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CHAPTER 3. ICD-9-CM OUTPATIENT CODING AND REPORTING GUIDELINES. Section IV Diagnostic Coding. Physician’s office Hospital-based outpatient services Part of Official Guidelines for Coding and Reporting, Section IV. Section IV Diagnostic Coding.

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chapter 3



section iv diagnostic coding
Section IV Diagnostic Coding
  • Physician’s office
  • Hospital-based outpatient services
  • Part of Official Guidelines for Coding and Reporting, Section IV
section iv diagnostic coding1
Section IV Diagnostic Coding
  • Guidelines do not address specific sequencing or diseases as inpatient do
  • Though not stated, if there is no outpatient guideline, follow inpatient guidelines
diagnostic coding guideline a
Diagnostic Coding Guideline A
  • Term first-listed diagnosis, rather than principal diagnosis
  • Outpatient Surgery: Reason for surgery
    • Even if surgery is cancelled due to contraindication
diagnostic coding guideline a1
Diagnostic Coding Guideline A
  • Observation Stay: Medical condition that occasioned admission
    • Assign a code from medical condition
  • Observation Stay: Complications from outpatient surgery lead to observation report:
      • Reason for surgery as first reported diagnosis
      • Codes for complications necessitating observation
selection of first listed diagnosis
Selection of First-Listed Diagnosis
  • Condition for encounter
    • Why patient presented, not necessarily most serious condition noted
  • Documented
  • Chiefly responsible for services provided
  • Also listco-existing conditions
diagnosis and services
Diagnosis and Services
  • Diagnosis and procedure MUST correlate
  • Medical necessity must be established through documentation
  • No correlation = No reimbursement
symptoms signs and ill defined conditions
Symptoms, Signs, and Ill-Defined Conditions
  • Can be the first-listed diagnosis if no more specific diagnosis available
  • Diagnoses often are not established at the time of the initial encounter/visit
diagnostic coding guideline b
Diagnostic Coding Guideline B
  • Use codes 001.0 through V91.99 to code:
    • Diagnosis
    • Symptoms
    • Conditions
    • Problems
    • Complaints
    • Or other reason(s) for visit
diagnostic guideline c
Diagnostic Guideline C
  • Documentation should describe patient's condition, using terminology that includes:
    • Specific diagnoses
    • Symptoms
    • Problems
    • Reasons for encounter
diagnostic guideline d
Diagnostic Guideline D
  • Selection of codes 001.0 through 999.9 (Chapters 1-17) frequently used to describe reason for encounter
diagnostic guideline e
Diagnostic Guideline E
  • Codes that describe symptoms and signs, as opposed to diagnoses, acceptable for reporting purposes when
    • An established diagnosis has NOT been determined by physician
diagnostic guideline f
Diagnostic Guideline F
  • V codes deal with encounters for circumstances other than disease or injury
    • Example: Well-baby checkup
  • See Section I.C.18 for information onV codes
section i c 18 classification of factors influencing health status and contact with health service
Section I.C.18. Classification of Factors Influencing Health Status and Contact with Health Service
  • V01-V91
    • Assigned as first-listed diagnosis for:
      • Admissions for evaluation
      • Following an accident that would ordinarily result in health problem, BUT there is none
    • Car accident, driver hits head, no apparent injury, admit to R/O head trauma
    • Never a secondary diagnosis
v codes
V Codes
  • Located after 999.9 in Tabular
  • Two digits before decimal (e.g., V10.1X)
  • Index for V codes is Alphabetic Index to Diseases
  • Main terms:
    • Contraception
    • Counseling
    • Dialysis
    • Status
    • Examination
uses of v codes
Uses of V Codes
  • Not sick BUT receives health care (e.g., vaccination)
  • Services for known/resolving disease/injury (e.g., chemotherapy)
  • Codes for “aftercare” (e.g., surgery or fracture)
  • Indicate birth status/outcome of delivery


uses of v codes1
Uses of V Codes


  • A circumstance/problem that influences patient’s health BUT NOTcurrent illness/injury
    • Example: Organ transplant status
    • Example: Birth status and outcome of delivery (newborn)
  • Section I.C.18.e. of Guidelines contains the V Code Table
    • Identifies if V code can be listed as first, first/additional, additional only
history v code categories in tabular
History V Code Categories in Tabular
  • V10 Personal history of malignant neoplasm
  • V11 Personal history of mental illness
  • V12 Personal history of certain other diseases
  • V13 Personal history of other diseases
  • V14 Personal history of allergy to medicinal agents
  • V15 Other personal history presenting hazards to health
  • V16 Family history of malignant neoplasm
  • V17 Family history of certain chronic disabling diseases
  • V18 Family history of certain other specific diseases
  • V19 Family history of other conditions

Condition no longer present or treated

diagnostic guideline g
Diagnostic Guideline G
  • Codes have either 3, 4, or 5 digits
  • 4 and/or 5 digit codes provide greater specificity (detail)


diagnostic guideline g1
Diagnostic Guideline G


  • 3-digit code used ONLY if no 4 or 5 digit
  • Where 4 and/or 5 digits provided, must be assigned
  • Diagnoses NOT coded to full digits available invalid
  • Claims bounce!
diagnostic guideline h
Diagnostic Guideline H
  • List first code for diagnosis, condition, problem, or other reason for encounter/visit shown in medical record to be chiefly responsible for services provided
  • List additional codes that describe any coexisting conditions
  • Assign V72.5 and/or V72.6x for routine lab/radiology test ordered without signs, symptoms, or associated diagnosis
diagnostic guideline i
Diagnostic Guideline I
  • Do NOT code diagnoses documented as probable, suspected, questionable, rule out, or working diagnoses
  • Rather, code condition(s) to suspected highest degree of certainty for that encounter/visit, such as symptoms, signs, abnormal test results, or other reason for visit
diagnostic guideline j
Diagnostic Guideline J
  • Chronic diseases treated on an ongoing basis may be coded and reported as many times as patient receives treatment and care for condition(s)
diagnostic guideline k
Diagnostic Guideline K
  • Code all documented conditions that coexist at time of visit, that require or affect patient care, treatment, or management
  • Do NOT code conditions previously treated, no longer existing


diagnostic guideline k1
Diagnostic Guideline K


  • “History of” codes (V10-V19) may be used as secondary codes if:
    • Impacts current care or treatment
special note about history of
Special Note About “History of”
  • Index to Disease, MAIN term “History”
  • Entries between “family” and “visual loss V19.0” = “family history of” (FHO)
  • Entries before “family” and after “visual loss” = “personal history of” (PHO)
  • Personal history = V10-V15
  • Family history = V16-V19
diagnostic guidelines l and m
Diagnostic Guidelines L and M
  • For patients receiving diagnostic services ONLY
  • Sequence first
    • Diagnosis
    • Condition
    • Problem


    • Other reason shown in medical record to be chiefly responsible for encounter


diagnostic guidelines l and m1
Diagnostic Guidelines L and M


  • Codes for other diagnoses (e.g., chronic conditions)
    • May be sequenced as secondary diagnoses
  • Exception: Therapeutic Services
    • Patients receiving chemotherapy (V58.11), radiation therapy(V58.0), or rehabilitation (V57.0-V57.9)
    • V code first diagnosis and problem for which service being performed second
diagnostic guideline n
Diagnostic Guideline N
  • For patients receiving preoperative evaluations ONLY
    • Code from category V72.8 (Other specified examinations)
    • Assign secondary code for reason for surgery
    • Code also any findings related to preoperative evaluation
diagnostic guideline o ambulatory surgery
Diagnostic Guideline O, Ambulatory Surgery
  • Code diagnosis which required ambulatory surgery
  • Pre- and post-op diagnosis different
    • Code the post-op diagnosis
diagnostic guideline p
Diagnostic Guideline P
  • Code routine prenatal visits with no complications:
    • V22.0 (Supervision of normal first pregnancy)
    • V22.1 (Supervision of other normal pregnancy)
    • DO NOT use these codes with pregnancy complication codes (Chapter 11, ICD-9-CM)
v91 multiple gestation placenta status
V91 Multiple Gestation Placenta Status
  • New in 2011
  • Identifies twins, triplets, quadruplets, other multiples
conclusion chapter 3

ConclusionCHAPTER 3