Wiki Outpatient surgery

[candmwalter@gmail.com]

Hi can someone please clarify for me when coding outpatient surgery the guidlines state as follows
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.

does this mean if a patient has been having abdominal pain and they go into surgery and they are found to have an inguinal hernia that you would code the abdominal pain instead of the inguinal hernia?

Thank you in advance for clarifying this for me.
Mary

 

[Palmtoptiger]

Hi!

I interpreted it the same way when i first read that guideline. However, in our practice, we code the established diagnosis as the primary/first listed.

In the example you've given,
Reason for Visit: Abdominal Pain
Primary Diagnosis: Inguinal Hernia

On Section IV. Diagnostic Coding and Reporting Guidelines for Outpatient Services. Under A. Selection of first listed diagnosis, it's stated that:

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.

On the general guideline, signs and symptom codes are acceptable pdx if there is no definite or established diagnosis. (see Section 1. B. 4) - this takes precedence over the outpatient guideline that you quoted.

Since there is a definite diagnosis after that encounter, inguinal hernia is the pdx.