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ICD-10-CM 1st Listed
Which codes must be listed first in OP setting?
| Question | Answer |
|---|---|
| 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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