![]() ![]() For example, abdominal pain for a CT, or absence of menstruation for a pregnancy test. What if a patient presents for diagnostic lab or x-ray services? Well, in these cases you will typically assign a code for the sign or symptom that prompted the test. Otherwise, it’s not necessary to add them. History codes (categories Z80- Z87) may be used as secondary codes if the historical condition or family history has an impact on current care or influences treatment. And be sure to NOT code conditions that were previously treated and no longer exist. ICD-10 instructs us to code all documented conditions that coexist at the time of the visit and affected patient care. Additional diagnoses can be used to describe other existing diagnoses. If they develop complications from the surgery and require overnight (or longer) observation, the reason for the surgery still needs to be coded first, followed by the complication code(s).Īs we discussed in previous blog posts, the first listed diagnosis should be the primary reason for the service on that day. This should be obtained from the post-operative diagnosis, not the pre-operative diagnosis. When a patient presents for outpatient surgery, the first listed diagnosis should be the main reason for surgery. You will not code diagnoses mentioned with these terms. ![]() New for 2020, the terms “consistent with” and “compatible with” have been added to describe uncertain diagnoses. Instead, signs and symptoms are used when a definitive diagnosis is not available. One of the most important differences in inpatient and outpatient diagnostic coding, is the ability to use “likely” and “possible” diagnosis in the inpatient setting, unlike in outpatient coding. The general guidelines from the other sections still apply, but there are a few variances you should always take note of. The guidelines in this section do not apply to inpatient services. Section IV: Diagnostic Coding and Reporting Guidelines for Outpatient Services, deals with reporting diagnosis codes specifically in outpatient hospital and provider-based office settings. ![]()
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