Step-By-Step Ch. 9: ICD-9-CM Outpatient Coding and Reporting Guidelines

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 Terms: Urinary Tract Infection
Established patient presented to clinic with exacerbation of Crohn’s disease. Patient’s rheumatoid arthritis is stable. No medication changes were made
First listed Diagnosis Terms: Crohn’s Disease
Initial office visit for sprained left knee.
First listed Diagnosis Terms: Sprain knee
Initial office visit for patient requiring management of COPD and CHF.
First listed Diagnosis Terms: COPD, CHF
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 Terms: Pneumonia
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. The patient will be seen in the office following the scheduled outpatient procedures.
Codes: 789.00, 787.91
Follow-up office visit for a 28-year old male with recent colonoscopy with biopsy and small bowel X-rays. The biopsy and small bowel X-rays confirmed that the patient had ulcerative colitis. The patient was started on sulfasalazine.
Codes: 556.9
Initial office visit for 55-year old male with fatigue and jaundice. Laboratory tests were ordered. He will return in 1 week for the results.
Codes: 780.79 782.4
Follow-up visit for 55-year old male with jaundice and fatigue. Diagnostic tests confirm that the patient has Hepatitis C. He will be treated with interferon therapy.
Codes: 070.70
Identify the main terms that describe the first-listed diagnosis for the following: A female patient was admitted as an outpatient for elective bilateral tube ligation. The patient was noted to be wheezing during the nurse’s assessment. She was seen by her physician and her surgery was cancelled because of an exacerbation of her asthma.
First-listed Diagnosis Terms: Admission, elective sterilization
A male patient was admitted as an outpatient for transurethral prostatic resection for symptomatic benign prostatic hypertrophy.
First-listed Diagnosis Terms: Benign prostatic hypertrophy
A patient was admitted as an outpatient for a cystoscopy for hematuria. The procedure was performed without complications. No abnormality or explanation for the hematuria was found.
First-listed Diagnosis Terms: Hematuria
Identify the terms that describe the first-listed diagnosis for the following:
A 35 year-old female patient was admitted to observation for severe nausea and vomiting (due to pelvic pain) following diagnostic laparoscopy for pelvic pain.
First-listed Diagnosis Terms: Abdominal Pain
A male patient was admitting to observation following an endoscopic retrograde cholangiopancreatography (ERCP) for acute pancreatitis. Patient has a biliary duct structure.
First-listed Diagnosis Terms: Biliary Duct Structure
Patient was admitted for observation because of urinary retention following a dilation and cutterage (D&C) for post-menopausal bleeding.
First-Listed Diagnosis Terms: Post-Menopausal Bleeding
Locate the V-Codes in the ICD-9-CM manual in Volume 2, Alphabetic Index and then in Volume 1, Tabular List, Code the following:
A person who has been in contact with smallpox.
Index Location: Smallpox, contact
V Code: V01.3
Prophylactic vaccination against smallpox
Index Location: Vaccination, prophylactic, smallpox
V Code: V04.1
Personal history of malignant neoplasm of the tongue
Index Location: History, malignant, neoplasm, tongue
V Code: V10.01
Assign the V-Code for the following:
Admission for cardiac pacemaker adjustment
Code: V53.31 (Cardiac, device, cardiac, fitting or adjustment)
Insertion of subdermal implantable contraceptive
Code: V25.5 (Contraceptive, insertion, subdermal implantable
Personal history of cancer of the prostate
Code: V10.46 (History (personal) malignant neoplasm, prostate)
Baby in for MMR (Measles, mumps, rubella) vaccination
Code: V06.4 (Vaccination, mumps, with measles and rubella [MMR])
Screening mammogram
Code: V76.12 (Screening, mammogram)
Clinic visit for pre-employment physical examination
Code: V70.5 (Examination, medical, pre-employment)
Assign ICD-9-CM codes to the following as directed:
The patient fell off his motorcycle when turning too sharply and hit his head on the sidewalk. The patient was wearing a helmet. The examination reveals no outwardly apparent head injury. The only injury noted on examination is abrasion of the elbow. The patient is admitted overnight to the observation unit to rule out head injury.
There will be three codes on this case: one for the observation of the head injury (a V Code), one for the abrasion, and one for the cause (falling from motorcycle reported with an E Code).
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”. Check the code in the Tabular. What is the V Code?
Code: V71.4
The second code is for the abrasion to the elbow. When you locate the term “abrasion” in the Index, you are referred to “see also Injury, superficial, by site” Locate “Injury, superficial, arm.” What is the code for the abrasion?
Code: 913.0
The E Code would be E816.2
A patient is admitted for observation and further evaluation following an alleged rape. There is only one code for this case. What is the V Code?
Code: V71.5
Identify the first-listed diagnosis and any coexisting conditions. Assign the ICD-9-CM codes:
Patient was seen in the office for a consultation of palpitations. Patient 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 Terms: Palpitations, Rheumatoid Arthritis
Codes: 785.1, 714.0
Patient is an established patient with memory loss. Patient also takes medication for diabetes type 2.
First-Listed Diagnosis Terms: Memory Loss, Type 2 Diabetes
Codes: 780.93, 250.00
A new patient was seen for flank pain. He or she was diagnosed with a urinary tract infection and antibiotics were prescribed. Patient has psoriasis, which is stable at this time
First-Listed Diagnosis Terms: Urinary Tract Infection
Codes: 599.0
Other Diagnosis Terms: Psoriasis
Codes: 696.1
Identify the diagnosis and ICD-9-CM codes to be assigned:
Patient is seen in the office for pain and stiffness of the right knee. X-Rays to rule out osteoarthritis were performed.
Diagnosis Terms and Codes: Knee Pain 719.46, Knee Stiffness 719.56
Office visit for established patient with wrist pain and numbness of fingertips. Studies ordered for probable carpal tunnel syndrome.
Diagnosis Terms and Codes: Wrist Pain 719.43, Wrist Numbness 782.0
Office consultation for a new patient with amenorrhea and galactorrhea. Studies to rule out pituitary tumor were ordered
Diagnosis Terms and Codes: Amenorrhea 626.0, Galactorrhea 611.6
Initial visit for a patient with a breast lump. Working diagnosis is breast cancer. Diagnostic workup has been scheduled.
Diagnosis Terms and Codes: Breast Lump 611.72
Match each code from the list of codes with the report to which it should be assigned and place the letters for the codes in the correct order:
A: 493.90 B: V67.01 C: 710.0 D:V45.81 E:250.00 F: 414.01 G: V88.01 H: V10.41 I: 692.4 J: V55.3 K: V72.0 L: V58.67
A patient with chronic asthma and systemic lupus erythematosus presents to the clinic for an office visit during which the physician assesses the status of the asthma and lupus erythematosus .
Codes: A. 493.90 C. 710.0
A patient with a history of coronary artery bypass graft of the native coronary aretery 6 months earlier due to arteriosclerosis. The patient is also evaluated by his internal medicine physician for his longstanding diabetes for which the patient takes insulin. The physician revises the patient’s diabetic medications and the Lipitor prescription based on a review of laboratory results.
Codes: E. 250.00 F. 414.01 D. V45.81 L. V58.67
A patient with a colostomy is evaluated by his internist for the patient’s complaints of redness and itching at the skin level opening of his colostomy bag. The physician diagnosed dermatitis due to a new brand of skin level plastic seal. He prescribes a topical salve, replaced the seal and requested the patient to return in 2 weeks if there is not significant improvement.
Codes: I. 692.4 J. V55.3
The patient is examined by the ophthalmologist for an annual eye examination. The patient has no complaints, and the physician indicates the patient’s vision is excellent.
Codes: K. V72.0
A follow-up vaginal pap smear is performed for a patient who is status-post hysterectomy that included the removal of both the cervix and the uterus. The procedure was performed for a primary malignancy. The patient had a previous smear, and both that smear and the current smear were negative for malignancy.
Codes: B. V67.01 G. V88.01 H. V10.41
Answer the following questions about the Diagnostic Coding and Reporting Guidelines for Outpatient Services:
When a patient is to have outpatient surgery and the surgery is not performed due to contradiction, the reason that 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 code V 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 preoperative 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 coded only to the highest degree of certainty with symptoms, signs, abnormal 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 use a code from the ICD-9-CM manual, Chapter 11, in conjunction with V22.0 or V22.1:
It is acceptable to code signs and symptoms even when a definitive diagnosis has been confirmed:
Identify the first-listed diagnoses and assign the appropriate ICD-9-CM codes in the following encounters or visits
Initial office visit for diaper rash
First-Listed Diagnosis Terms: Diaper Rash
Code: 691.0
Established patient presents with dyspnea and lower extremity edema. The physician determined that the patient’s symptoms were due to an exacerbation of congestive heart failure.
First-Listed Diagnosis Terms: Heart Failure
Code: 428.0
Established patient seen for management of vitamin B12 deficiency and hypertension
First-Listed Diagnosis Terms: B12 Deficiency
Code: 266.2
Other Diagnosis Terms: Hypertension
Code: 401.9
Patient was admitted as an outpatient for an arthroscopic knee procedure to repair old anterior cruciate ligament tear.
First-Listed Diagnosis Terms: Anterior Cruciate Ligament Tear
Code: 717.83
Patient is admitted to observation for syncope. Patient has diabetes mellitus. After testing, no cardiac or other cause was found
First-Listed Diagnosis Terms: Syncope
Code: 780.2
Other Diagnosis Terms: Diabetes Mellitus
Codes: 250.01
Patient was admitted for pain management following biopsy of the kidney for Stage IV chronic kidney disease
First-Listed Diagnosis Terms: Stage IV Chronic Kidney Disease
Code: 585.4
Other Diagnosis Terms: Postoperative
Codes: V45.89
Patient is seen by pulmologist for surgical clearance for upcoming surgery. Patient has emphysema and is scheduled to have an endartectomy for severe carotid stenosis on the right
First-Listed Diagnosis Terms: Emphysema
Code: 492.8
Other Diagnosis Terms: Cartoid Stenosis
Codes: 433.10
Patient had an outpatient cystoscopy. The preoperative diagnosis is hematuria. Postoperative diagnosis is hematuria due to bladder cancer
First-Listed Diagnosis Terms: Hematuria
Code: 599.70
Other Diagnosis Terms: Bladder Cancer
Code: 188.9
Assign the appropriate V Code for the following:
Exposure to asbestos
Personal history of colonic polyps
Heart transplant status