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

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.

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

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

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

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.

An established patient is seen for migraines and seizures, to rule out the possibility of a brain tumor.Identify the primary diagnosis(es).____________________

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

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

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

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

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

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: ____________________

Z codes cannot be used in the outpatient setting.

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

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

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.

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

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

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