 2013 by Saunders, an imprint of Elsevier Inc.

Slide 11

Only diagnostic service provided, report

first reason for service

Example: Pt presents for routine, periodic

gynecological exam, report Z01.419
No signs, symptoms, or associated diagnosis

Example: Pt presents for diagnostic imaging

for left, central breast mass, report N63,
unspecified breast lump
Later DX: Malignant neoplasm, report C50.112

Copyright 2013 by Saunders, an imprint of Elsevier Inc.

Slide 12

Pt receiving only therapeutic service,

report reason for encounter

Example: Outpatient chemotherapy for right

breast cancer, report Z51.11 (chemo) and
C50.911 (malignant neoplasm, right breast)

Copyright 2013 by Saunders, an imprint of Elsevier Inc.

Slide 13

First-listed code is preop exam

Subcategory Z01.81 code (encounter for preprocedural exam)

Z01.810 Preop cardiovascular exam
Z01.811 Preop respiratory exam
Z01.812 Preop lab
Z01.818 Preop exam, NOS exam before chemo

Additional code, reason for surgery

Copyright 2013 by Saunders, an imprint of Elsevier Inc.

Slide 14

Report most definitive DX

Usually postoperative DX

Copyright 2013 by Saunders, an imprint of Elsevier Inc.

Slide 15

Routine outpatient prenatal encounters

with no complications, report category
Z34, supervision of routine pregnancy

Example: 19-year-old female presents for initial

prenatal exam, first pregnancy, Z34.00

Prenatal encounters for high-risk patients

report as first-listed, O09 (supervision of
high-risk pregnancy)

Example: 29-year-old first trimester female

patient presents for prenatal encounter with
varicose veins of legs, O22.01
Copyright 2013 by Saunders, an imprint of Elsevier Inc.

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ICD-10-CM OUTPATIENT
CODING AND REPORTING

Copyright 2013 by Saunders, an imprint of Elsevier Inc.

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