The difference between the official coding guidelines for using V codes in an inpatient and outpatient setting is the guidelines for an outpatient setting indicates code sequencing for physician office and clinical encounters. V codes also may be used as the principal and secondary diagnosis in the inpatient setting compared to those that may be as the first listed or secondary diagnosis in the outpatient setting. The most important difference in the official guidelines of V codes is that the definition of principal diagnosis applies only to inpatients in acute, short-term, general hospitals. This means that the V coding guidelines for inconclusive diagnoses were developed for inpatient reporting and do not apply to an outpatient setting. Diagnoses are often not established at the time of the initial outpatient encounter or visit, because of this, it is an extremely important guideline when using V codes. In many outpatient cases, the diagnosis V code for a presenting sign or symptom must be assigned because a definitive diagnosis has not yet been determined.
2. You’ve started your first day at Venture Outpatient Surgery Center. Explain how you would code an operative report.
To code an operative report the coder should first read through the entire report and take notes any possible diagnoses or abnormalities noted and any procedures performed. The coder should then review the physician’s list of diagnoses and procedures to see if they match. If the coder should locate a potential diagnosis or procedure not listed by the physician, they should bring this to the physician’s attention to see if it is significant enough to code. If preoperative and postoperative diagnoses are different, the coder should use the postoperative diagnosis. The coder should also review the pathology report if specimens were sent to pathology, to verify the diagnosis.... [continues]
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