STEP-BY-STEP MEDICAL CODING - CHAPTER 3

First listed diagnosis

Outpatient setting, first listed is the diagnosis used in lieu of the principal diagnosis

If diagnosis cannot be determined then use signs and symptoms

Looking up code process

Alphabetic index first and then use the Tabular

Determining first listed diagnosis

CC is used as a key

Try to see if there is a diagnosis

If no diagnosis is found in notes than you can use CC (which are the signs and symptoms)

Additional diagnosis

Listed under first listed diagnosis

Some cases need additional diagnosis to describe complications, reasons for cancelled procedures, and other coexisting conditions

Z codes

located in Chapter 21

Factors influencing Health Status and Contact with Health Services codes (Z00-Z99) are provided to deal with occasions when circumstances other than a disease or injury are recorded as diagnosis or problems

What does each chapter represent in the tabular

different organ system or type of disease

Status Codes

Indicates a patient is either a carrier of a disease or has the sequelae or residual of a past disease or condition. It shows that the status may affect the course of treatment for current condition. It is different from a history code because the patient currently has the disease as well as whatever they are being seen for.

External cause codes

Never reported as first diagnosis

Used to clarify an injury or adverse effects

Reasons to use Z Codes

1. Patient is not sick but has specific reason for visit

2. Patient who has known disease or injury receives services for treatment of that disease or injury (ex. chemotherapy treatment)

3. A circumstance or problem is present and influences a patients health status but is not in itself the current illness

4. To indicate the birth status and outcome of the delivery of a newborn.

Chronic disease coding

If a patient has a chronic condition that is treated on an ongoing basis, you can report the condition as many times as the patient receives care or treatment for the condition

Documented Conditions

Code conditions that coexist at the time of the encounter and for which the physician provides care, treatment or management

Observation Stay Z codes

Two categories Z03 and Z04. Can be listed as first diagnosis

Diagnostic Service coding

When a diagnostic service is provided to a patient during an encounter, the reason for the service is the diagnosis stated

Therapeutic Service coding

Report the diagnosis, condition or problem or other reason for the encounter when a patient presents for a therapeutic service

Preoperative evaluation

When the only service is a preoperative examination, report the appropriate Z code along with any codes that indicate significant conditions.

Prenatal visits

1. Routine outpatient prenatal visits use category Z34

2. Prenatal outpatient visits for high risk patients use code from O09