2022 OUTPATIENT CODING ICD-10- CM/CPT/HCPCS (Domain 1)

2022 OUTPATIENT CODING ICD-10- CM/CPT/HCPCS (Domain 1) Encounter and Visit are often used interchangeably in describing ____________ - ✔✔Outpatient Service (Diagnostic Coding and Reporting Guidelines for Outpatient Se ...

2022 OUTPATIENT CODING ICD-10- CM/CPT/HCPCS (Domain 1) Encounter and Visit are often used interchangeably in describing ____________ - ✔✔Outpatient Service (Diagnostic Coding and Reporting Guidelines for Outpatient Services) In the outpatient setting, the term _______diagnosis is used in lieu of principal diagnosis. - ✔✔FirstListed (Selection of first-listed condition) In determining the first-listed diagnosis the coding conventions of ICD-10-CM, as well as the general and disease specific guidelines take precedence over ______ - ✔✔Outpatient guidelines. (Selection of first-listed condition) _________often are not established at the time of the initial encounter/visit. - ✔✔Diagnoses (Selection of first-listed condition) Begin the search for the correct code through the Alphabetic Index. Never begin searching initially in the Tabular List ______________ - ✔✔Alphabetic Index Tabular List (Selection of first-listed condition) Codes that describe symptoms and signs, are _______ when a diagnosis has not been established (confirmed) by the provider - ✔✔acceptable (Selection of first-listed condition) When a patient presents for outpatient surgery (same day surgery), code the reason for the surgery as ___________ even if the surgery is not performed due to a contraindication. - ✔✔The first-listed diagnosis (reason for the encounter), (Outpatient Surgery & observation) When a patient is admitted for observation for a medical condition, assign a code for the medical condition as _____ - ✔✔First-Listed diagnosis. (Outpatient Surgery & observation) When a patient presents for outpatient surgery and develops complications requiring admission to observation, code ___________ as the first listed diagnosis, followed by codes for the complications as __ diagnoses. - ✔✔The reason for the surgery; secondary (Outpatient Surgery & observation) For patients receiving diagnostic services only during an encounter/visit, sequence first _____________ provided during the encounter/visit. - ✔✔The diagnosis, condition, problem, or other reason for encounter/visit shown in the medical record to be chiefly responsible for the outpatient services (Patients receiving diagnostic services only) (Patients receiving diagnostic services only), Codes for other diagnoses (e.g., chronic conditions) may be sequenced as _______diagnoses. - ✔✔Additional Encounters for routine laboratory/radiology testing in the absence of any signs, symptoms, or associated diagnosis, assign ___________. - ✔✔Z01.89 (Patients receiving diagnostic services only) If routine testing is performed during the same encounter as a test to evaluate a sign, symptom, or diagnosis, assign _____________code - ✔✔Both the Z code and the code describing the reason for the non-routine test (Patients receiving diagnostic services only) Diagnostic tests that have been interpreted by a physician, and the final report is available at the time of coding, code ______________ - ✔✔Any confirmed or definitive diagnosis(es) documented in the interpretation. Do not code related signs and symptoms as additional diagnoses. Please note: This differs from the coding practice in the hospital inpatient setting regarding abnormal findings on test results. (Patients receiving diagnostic services only) Patients receiving therapeutic services only during an encounter/visit, sequence first _______________ - ✔✔The diagnosis, condition, problem, or other reason for encounter/visit shown in the medical record (Patients receiving therapeutic services only) Codes for other diagnoses (e.g., chronic conditions) may be sequenced as ___________ - ✔✔Additional diagnoses. The only exception to this rule is that when the primary reason for the admission/encounter is chemotherapy or radiation therapy, the appropriate Z code for the service is listed first, and the diagnosis or problem for which the service is being performed listed second. (Patients receiving therapeutic services only) CPT/HCPCS is the system used for coding all ___________ encounters whether performed in the physician's office, emergency department, clinic or other ambulatory care setting. - ✔✔outpatient (Procedure Coding) The HCPCS system is comprised of the _____________