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

Code all the documented conditions that coexist at the time of an encounter/visit and require or affect patient care, treatment, or management.

A patient is admitted to an observation unit for a medical condition that has worsened and is then admitted as an inpatient to the same hospital for the same medical condition. The primary diagnosis would be the medical condition that led to the admission.

The term "primary diagnosis" is the same as the first-listed diagnosis.

For an outpatient service, a history code (Z80-Z87) may be assigned as a secondary code if the historical condition or family history has an impact on the current care or has an influence on the treatment.

Corneal ulcer with hypopyon of left eye. ICD-10-CM Code: ___________________

Section IV of the Official Guidelines for Coding and Reporting applies to both the inpatient and outpatient settings.

Encounter for blood type testing prior to surgery. ICD-10-CM Code: ___________________

Screening for respiratory tuberculosis. ICD-10-CM Code: ___________________