Step-by-Step 2016: Ch 3 (Outpatient Coding and Reporting)

urinary tract infection
Established patient complaining of painful urination and frequency. Patient is a type 2 diabetic. Lab work revealed a urinary tract infection and blood glucose was within normal limits. First listed diagnosis:
Crohn’s disease
Established patient presented to clinic with exacerbation of Crohn’s disease. Patient’s rheumatoid arthritis is stable and no medical ion changes were made. First listed diagnosis:
sprained knee
Initial office visit for sprained left knee. Patient has a history of hypertension and asthma, both stable at this time. First listed diagnosis
Initial office visit for patient requiring equal management of COPD and CHF. First listed diagnosis:
Established patient seen for cough, fever, and shortness of breath. Chest x-ray confirmed physician’s diagnosis of pneumonia and patient was sent home on antibiotics. First listed diagnosis:
R10.9 (Pain, abdominal), K92.1 (Blood, in, feces)
Initial office visit for a 28-year old male with persistent abdominal pain and bloody diarrhea. Patient was scheduled for small-bowel x-rays and colonoscopy and will be seen in the office following those outpatient procedures
K51.90 (Colitus, ulcerative chronic)
Follow-up office visit for a 28-year old male with recent colonoscopy with biopsy and small bowel x-rays confirmed that the patient had ulcerative colitis and the patient was started on sulfasalazine. Code:
R53.83 Fatigue; R17 (Jaundice (yellow))
Initial office visit for 55-year old male with fatigue and jaundice. Laboratory tests were ordered and patient will return in 1 week for the results. Codes:
B19.20 (Hepatitis C (viral))
Follow-up visit for 55-year old male with jaundice and fatigue. Diagnostic tests confirm that the patient has hepatitis C. Code:
According to the Guidelines, which category code should you reference to report inoculations and vaccinations:
According to the Guidelines, this category is referenced when reporting suspected exposure to a communicable disease:
Can Z codes only be used in the outpatient setting?
Y92.815 (place of occurrence, train)
Railway accident involving derailment without antecedent collision, injuring a porter. Place of occurrence code:
Admission for elective sterilization
A female patient was admitted as an outpatient for elective b ilatateral tubal ligation. The patient was noted to be wheezing during the nurse’s assessment. She was seen by her physician and her surgery was canceled because of an exacerbation of her asthma. First listed Diagnosis:
Benign prostatic hypertrophy
A male patient was admitted as an outpatient for transurethral prostatic resection for symptomatic benign prostatic hypertrophy. First listed Diagnosis:
A patient was admitted as an outpatient for cystoscope for heanmaturia. The procedure was performed without complications. No abnormality or explanation for the hematuria was found. First listed Diagnosis:
V48.5XXA (Accident, transport, car occupant, driver, no collision accident [traffic])
Motor vehicle traffic accident due to tire blowout; driver of the car was injured, initial encounter. Injured person code:
V86.59XA (Accident, transport, all-terrain vehicle occupant, driver)
Driver of an ATV 9off-road vehicle) is injured when he collides with a fence. Injured person
V80.790A (Accident, transport, animal-rider, collision with, non-motor vehicle)
Horse being ridden, rider injured, and non-motor vehicle collision, initial encounter. Injured person code:
V91.83XA (Accident, watercraft, causing, injury NEC)
Accident to watercraft causing other injury; occupant of small powered boat injured due to collision, initial encounter. External cause code:
Contact, smallpox (laboratory); Z20.89
A person who has been in contact with smallpox. Index location: Code:
Immunization, encounter for; Z23
Prophylactic vaccination against smallpox. Index location: Code:
History, personal, malignant neoplasm (of), oral cavity, specified site; Z85.818
Personal history of malignant neoplasm of the lip. Index location: Code:
Z45.018 (Admission for, adjustment (of), oral cavity, specified site; Z85.818
Admission for cardiac pacemaker adjustment. Code:
Z30.018 (Contraception, initial prescription, specified type, NEC)
Initial prescription and insertion of subterm all implantable contraceptive. Code:
Z85.46 (History, personal, malignant neoplasm [of], prostate
Personal history of cancer of the prostate. Code:
Z23 (Immunization, encounter for)
Baby in for MMR (Measles, mumps, rubella) vaccination. Code:
Z12.31 (Mammogram, routine)
Screening mammogram. Code:
Z02.1 (Encounter, administrative purposes only, examination for, employment)
Clinic visit for pre-employment physical examination. Code:
The I-10 code to report observation for suspected exposure to anthrax, ruled out, is
When reporting the diagnosis for a patient admitted to observation status for a medical condition, assign a code for the ____ condition as the first listed diagnosis.
Z04.1; b. S40.811A
The patient fell off his motorcycle when turning too sharply and his his head on the sidewalk. The patient was wearing a helmet. The examination reveals no outward head injury. The only injury noted on examination is abrasion of the right upper arm. The patient is admitted overnight to the obese ration unit to rule out head injury. No head injury was found.
A. Hospital observation is located in the index under the main term “Observation,” Listed under the main term are the reasons for observation. The subterm is “accident NEC” and subterm “transport.” CCheck the code in the Tabular. What is the Z code. Code:
The second code is for the abrasion to the right upper arm. When you locate “Abrasion” and subterm “arm (upper)” you are directed to S40.81-0 (the “-” indicates that the Tabular is to be referenced for the additional characters. What is the code for the abrasion? Code:
An adult patient is admitted for observation and further evaluation following an alleged rape, ruled out. There is only one code for this case. What is that Z code? Code:
Pelvic pain
A 35 year old female patient was admitted to observation of severe nausea and vomitting following diagnostic laparoscopy for pelvic pain. First listed diagnosis:
Biliary duct stricture
A male patient was admitted to observation following an endoscopic retrograde cholangiopancreatography (ERCP) for acute pancreatitis. Patient has a biliary duct stricture. First listed diagnosis:
Post-menopausal bleeding
Patient was admitted for observation because of urinary retention following a Dilation and Curettage (D&C) for post-menopausal bleeding. First listed diagnosis:
Palpitations R00.2, Arthritis, rheumatoid, M06.9
Patient was seen in the office for a consultation for palpitations. Patient also has rheumatoid arthritis. Medications that the patient takes for the arthritis were reviewed to see if they could be the cause of the palpitations.
First listed diagnosis: _______
Code: _______
other diagnosis: _______
code: _______
Memory loss R41.3, diabetes mellitus, type II E11.9, long-term (current) use of insulin Z79.4
Patient is an established patient with memory loss. Patient also has a long-term (current) use of insulin for diabetes type 2.
First listed diagnosis: _______
Code: _______
Other diagnoses: _______ and _______
Codes: _______ and _______
Urinary tract infection N39.0, psoriasis L40.0
Patient is a new patient who was seen for flank pain and diagnosed with a urinary tract infection, and antibiotics were prescribed. Patient has psoriasis, which is stable at this time.
First listed diagnosis: _______
Code: _______
Other diagnosis: _______
Code: _______
Pain, joint, knee M25.561, Stiffness, knee M25.661. Osteoarthritis is not reported because it has not been confirmed and is a “rule out” diagnosis
Patient is seen in the office for pain and stiffness of the right knee. X-rays to rule out osteoarthritis were performed.
Reported diagnosis and code: _______
Reported diagnosis and code: _______
Diagnosis not reported: _______
Pain, wrist M25.532, numbness R20.0 Carpal tunnel syndrome is not reported because the condition has not been confirmed, rather it is a “probable” condition
Office visit for established patient with left wrist pain and numbness of fingertips. Studies ordered for probable carpel tunnel syndrome.
Reported diagnosis and code: _______
Reported diagnosis and code: _______
Diagnosis not reported: _______
Amenorrhea N91.2, Galactorrhea not associated with childbirth, N64.3. Pituitary tumor is not coded because it has not been confirmed
Office consultation for a new patient with amenorrhea and Galactorrhea. Studies to rule out pituitary tumor were ordered.
Reported diagnosis and code: _______
Reported diagnosis and code: _______
Diagnosis not reported: _______
Breast lump N63. Breast cancer is not reported because the condition has not been confirmed
Initial visit for a patient with a breast lump. Working diagnosis is breast cancer. Diagnostic work up has been scheduled
Reported diagnosis and code: _______
Diagnosis not reported: _______
J44.0 (Bronchitis, acute or subacute, with, chronic obstructive pulmonary disease), F17.210 (Dependence, nicotine, cigarettes)
Harry Drew, a patient with chronic obstructive pulmonary disease, presents for a one-week follow-up for bronchitis. He continues to smoke 1 package of cigarettes per day, against repeated medical advice.
Codes: _______, _______
J44.9 (disease, airway, obstructive, chronic), F17.210 (Dependence, nicotine, cigarettes)
Harry Drew presents 10 days later for repeated follow-up regarding his bronchitis and to ensure that the infection had responded to the antibiotic prescribed 10 days previously. the physician determined that the bronchitis had responded well and no further bronchitis was identified. The patient’s COPD continues to inhibit his activities. He continues to smoke 1 package of cigarettes per day and since his bronchitis has improved he says he is smoking “a bit more”
Codes _______, _______
Z01.83 (Encounter, blood typing)
David presents for blood typing for his surgery in two days.
Code: _______
Z00.00 (Examination, annual)
Chris, a 42 year-old male patient, presents for his annual examination.
Code: _______
Z51.11 (Chemotherapy, neoplasm); C56.2 (Table of Neoplasms, Neoplasm, ovary. Malignant Primary)
The patient presents for a chemotherapy treatment due to primary, malignant ovarian cancer of the left ovary.
Codes: _______
D52.0 (Anemia, deficiency, folate, dietary)
A patient with dietary folate deficiency anemia presents of a folate injection.
Code: _______
Z01.82 (Examination, allergy)
A patient presents for allergy testing
Code: _______
Pre operative cardiovascular examination
Pre operative respiratory examination
Pre operative examination
What Z code would you report for the pre-procedural consultation
Code: _______
Lung mass
Sam is a 7 year old male patient who is brought to Dr. Well;s office for a pre procedural consultation of a mass on his left lung. Dr. Well reviews the patient’s X-rays and MRI taken the previous week and sent from Dr. Gross man, Sam’s pediatrician. In addition to the Z code, you would report what diagnosis?
Z code
Would the Z code or diagnosis code be first listed?
When a patient is to have outpatient surgery and the surgery is not performed due to contradiction, the reason the surgery was not performed is the first listed diagnosis
It is appropriate to code the postoperative diagnosis as it is the most definitive diagnosis for ambulatory surgery
Chronic diseases that are treated on an ongoing basis should be coded and reported as often as the patient receives treatment and care for the chronic conditions
In the physician office it is acceptable to report Z codes as a first listed diagnosis
In the outpatient setting it is unacceptable to have a sign or symptom as the first listed diagnosis
When coding an encounter for pre operative evaluation, the reason that the patient is having the surgery or procedure performed is the first listed diagnosis
In the outpatient setting, diagnoses that are documented as “probable,” “suspected”, “rule out” or “questionable” are reported to the highest degree of certainty, such as symptoms, signs abnormal test results, or other reasons for the visit
The first listed diagnosis is defined as the diagnosis that is the most serious
It is acceptable to report a code from Chapter 15 in conjunction with Z34.00 or Z34.80
It is acceptable to code signs and symptoms even when a definitive diagnosis has been confirmed.
First listed diagnosis: diaper rash
code: L22
Initial office visit for diaper rash
first- listed diagnosis: Congestive Heart failure
code i50.9
estalished patient presents with dyspnea and lower extremity edema. the physician determined that the patient’s symptoms were due to an exacerbation of congestive hear failure.
First listed diagnosis: Vitamin B12 deficiency
code: e53.8
Other diagnoses: hypertension
Code: I10
established patient seen for management of vitamin b12 deficiency and hypertension
first: anterior cruciate ligament tear or left ACL tear
patient was admitted as an outpatient for left arthroscopic knee procedure to repair old anterior cruciate ligament
first: syncope
Code: R55
Other diagnosis: diabetes mellitus
Code: E11.9
patient was admitted to observation for syncope, patient has diabetes mellitus. after testing, no cardiac or other cause was found
First listed diagnosis: acute post procedural pain
Code: G89.18
Other diagnosis: chronic kidney disease
Code: N18.4
patient was admitted for pain management following biopsy of the kidney for stage IV chronic kidney disease
Encounter for Preprocedural respiratory Examination
Code: Z01.811
other: carotid stenosis, emphysema
Code: I65.21, J43.9
patient is seen by pulmonologist for surgical clearance for upcoming surgery. patient has emphysema and is scheduled to have an endarterectomy for severe carotid stenosis on the right
First listed diagnosis: bladder cancer
Code: C67.9
Patient had an outpatient cystoscopy. The preoperative diagnosis is hematuria. Postoperative diagnosis is hematuria due to bladder cancer.
Assign the appropriate Z code to: exposure to asbestos.
Assign the appropriate Z code to: personal history of colonic polyps.
Assign the appropriate Z code to: heart transplant status.
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