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

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

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.

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.

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

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

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

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

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