The term first-listed diagnosis/condition is used in the outpatient setting in lieu of principal diagnosis, once again because of the timing. Often, diagnoses are not established at the time of the initial encounter in the outpatient setting and it may take two or more visits prior to a confirmed diagnosis. The documentation to support the reason for the visit should describe the patient's condition, using terminology that includes either specific diagnoses and/or symptoms, problems, or reasons for the encounter. In the instance where a discrepancy is discovered, determining the first-listed diagnosis per the coding conventions of ICD-9-CM, as well as the general and disease-specific guidelines within ICD-9-CM, will have precedence over the outpatient guidelines.
•In the outpatient setting, code all documented conditions that coexist at the time of the encounter AND require or affect patient care treatment or management. Do NOT code conditions that were previously treated and no longer exist. However, history codes (V10-V19) may be used as additional codes if the historical condition or family history has an impact on current care or influences treatment. Codes for other diagnoses (e.g., chronic conditions the patient receives treatment for, including medication management) and care should be sequenced as additional diagnoses. •For visits in the outpatient setting for routine laboratory/radiology testing in the absence of any signs, symptoms or associated diagnosis, assign V72.5 and/or a code from subcategory V72.6. If routine testing is performed during the same encounter as a test to evaluate a sign, symptom or diagnosis, it is appropriate to assign both the V code and the code describing the reason for the non-routine test. Please review individual coding policies at your facility for guidance on using these generic codes. •Reporting visits in the outpatient setting for diagnostic tests that have been interpreted by a physician...
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