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ICD-10-CM 1st Listed

Which codes must be listed first in OP setting?

QuestionAnswer
Patient had pre-op exam. Which code is first listed? 2nd listed? After that? Z code for pre-op exam - 1st. Reason for surgery - 2nd; findings from pre-op exam after that.
Patient had only diagnostic testing done during visit. What is the 1st listed code? Reason for the testing.
Patient had only therapeutic treatment during visit. What is the 1st listed code? Condition or diagnosis being treated.
Which takes precedence in OP setting? Outpatient guidelines or ICD-10 disease and chapter-specific guidelines? ICD-10 disease and chapter-specific guideline
Patient arrives for scheduled surgery. What is the first-coded diagnosis? Reason for the surgery
When coding Z codes, how can the coder know whether the Z-code can or must be first-listed? Check the notes
If a diagnosis code from one of the Chapters indicates the current status of the patient, should a Z status code be used? No
Under what conditions are External Cause diagnosis codes first-listed? None. They are never first-listed.
Where would the coder look to locate a code indicating the circumstance of an accident? Is it part of the Alphabetic Index? Index of External Cause. No, it is separate.
If a patient is being treated for a condition that influences the patient's health, but is not the current problem, i.e., allergy to medication, what is the first-listed ICD-10 code? The condition(s) being treated would be first-listed. the Personal history of the allergy would be an additional code.
If patient is admitted for Observation for a medical condition, which diagnosis code would be first-listed? the medical condition would be first listed.
If patient is admitted for Observation following a complication that arose during OP surgery, which diagnosis code would be first-listed? 2nd listed? The reason for the surgery would be 1st-listed. The complication would be second listed.
If a newborn is suspected to have a condition that is later proven not to be present in the absence of signs and symptoms, but was observed and evaluated for the condition, what code would be used? Z05.0-Z05.9 - Observation of newborn codes
If a newborn has signs and symptoms of a suspected condition, what diagnosis codes would be used? Codes for signs and symptoms of the suspected problem without the Z codes for observation of newborns.
Uncertain diagnosis - code or not to code? Which setting is which? Inpatient - code uncertain dx Outpatient - do NOT code uncertain dx; just code sx/sx, abnormal test results, etc.
Chronic diseases. How often can the coder use the dx code for a chronic disease? As often as care provided addresses the chronic condition.
Does renewing medication count as providing treatment for chronic conditions? YES
If the primary reason for the visit is for DIAGNOSTIC testing, and the patient has other chronic conditions, should the chronic conditions be coded? Yes as additional codes following the primary reason for the tests.
If routine tests and tests being performed for active symptoms are both performed at the same encounter, how should the diagnoses be coded? Include both the Z code for routine testing as well as the codes for signs/symptoms/diagnosis.
If patient a has signs/symptoms and a diagnostic test is performed to evaluate sx/sx, and during the same encounter, the physician performs interpretation of the test results, what dx codes should be reported? Should sx/sx also be reported? If there is a definitive diagnosis, that definitive dx should be coded and the sx/sx would NOT be coded.
If the primary reason for the visit is for THERAPEUTIC services only, and the patient has other chronic conditions, should the chronic conditions be coded? Yes, as additional codes following the primary reason for the reason for encounter/visit with exception of chemo/rad tx.
Pre-op exam codes are in what range of codes? Z01.810-Z01.818
When coding an outpatient surgery, what diagnosis code would be used if the post-op diagnosis is different from the pre-op dx? Use the Post-op diagnosis code.
For normal, uncomplicated pregnancy, which codes should be used? Z codes from Category Z34.
Which diagnosis codes are used for high-risk pregnancy prenatal care? Category O09
If there are no complications with labor and delivery/birth, which diagnosis code would be used? O80 - full-term uncomplicated delivery.
For high-risk pregnancy routine prenatal care, what would be the 1st-listed code? Category O09 code should be first listed. Additional Chapter 15 codes would be added if appropriate.
True or False? Category O09 codes are intended only for prenatal care. True
True or False? Sequelae includes presence of prosthesis or mechanical device from a past condition or disease. True
Sequelae are coded with what codes? status Z codes
True or False? History codes are used for conditions that no longer exist. True
Created by: ZonaB2
 

 



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