When using ICD-10-CM, the term "first listed diagnosis" is used instead of the principal diagnosis. This is where ICD-10-CM coding guidelines are used and take priority over other coding rules in the outpatient setting. The reason for the encounter documented in the medical record will generally be the first listed diagnosis.
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In the outpatient setting, the term first-listed diagnosis is used in lieu of principal diagnosis. In determining the first-listed diagnosis the coding conventions of ICD-10-CM, as
Thus, the first-listed diagnosis or condition is governed by circumstances of admission, reflecting the reason the patient is present for the care.
It has been stressed by the guidelines laid down that the outpatient surgery encounter rules are to assign the diagnosis code as first-listed for the condition that the surgery was performed.
Rules for Choosing the First Listed Diagnosis. If there is no specific diagnosis established and the patient presents with only signs or symptoms, the signs and symptoms may be the first listed diagnosis. If a patient is seen for a procedure/surgery, the reason for the encounter (procedure/surgery) is the first listed diagnosis.
The reason for the encounter documented in the medical record will generally be the first listed diagnosis. If there is no specific diagnosis established and the patient presents with only signs or symptoms, the signs and symptoms may be the first listed diagnosis. If a patient is seen for a procedure/surgery, the reason for the encounter ...
For hospital charges, the diagnosis is given upon discharge: The Uniform Hospital discharge Data Set (UHDDS) states the definition of the principal diagnosis is: “That condition established after study to be chiefly responsible for occasioning the admission of the patient to the hospital for care. ”.
It is acceptable to code with signs and symptoms if there has been no definitive diagnosis made. However, if there are signs and symptoms commonly associated with a disease or illness, they should be reported. Signs and symptoms that may not be a part of the disease should be reported as well.
Coding for signs and symptoms from Chapter 18, should not be used if there is a more definitive diagnosis. For example, do not code the first listed diagnosis as a fever if the patient has influenza with pneumonia; you might want to code from J09-J18 Influenza and pneumonia. It is acceptable to code with signs and symptoms if there has been no ...
status codes. Status codes indicate that a patient is either a carrier of adisease or has the sequelae or residual of a past disease or condition. This includes such things as the presence of prosthetic or mechanical devices resulting from past treatment. A status code is informative, because the status may affect the course ...
Z codes are for use in any healthcare setting. Z codes may be used as either a first-listed (principal diagnosis code in the inpatient setting) or secondary code, depending on the circumstances of the encounter. Certain Z codes may only be used as first-listed or principal diagnosis. Z codes are not procedure codes.
Procedure codes are required to identify the actual administration of the injection and the type (s) of immunizations given. Code Z23 may be used as a secondary code if the inoculation is given as a routine part of preventive health care, such as a well-baby visit. status codes. Status codes indicate that a patient is either a carrier ...
A status code is informative, because the status may affect the course of treatment and its outcome. A status code is distinct from a history code. The history code indicates that the patient no longer has the condition. A status code should not be used with a diagnosis code from one of the body system chapters, ...
A status code should not be used with a diagnosis code from one of the body system chapters, if the diagnosis code includes the information provided by the status code. For example, code Z94.1, Heart transplant status, should not be used with a code from subcategory T86.2, Complications of heart transplant.
These coding guidelines for outpatient diagnoses have been approved for use by hospitals/ providers in coding and reporting hospital-based outpatient services and provider-based office visits. Guidelines in Section I, Conventions, general coding guidelines and chapter-specific guidelines, should also be applied for outpatient services and office visits.#N#Information about the use of certain abbreviations, punctuation, symbols, and other conventions used in the ICD-10-CM Tabular List (code numbers and titles), can be found in Section IA of these guidelines, under "Conventions Used in the Tabular List." Section I.B. contains general guidelines that apply to the entire classification. Section I.C. contains chapter-specific guidelines that correspond to the chapters as they are arranged in the classification. Information about the correct sequence to use in finding a code is also described in Section I.#N#The terms encounter and visit are often used interchangeably in describing outpatient service contacts and, therefore, appear together in these guidelines without distinguishing one from the other.#N#Though the conventions and general guidelines apply to all settings, coding guidelines for outpatient and provider reporting of diagnoses will vary in a number of instances from those for inpatient diagnoses, recognizing that:#N#The Uniform Hospital Discharge Data Set (UHDDS) definition of principal diagnosis does not apply to hospital-based outpatient services and provider-based office visits.#N#Coding guidelines for inconclusive diagnoses (probable, suspected, rule out, etc.) were developed for inpatient reporting and do not apply to outpatients.
When a patient is admitted for observation for a medical condition, assign a code for the medical condition as the first-listed diagnosis.#N#When a patient presents for outpatient surgery and develops complications requiring admission to observation, code the reason for the surgery as the first reported diagnosis (reason for the encounter), followed by codes for the complications as secondary diagnoses.
In the outpatient setting, the term first-listed diagnosis is used in lieu of principal diagnosis.#N#In determining the first-listed diagnosis the coding conventions of ICD-10-CM, as well as the general and disease specific guidelines take precedence over the outpatient guidelines.#N#Diagnoses often are not established at the time of the initial encounter/visit. It may take two or more visits before the diagnosis is confirmed.#N#The most critical rule involves beginning the search for the correct code assignment through the Alphabetic Index. Never begin searching initially in the Tabular List as this will lead to coding errors.
ICD-10-CM provides codes to deal with encounters for circumstances other than a disease or injury. The Factors Influencing Health Status and Contact with Health Services codes ( Z00 - Z99) are provided to deal with occasions when circumstances other than a disease or injury are recorded as diagnosis or problems.#N#See Section I.C.21. Factors influencing health status and contact with health services.
The subcategories for encounters for general medical examinations, Z00.0-, provide codes for with and without abnormal findings. Should a general medical examination result in an abnormal finding, the code for general medical examination with abnormal finding should be assigned as the first-listed diagnosis. An examination with abnormal findings refers to a condition/diagnosis that is newly identified or a change in severity of a chronic condition (such as uncontrolled hypertension, or an acute exacerbation of chronic obstructive pulmonary disease) during a routine physical examination. A secondary code for the abnormal finding should also be coded.
ICD-10-CM is composed of codes with 3, 4, 5, 6 or 7 characters. Codes with three characters are included in ICD-10-CM as the heading of a category of codes that may be further subdivided by the use of fourth, fifth, sixth or seventh characters to provide greater specificity.
When a patient presents for outpatient surgery (same day surgery), code the reason for the surgery as the first-listed diagnosis (reason for the encounter), even if the surgery is not performed due to a contraindication.
First-listed diagnosis: Terms “principal” and “primary” are often used interchangeably to define the diagnosis that is sequenced first. The term first-listed diagnosis/condition is used in the outpatient setting in lieu of principal diagnosis, and because of the timing. Moreover, in cases of an existence of a discrepancy, ...
The definition of principal diagnosis (originally developed in 1985) under the Uniform Hospital Discharge Data Set (UHDDS) is said to apply only to inpatients during acute, short-term, long-term care and psychiatric hospitals, dependent on the length of stay parameters.
Primary diagnosis: This term is often used to indicate the reason for the continued stay in the LTC facility. It is also used interchangeably with the principal diagnosis. The primary diagnosis should be listed first.
The main purpose of a diagnosis is to determine , within a certain degree of accuracy, the underlying CAUSE of the patient’s condition. It is very critical to stress the importance of proper medical coding of a diagnosis.
When using V codes, usually implemented for occasions when circumstances other than a disease or injury are recorded as a diagnosis or problem, they may be used as either a first-listed or as an additional diagnosis, but depends on the circumstances of the encounter/visit.
Take note that, chronic conditions may not always be the reason the condition is treated during the visit. But, the main reason for the visit, or what was addressed during the visit, should be the first diagnosis listed. For instance, in the case of a patient with a history of asthma, if the physician codes the exacerbation ...
Other additional codes for any coexisting conditions are to be then listed. It should be remembered that, your diagnosis—the disorder you are evaluating and/or treating—is considered the primary diagnosis and should be listed first on the claim form. Other supporting diagnoses are considered secondary and should be listed after your primary ...
Guide to Infection Prevention for Outpatient Settings: Minimum Expectations for Safe Care pdf icon [PDF 42 pages] This summary guide and companion checklist (Appendix A) describes infection prevention recommendations for outpatient (ambulatory care) settings.
The Outpatient Settings Policy Options pdf icon [PDF – 37 pages] document and accompanying worksheet pdf icon [PDF – 75 KB] are designed to assist state, local, and territorial health departments and policymakers to assess current outpatient policies and consider options for improving practices.
This document has been developed for outpatient oncology facilities to serve as a model for a basic infection control and prevention plan. It contains policies and procedures tailored to these settings to meet minimal expectations of patient protections as described in the CDC Guide to Infection Prevention in Outpatient Settings.
CDC has numerous resources to assist clinicians in delivering safe care. Please visit: