Question

Overview in the outpatient setting the first sted diagnosis is reported (instead of the inpatient setting's principal diagnosis), and it is the condition chiefly responsible for the outpatient services provided during the encounter visit. It is determined in accordance with ICD-10-CM coding conventions (or rules) as well as general and disease specific coding guidelines. Because diagnoses are often not established at the time of the patient's initial encounter or visit, two or more visits may be required before the diagnosis is confirmed When outpatient records are reviewed for the selection of ICD-10-CM codes to report to third-party payers, documentation in the patient record serves as the basis for coding. This means that information in the record supports the codes submitted on claims for third-party payer reimbursement processing. The patient's diagnosis must justify diagnostic and/or therapeutic procedures or services provided, which is called medical necessity Claims are also denied if the medical necessity of procedures or services is not established every procedure or service reported on the health insurance claim must be linked to a condition that justifies the necessity for performing that procedure or providing that service of the procedures or services delivered are determined to be unreasonable and unnecessary, the claim is denied. Assigning ICD-10-CM codes to diagnostic statements in previous exercises allowed you to develop skills in interpreting and applying coding conventions and guidelines. Reviewing patient records to locate diagnostic statements and assigning ICD-10-CM codes will further develop your coding skills Selecting the First-Listed Diagnosis Review each case and underline the first-listed diagnosis EXAMPLE: Patient was seen in the office to rule out cervical radiculopathy. Patient has a recent history of pain in both scapular regions along with spasms of the left upper trapezius muscle. Patient has limited range of motion, neck and left arm X-rays reveal significant cervical osteoarthritis Do not select differential diagnoses such as rule out cervical radiculopathy" as the answer because such diagnoses are not coded and reported on the CMS-1500 claim for outpatient cases. "Spasms of the left upper trapezius muscle" and "limited range of motion, neck and left arm are symptoms of cervical osteoarthritis, which is reported as the first-listed diagnosis in block 21, line 1, of the CMS-1500 claim 1. Pain, left knee. History of injury to left knee 20 years ago. Patient underwent arthroscopic surgery and medial meniscectomy, right knee (10 years ago). Probable arthritis, left knee 2. Patient admitted to the emergency department with complaints of severe chest pain. Possible myocardial infarction EKG and cardiac enzymes revealed normal findings. Diagnosis upon discharge was gastroesophageal reflux disease. 3. Female patient seen in the office for follow-up of hypertension. The nurse noticed upper arm bruising on the patient and asked how she sustained the bruising. The physician renewed the patient's hypertension prescription of hydrochlorothiazide 4 A 10-year-old male was seen in the office for sore throat. Nurse swabbed patient's throat and sent swabs to the hospital lab for strep test. Physician documented likely strep throat' on the patient's record 5. Patient was seen in the outpatient department to have a lump in his abdomen evaluated and removed. Surgeon removed the lump, and pathology report revealed that the lump was a lipoma

Answer 1

Instructions: Review each case and identify the first-listed diagnosis.

1. Pain, left knee. History of injury to left knee 20 years ago. Patient underwent arthroscopic surgery and medial meniscectomy, right knee (10 years ago). Probable arthritis, left knee.

FIRST-LISTED DIAGNOSIS: Pain in the Left Knee

Rationale:

The patient ultimate problem is a pain in the left knee. Arthritis must be ruled out through a proper lab test. So the first-listed diagnosis is the pain.

2. Patient admitted to the emergency department (ED) with complaints of severe chest pain. Possible myocardial infarction. EKG and cardiac enzymes revealed normal findings. Diagnosis upon discharge was gastroesophageal reflux disease.

FIRST-LISTED DIAGNOSIS: Severe chest pain

Rationale:

The patient chief complaint at the time of arrival is chest pain. Chest pain is ruled out as a cause for gastroesophageal reflux disease after the laboratory findings. but the initial diagnosis is chest pain. So it should be coded as the first-listed diagnosis.

3. Female patient is seen in the office for follow-up of hypertension. The nurse noticed upper arm bruising on the patient and asked how she sustained the bruising. The physician renewed the patient’s hypertension prescription, hydrochlorothiazide.

FIRST-LISTED DIAGNOSIS: Follow up of hypertension.

Rationale:

The patient mainly came for the physician office for the follow-up treatment of hypertension. Bruising is identified during the visit. So bruising is not included as the first-Listed Diagnosis.

4. Ten-year-old male seen in the office for sore throat. Nurse swabbed the patient’s throat and sent swabs to the hospital lab for the strep test. Physician documented “likely strep throat” on the patient’s record.

FIRST-LISTED DIAGNOSIS: Sore throat

Rationale:

The male patient visits the physician office for sore throat. The chief complaint of the patient is a sore throat. Patient's swab test has sent to the lab, but the results are awaiting to confirm the diagnosis. So the first Listed Diagnosis is a sore throat.

5. Patient was seen in the outpatient department to have a lump in his abdomen evaluated and removed. The surgeon removed the lump and pathology report revealed that the lump was a lipoma.

FIRST-LISTED DIAGNOSIS: Lipoma of the abdomen.

Rationale:

Even though the lump was removed, the pathology report reveals that lump as lipoma which needs further evaluation and management. The lump was now viewed as a lipoma. So it is the first -Listed diagnosis is lipoma of the abdomen.