Coding Tip: Diagnosis Reporting on Outpatient Records
RHIT, CDIP, CCS, CCS-P
Director of Coding Quality Assurance
AHIMA Approved ICD-10-CM/PCS Trainer
Today’s coding tip addresses diagnosis reporting on outpatient records.
In the outpatient setting, it can be difficult to know what diagnoses are reportable and what should be the first listed code/primary diagnosis for the account.
In outpatient coding, coders are allowed to code from the pathology and radiology reports without the attending/treating physician confirming the diagnosis. The pathologist and radiologist are physicians and as long as they have interpreted the tissue or test then it may be coded. Coders should code to the highest degree of certainty at the time of coding. If there is a final report available at the time of coding, which is authenticated by a physician, it may be used to code from.
Outpatient coders may not code from laboratory reports unless the physician has made a notation regarding the findings with a diagnosis from the laboratory results.
This guidance did not change with the implementation of ICD-10 but there still are a lot of questions regarding this. The recent AHA Coding Clinic for ICD-CM/PCS does confirm that the previous advice is still current. This publication also gives excellent examples of outpatient coding scenarios.
AHA Coding Clinic® for ICD-10-CM and ICD-10-PCS, Fourth Quarter 2015 Pages: 20-21
AHA Coding Clinic® for ICD-10-CM and ICD-10-PCS, First Quarter 2017 Pages: 4-7
Official Guidelines for Coding and Reporting FY 2017, Page: 104-108
The information contained in this coding advice is valid at the time of posting. Viewers are encouraged to research subsequent official guidance in the areas associated with the topic as they can change rapidly.