ICD-10-CM —

Guidelines for
Physician Coder
IMPLEMENTATION OF ICD-10 OUTPATIENT DIAGNOSIS MODULE
TIH MAIN CAMPUS

• INTRODUCTION:

In order to capture all the diagnosis in clinics and to establish uniformity of data, EMR team
along with H.I has developed an outpatient module under guidelines of International
classification of disease 10th Revision.
• AIMS AND OBJECTIVES:

With the help of outpatient diagnosis module we will be able to capture and utilize all the
diagnosis for clinical research, disease prevalence, administration and public health
planning etc.
BENEFITS OF OUTPATIENT CODING
 To achieve uniformity of hospital data.
 To measure the quality, safety and efficacy of care.
 Improve disease management.
 Conducting research ,epidemiological studies and
clinical trials.
 Setting health policy.
 Monitoring resource utilization.
 Preventing and detecting healthcare fraud and abuse.
Diagnostic coding and reporting guidelines for outpatient
services
• Outpatient Services Guidelines
 – First listed diagnosis.
 – Secondary diagnosis.
 – Co-morbids e.g. (hypertension, diabetes, etc.).
 – Status (angioplasty, bypass, drug, hormone).
 – Cause of injury/fracture/burn/poisoning.
• Selection of first-listed condition

 In outpatient setting, the first-listed diagnosis term is used in lieu of principal

diagnosis.

 Diagnosis often are not established at the time of the initial encounter/visit. It may
take two or more visits for the diagnosis to be confirmed.

 The most critical step involves the searching for the correct code through the
Alphabetic Index.
• ICD-10-CM code for the diagnosis, condition, problem or other
reason for encounter/visit

 List first the ICD-10-CM code for the diagnosis, condition, problem or other reason for
encounter/visit shown in the medical record to be chiefly responsible for the services
provided.
 List additional codes that describe any coexisting conditions. In some cases the first-listed
diagnosis may be a symptom when a diagnosis has not been established (confirmed) by the
physician. This is an exception to the first-listed guideline.
• Outpatient surgery

 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.
• Uncertain diagnosis

 Please Do not code diagnoses documented as “probable,” “suspected,” “questionable,”

“rule out,” “working diagnosis” or other similar terms indicating uncertainty.
 Rather, code the condition(s) to the highest degree of certainty for that encounter/visit, such
as symptoms, signs, abnormal test results, or other reason for the visit.
• Chronic diseases/Co-morbids

 Code Chronic diseases treated on an ongoing basis may be coded and reported as many times
as the patient receives treatment and care for the condition.

 Code all documented conditions that coexist at the time of the encounter/visit, and require or
affect patient care treatment or management. Do not code conditions that were previously
treated and no longer exist.

 However, history codes (categories Z80–Z87) may be used as secondary codes if the
historical condition or family history has an impact on current care or influences treatment.
• Patient receiving diagnostic services only

 For encounter of routine laboratory/radiology testing in the absence of any signs, symptoms
or associated diagnosis, assign Z01.89, “Encounter for other specified special
examinations.”

 For outpatient encounters the diagnostic tests that have been interpreted by a physician, and
the final report is available at the time of coding, code any confirmed or definitive diagnosis
documented in the interpretation.
NOTE: Do not code related signs and symptoms as additional diagnosis.
• Patients receiving therapeutic services only

 For patients receiving therapeutic services only during an encounter/visit, sequence first the
diagnosis, condition, problem or other reason for encounter/visit shown in the medical record
to be chiefly responsible for the outpatient visit.

 The only exception to this rule is that when the primary reason for the admission/encounter is
chemotherapy or radiation therapy, the appropriate Z code for the service is listed first, and
the diagnosis or problem for which the service is being performed listed second.
• Z51.11 Encounter for antineoplastic chemotherapy
• Patients receiving preoperative evaluations only

 For patients receiving preoperative evaluations only, first sequence a code from subcategory
Z01.81, “Encounter for preprocedural examinations,” to describe the pre-op
consultations. Assign a code for the condition to describe the reason for the surgery as an
additional diagnosis. Also code any findings related to the pre-op evaluation.
 We also have code for pre-employment check up
Z02.1 Encounter for pre-employment examination
• Encounters for general medical examinations with abnormal
findings

 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. A secondary code for the abnormal finding should also
be coded.
 Z00.00 Encounter for general adult medical examination without abnormal findings
• Sequelae (late effects)
 A sequela is the residual effect (condition produced) after the acute phase of an illness or
injury has terminated.
 There is no time limit on when a sequela code can be used. The residual may be apparent
early, such as in cerebral infarction, or it may occur months or years later, such as that due to
a previous injury.
 Coding of sequelae generally requires two codes sequenced in the following order:
• The condition or nature of the sequela is sequenced first.
• The sequela code is sequenced second.
Sequelae of cerebrovascular disease

 The neurologic deficits caused by cerebrovascular disease may be present from the onset or
may arise at any time after the onset of the condition

 Should the affected side be documented, but not specified as dominant or nondominant, and
the classification system does not indicate a default, code selection is as follows:
• For ambidextrous patients, the default should be dominant.
• If the left side is affected, the default is nondominant.
• If the right side is affected, the default is dominant.
 Sequelae (late effects) of external cause guidelines

• Sequelae external cause codes

 Sequelae codes should be used with any report of a late effect or sequela resulting from a
previous injury.
• Sequelae external cause code with a related current injury
 A sequela external cause code should never be used with a related current nature of injury code.
• Use of sequelae external cause codes for subsequent visits
 Use a late-effect external cause code for subsequent visits when a late effect of the initial injury
is being treated.
 Do not use a late-effect external cause code for subsequent visits for follow-up care (e.g., to
assess healing, to receive rehabilitative therapy) of the injury when no late effect of the injury
has been documented.
 Outpatient Coding Scenario
Medicine

• SCENARIO 1
A 35 year old male visited in clinic with fever cough and was initially diagnosed with acute bronchitis.
• CODING SCENARIO 1
J20.0 Acute bronchitis due to Mycoplasma pneumoniae 
J20.1 Acute bronchitis due to Hemophilus influenzae 
J20.2 Acute bronchitis due to streptococcus 
J20.3 Acute bronchitis due to coxsackievirus 
J20.4 Acute bronchitis due to parainfluenza virus 
J20.5 Acute bronchitis due to respiratory syncytial virus 
J20.6 Acute bronchitis due to rhinovirus 
J20.7 Acute bronchitis due to echovirus 
J20.8 Acute bronchitis due to other specified organisms 
J20.9* Acute bronchitis, unspecified
• SCENARIO 2
A 55 year old female visited in clinic with lethargy,  dizziness, weakness, pallor,
headache, physician suspected iron deficiency anemia, so her labs were done and
results were awaited.

CODING SCENARIO 2
we do not code iron deficiency anemia as it is a suspected diagnosis.
only signs and symptoms are coded as first listed diagnosis. If the diagnosis
confirmed assign code iron deficiency anemia.
 R53.83 : Exhaustion, exhaustive (physical NEC) ,Fatigue, Lethargy,
Overstrained ,Overworked ,Prostration ,Tiredness ,Vitality

 D50.9 : Iron deficiency anemia, unspecified

General Surgery

• SCENARIO 1
A 20 year old young boy visited in clinic with recently diagnosed Congenital Diaphragmatic
hernia he was here for further evaluation

CODING SCENARIO 1
K44.9 Diaphragmatic hernia without obstruction or gangrene
K44.0 Diaphragmatic hernia with obstruction, without gangrene
K44.1 Diaphragmatic hernia with gangrene
Q79.0 Congenital diaphragmatic hernia
• SCENARIO 2
A 55 year old female visited in clinic with Sudden and rapidly intensifying pain in the upper right portion
of her abdomen with nausea and vomiting she was previously treated for cholecystitis in this visit
physician is suspecting of cholelithiasis.
Ultrasound and Lfts are suggested for further evaluation.
CODING SCENARIO 2
R10.0 Acute abdomen 
R10.10 Upper abdominal pain, unspecified 
R10.11 Right upper quadrant pain 
R10.12 Left upper quadrant pain 
R10.13 Epigastric pain 
R10.2 Pelvic and perineal pain 
R10.30 Lower abdominal pain 
R10.31 Right lower quadrant pain 
R10.32 Left lower quadrant pain 
R10.33 Periumbilical pain 
R10.84 Generalized abdominal pain 
R10.9* Unspecified abdominal pain
Orthopedic
• SCENARIO 1
A 72 year old male initially went to clinic with history of fall in washroom last night at his
home , x-ray were done that showed intertrochenteric fracture,he was hypertensive with
the history of angioplasty.

CODING SCENARIO 1
S72.141 Displaced intertrochanteric fracture of right femur
S72.142 Displaced intertrochanteric fracture of left femur
S72.143 Displaced intertrochanteric fracture of unspecified femur
S72.144 Nondisplaced intertrochanteric fracture of right femur
S72.145 Nondisplaced intertrochanteric fracture of left femur
S72.146 Nondisplaced intertrochanteric fracture of unspecified femur
 S72.146 Displaced intertrochanteric fracture of unspecified femur
 I10 Hypertension, hypertensive (accelerated) (benign) (essential)
(idiopathic) (malignant) (systemic)
 Z98.61 status coronary angioplasty
 W01.10 Fall on same level from slipping, tripping and stumbling with
subsequent striking against unspecified object
 Y92.002 Bathroom of unspecified non-institutional (private) residence single-
family (private)house as the place of occurrence of the external cause
• SCENARIO 2
A 6 year old child visited in clinic with a left knee strain injury that occurred on a
private recreational playground when a child landed incorrectly from a trampoline
initial diagnosis were knee strain.

CODING SCENARIO 2
 Injury: S86.812A, Strain of other muscle(s) and tendon(s) at lower leg
level, left leg, initial encounter
 External cause: W09.8xxA, Fall on or from other playground
 Place of occurrence: Y92.838, Other recreation area as the place of occurrence
of the external cause
Gastroenterology
• SCENARIO 1
A 43 year old male visited in clinic with epigastric pain, indigestion, nausea. He was known case of
hypertension and hypothyroidism .
CODING SCENARIO 1
R10.12 Left upper quadrant pain
R10.13 Dyspepsia , Epigastric pain
R10.2 Pelvic and perineal pain
R10.30 Lower abdominal pain, unspecified

We will code hypertension and hypothyroidism additionally.

I10 Hypertension, hypertensive (accelerated) (benign) (essential) (idiopathic) (malignant) (systemic)
E03.9 Hypothyroidism (acquired),unspecified , Hoffmann's syndrome , Myxedema (adult) (idiocy)
(infantile) (juvenile)
• SCENARIO 2
A 50 year old female visited in clinic with recently diagnosed celiac disease.
she was known case of diabetes and previously treated for T.B lung
patient came for further workup.
physician advice for colonoscopy and labs for further evaluation .

CODING SCENARIO 2
K90.0 Celiac disease
E11.8 Type 2 diabetes mellitus with unspecified complications
Z86.11 Personal history of tuberculosis
 Plastic Surgery
• SCENARIO 1
A 1 year old child visited in clinic cleft hard palate with bilateral cleft lip, physician advice for cleft lip and palate repair.

CODING SCENARIO 1
Q36.0 Cleft lip, bilateral
Q36.1 Cleft lip, median
Q36.9 Cleft lip, unilateral
Q37.0 Cleft hard palate with bilateral cleft lip
Q37.1 Cleft hard palate with unilateral cleft lip
Q37.2 Cleft soft palate with bilateral cleft lip
Q37.3 Cleft soft palate with unilateral cleft lip
Q37.4 Cleft hard and soft palate with bilateral cleft lip
Q37.5 Cleft hard and soft palate with unilateral cleft lip
Q37.8 Unspecified cleft palate with bilateral cleft lip
Q37.9 Unspecified cleft palate with unilateral cleft lip
• SCENARIO 2

A 5 year old girl visited in clinic with scar due to burn one year back patient came
for further workup.
physician advice for scar revision.

CODING SCENARIO 2
L90.5 Scar conditions and fibrosis of skin
 Peads Surgery
• SCENARIO 1
A 5 year old child visited in clinic with abdominal pain and diagnosed with recurrent inguinal hernia unilateral

CODING SCENARIO 1
K40.30 Unilateral inguinal hernia, with obstruction, without gangrene, not specified as recurrent
K40.31 Unilateral inguinal hernia, with obstruction, without gangrene, recurrent
K40.40 Unilateral inguinal hernia, with gangrene, not specified as recurrent
K40.41 Unilateral inguinal hernia, with gangrene, recurrent
K40.90 Unilateral inguinal hernia, without obstruction or gangrene, not specified as recurrent
K40.91 Unilateral inguinal hernia, without obstruction or gangrene, recurrent
 Obs/Gyn
• SCENARIO 1
A 30 year old female 27 weeks pregnant visited in clinic with headache, her vitals shows high b.p initially
physician diagnose for pregnancy induced hypertension .
further workup was recommended .
CODING SCENARIO 1
O13.1 : Gestational [pregnancy-induced] hypertension without significant proteinuria, first trimester
O13.2 : Gestational [pregnancy-induced] hypertension without significant proteinuria, second
trimester
O13.3 : Gestational [pregnancy-induced] hypertension without significant proteinuria, third trimester
O13.9 :Gestational [pregnancy-induced] hypertension without significant proteinuria, unspecified
trimester

We will code weeks of gestation additionally.

Z3A.27: 27 weeks gestation of pregnancy
• SCENARIO 2
A 25 year old female visited in clinic with menorrhagia & abdominal pain.
physician advice for ultrasound

CODING SCENARIO 2
N92.0 Menorrhagia (primary) ,Polymenorrhea
Epimenorrhea,Excessive and frequent menstruation with regular cycle,
Flooding ,Hypermenorrhea ,
 Urology

• SCENARIO 1
A 35 year old male visited in clinic with burning micturition, with his recent outside reports of urine
culture, that shows E-coli. He was diagnosed with urinary tract infection
physician prescribe antibiotics.

CODING SCENARIO 1
N39.0 Urinary tract infection, site not specified, UTI ,Pyuria (bacterial)
B96.29 Other Escherichia coli [E. coli] as the cause of diseases classified elsewhere
• SCENARIO 2
A 19 year old male visited in clinic with lower abdominal pain.
Physician is suspecting kidney stone.
Physician advice for ultrasound KUB.

CODING SCENARIO 2
R10.1 Pain localized to upper abdomen
R10.10 Upper abdominal pain, unspecified
R10.11 Right upper quadrant pain
R10.12 Left upper quadrant pain
R10.30 Lower abdominal pain, unspecified
Nephrology
• SCENARIO 1
A 65 year old male visited in clinic for follow-up examination, as he was known case of ESRD & hypertension
CODING SCENARIO 1
N18.1 Chronic kidney disease, stage 1
N18.2 Chronic kidney disease, stage 2 (mild)
N18.3 Chronic kidney disease, stage 3 (moderate)
N18.4 Chronic kidney disease, stage 4 (severe)
N18.5 Chronic kidney disease, stage 5
N18.6 End stage renal disease
Additional code:
I11.9 Hypertensive heart disease without heart failure
I12.0 Hypertensive chronic kidney disease with stage 5 chronic kidney disease or end stage renal disease
I12.9 Hypertensive chronic kidney disease with stage 1 through stage 4 chronic kidney disease, or unspecified chronic
kidney disease
I13.0 Hypertensive heart and chronic kidney disease with heart failure and stage 1 through stage 4 chronic kidney
disease, or unspecified chronic kidney disease
• SCENARIO 2
A 29 year old male visited in clinic due to severe swelling in ankle and foot, weight gain due to
fluid overload, he was known case of nephrotic syndrome
Physician planned to admit the patient for further workup.

CODING SCENARIO 2
N04.0 Nephrotic syndrome with minor glomerular abnormality
N04.1 Nephrotic syndrome with focal and segmental glomerular lesions
N04.2 Nephrotic syndrome with diffuse membranous glomerulonephritis
N04.3 Nephrotic syndrome with diffuse meningeal proliferative glomerulonephritis
N04.4 Nephrotic syndrome with diffuse endocapillary proliferative glomerulonephritis
N04.5 Nephrotic syndrome with diffuse mesangiocapillary glomerulonephritis
N04.6 Nephrotic syndrome with dense deposit disease
N04.7 Nephrotic syndrome with diffuse crescentic glomerulonephritis
N04.8 Nephrotic syndrome with other morphologic changes
N04.9 Nephrosis, nephrotic (Epstein's) (syndrome)
 E.N.T
• SCENARIO 1
A 15 year old male visited in clinic with recurrent tonsillitis
physician advice for tonsillectomy.

CODING SCENARIO 1
J03.91 Acute recurrent tonsillitis, unspecified

• SCENARIO 2
A 25 year old male visited in clinic with deviated nasal septum
physician advice for septoplasty.

CODING SCENARIO 2
J34.2 Deviated nasal septum, Crooked septum, nasal
 Pulmonology
• SCENARIO 1
A 55 year old male visit in clinic with fever , SOB , cough , and labs showed increase CRP. NOVEL /PCR
corona virus test diagnosis made was Covid positive
CODING SCENARIO 1
B97.21 : SARS-associated coronavirus as the cause of diseases classified elsewhere
• SCENARIO 2
A 25 year old female visited in clinic with acute exacerbation of asthma
CODING SCENARIO 2
J45.50 Severe persistent asthma, uncomplicated
J45.51 Severe persistent asthma with (acute) exacerbation
J45.52 Severe persistent asthma with status asthmaticus
J45.901 Unspecified asthma with (acute) exacerbation
J45.902 Unspecified asthma with status asthmaticus
 Rheumatology
• SCENARIO 1
A 55 year old female presented in clinic with swollen joints with pain.
Physician suspected rheumatoid arthritis.
Physician advice for x-rays, Rheumatoid factor and Cbc
CODING SCENARIO 1
M25.40 Effusion, unspecified, site
M25.41 Effusion, shoulder
M25.42 Effusion, elbow
M25.43 Effusion, wrist
M25.44 Effusion, hand
M25.45 Effusion, hip
M25.46 Effusion, knee
M25.47 Effusion, ankle and foot
M25.48 Effusion, other site
Swollen joint is guided as effusion joints in ICD-10 CM
• SCENARIO 2

A 25 year old female visited in clinic with acute flare of SLE , she was known case
of SLE since two years.
physician advice to admit the patient

CODING SCENARIO 2
M32.9 Systemic lupus erythematosus, unspecified
 Eye
• SCENARIO 1
A 55 year old male referred in clinic due to blurred vision initial assessment was made , physician diagnosed
cataract in left eye and advice for Phaco+IOL

CODING SCENARIO 1
H25.9 Unspecified age-related cataract

NOTE : Patients with age 50 and above are labelled as senile cataract and below 50 are labelled as
unspecified cataract.
 Cardiology
• SCENARIO 1
A 55 year old male referred in clinic due to palpitations,sweating,high pulse.
physician admitted patient for further workup.
CODING SCENARIO 1
R00.2 Awareness of heart beat ,Palpitations (heart)

• SCENARIO 2
A 65 year old female visit clinic due to headache, dizziness her b.p was high
physician admitted patient for further workup.
CODING SCENARIO 2
R03.0 Elevated blood-pressure reading, without diagnosis of hypertension
Oncology
• SCENARIO 1
A 15 year old young boy visit in clinic for follow-up ,recently treated as ALL and on induction
phase .
physician admitted patient for further workup.

CODING SCENARIO 1
Z08 Encounter for follow-up examination after completed treatment for malignant neoplasm
C91.00 Acute lymphoblastic leukemia having achieved remission
 Hope this guideline will assist you in expeditious Outpatient coding.
If you have any further query feel free to contact EMR at Extension: 2718
OR send your query at email: [email protected] / [email protected]

Thank you