Resource Outpatient Coding Tips

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• Uncertain diagnoses are NOT reported in the outpatient setting. The signs, symptoms, abnormal test results, or other reasons for the visit would be reported.
• Chronic diseases in the outpatient setting should be reported. If a condition is under current treatment it should be reported for each visit as long as the patient is receiving treatment for the condition. Remember though that there are chronic diseases that are systemic conditions and the patient will have them for the remainder of their life. Some of these are HTN, COPD, asthma, emphysema, and diabetes. It may be that some research is necessary to determine if the condition is one that has a cure or if it is one that they will have forever.
• All outpatient orders should be reviewed to determine if additional signs, symptoms, or diagnoses are provided
• Coders may report confirmed diagnoses on radiology and pathology reports (except for incidental findings)
• “Z” codes help paint the entire health picture for the patient. If there is a specific code for a past or family condition, it will most likely always be reported
• Code only confirmed diagnosis on outpatient encounters
• Remember to report any long term use of specific medications
• Sometimes it is the “Z” codes that will help meet medical necessity for outpatient testing
• Chronic conditions should be reported on each visit when they are under treatment or are systemic medical conditions
• Chronic systemic conditions should be reported even in the absence of intervention or further evaluation. These conditions will affect patients for the rest of their lives or most of their lives and require continuous clinical monitoring and evaluation. Certain medications are not to be used if a patient has a certain condition or can’t be mixed when taking a certain medication. This should always be part of the physician’s medical decision-making process.
• Coders may not assign a diagnosis code based on the up/down arrows on order or MD note.
• Coders should remember that additional diagnoses reported on claims can help in supporting the medical decision making that went into treating this patient
• Any diagnosis that requires treatment or monitoring would be reported regardless of if it is chronic or develops during the visit
• Past medical conditions and diagnoses help improve communication with other healthcare providers and registries. The diagnoses are not just reported for payment but statistics.
• Signs and symptoms may be reported in addition to specific diagnosis codes if the physician has not clearly documented the link between signs/symptoms and the condition. This is due to limited documentation in outpatient records and the need for additional follow-up testing that may be necessary.

Coders must review the entire outpatient encounter rather than only focusing on the reason for the visit. Diagnoses and symptoms may be found in radiology orders and impressions, orders for labs, anesthesia evaluations, history of present illness, a physical exam by the physician, past medical history, current medications, and the final impression. Not all of these will be present for every outpatient encounter, but they should be reviewed if present. Reviewing these areas will ensure that all pertinent secondary diagnoses and status codes are reported.

 

[WhitneyH_24046]

Great info! Thanks Lori!