Exam 3: ICD-10-CM Outpatient Coding and Reporting Guidelines

Z codes may be assigned as first-listed or a secondary diagnosis.

An established patient is seen for migraines and seizures, to rule out the possibility of a brain tumor. ____________________

An established patient is seen for management of diabetes and hypothyroidism and the physician spends equal time on each diagnosis. ____________________

Established patient seen for redness and sensitivity to light in her right eye. The documentation states the diagnosis is iritis. ____________________

In the inpatient hospital setting, probable, suspected, and rule-out diagnoses cannot be reported by the facility as though the condition exists.

If the pre- and postoperative diagnoses are different, the preoperative diagnosis should be reported.

Initial office visit for patient with nausea and vomiting. Physician documented the nausea and vomiting were due to acute appendicitis. ____________________

Long-term (current) use of aspirin. ICD-10-CM Code: ___________________

Long-term (current) use of systemic steroids. ICD-10-CM Code: ___________________

Preoperative examination for a patient who will receive a renal transplant due to ESRD, currently on dialysis. ICD-10-CM Codes: ________________, ________________, ________________

Established patient presents with chest pain. He has a history of previous myocardial infarction and coronary artery bypass surgery. ____________________

Z codes cannot be used in the outpatient setting.

Patient admitted to observation following a highway accident in which he was the driver of the car that was struck by another car. No injuries indicated during this initial encounter. ICD-10-CM Codes: ___________________, ______________________

A multigravida 48-year-old patient presents for routine prenatal visit, first trimester. No complications are noted. ICD-10-CM Code: ___________________

Exposure to German measles. ICD-10-CM Code: ___________________

Assign Z01.89, Encounter for other specified special examinations, for encounters for routine laboratory/radiology testing in the absence of any signs, symptoms, or associated diagnoses.

A patient may have an unconfirmed diagnosis for more than three visits if a definitive diagnosis has not been stated by the physician in the medical documentation.

In the outpatient setting, a diagnosis that is documented as "rule out" should not be reported.

When an encounter is for a therapeutic service, the first-listed code is the diagnosis, condition, or problem shown to be chiefly responsible for the therapeutic service.

Screening colonoscopy for colon cancer. ICD-10-CM Code: ___________________