--- title: Diagnosis Reporting on Outpatient Records description: In outpatient coding, coders are allowed to code from the pathology and radiology reports without the treating physician confirming the diagnosis. image: https://hiacode.com/hubfs/iStock-1356206631.jpg --- # Diagnosis Reporting on Outpatient Records ![HIAcode](https://hiacode.com/hubfs/Logos/HIA_RGB_PrimaryLogo_Icon%20(1)_Artboard%201.png) [HIAcode](https://hiacode.com/blog/author/hiacode) Jul 26, 2022 [Medical Coding Tips](https://hiacode.com/blog/tag/medical-coding-tips) ![Diagnosis Reporting on Outpatient Records](https://hiacode.com/hubfs/iStock-1356206631.jpg) - Share on: - [![](https://hiacode.com/hubfs/Facebook%20svg.svg)](http://www.facebook.com/share.php?u=https://hiacode.com/blog/education/coding-tip-diagnosis-reporting-on-outpatient-records) - [![](https://hiacode.com/hs-fs/hubfs/twitter.png?width=32&height=32&name=twitter.png)](https://twitter.com/intent/tweet?text=I+found+this+interesting+blog+post&url=https://hiacode.com/blog/education/coding-tip-diagnosis-reporting-on-outpatient-records) - [![](https://hiacode.com/hubfs/LinkedIn%20svg.svg)](http://www.linkedin.com/shareArticle?mini=true&url=https://hiacode.com/blog/education/coding-tip-diagnosis-reporting-on-outpatient-records) - [![](https://hiacode.com/hubfs/mdi_email.svg)](mailto:?subject=Check%20out%20https://hiacode.com/blog/education/coding-tip-diagnosis-reporting-on-outpatient-records%20&body=Check%20out%20https://hiacode.com/blog/education/coding-tip-diagnosis-reporting-on-outpatient-records&media=https://20824215.fs1.hubspotusercontent-na1.net/hubfs/20824215/iStock-1356206631.jpg) - ![](https://hiacode.com/hubfs/entypo_link.svg) copied ## Diagnoses in the Outpatient Setting  In the outpatient setting, it can be difficult to know what diagnoses are reportable and what should be the first listed code/primary diagnosis for the account. In outpatient coding, coders are allowed to code from the pathology and radiology reports without the attending/treating physician confirming the diagnosis. The pathologist and radiologist are physicians and if they have interpreted the tissue or test then it may be coded. Coders should code to the highest degree of certainty at the time of coding. If there is a final report available at the time of coding, which is authenticated by a physician, it may be used to code from. Outpatient coders may **not **code from laboratory reports unless the physician has made a notation regarding the findings with a diagnosis from the laboratory results. This guidance did not change with the implementation of ICD-10 but there still are a lot of questions regarding this. The recent AHA Coding Clinic for ICD-CM/PCS does confirm that the previous advice is still current. This publication also gives excellent examples of outpatient coding scenarios. Coders should be aware of the new guidance in Coding Clinic for ICD-10-CM/PCS, Third Quarter 2021: Page 32 that addresses reporting of additional diagnoses in the outpatient setting. *Authored by Kim Boy, RHIT, CDIP, CCS, CCS-P* ***References:*** *AHA Coding Clinic® for ICD-10-CM/PCS, Third Quarter 2021 Page 32* *AHA Coding Clinic® for ICD-10-CM and ICD-10-PCS, Fourth Quarter 2015 Pages: 20-21* * AHA Coding Clinic® for ICD-10-CM and ICD-10-PCS, First Quarter 2017 Pages: 4-7* * Official Guidelines for Coding and Reporting FY *2017, Page: 104-108   --- [HIA’s comprehensive auditing approach](https://hiacode.com/acute-review-services) includes [acute coding audits](https://hiacode.com/acute-review) and [Clinical Documentation Integrity (CDI) audits](https://hiacode.com/clinical-documentation-integrity). ---   [![Medical Coding Auditing Services](https://no-cache.hubspot.com/cta/default/20824215/92d7fb18-9eb2-4e67-b38c-cefd4ca70b1e.png)](https://cta-redirect.hubspot.com/cta/redirect/20824215/92d7fb18-9eb2-4e67-b38c-cefd4ca70b1e) > ***The information contained in this coding advice is valid at the time of posting. 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[ Read More](https://hiacode.com/blog/proactive-coding-quality-assurance) ## Subscribe to our Newsletter Weekly medical coding tips and coding education delivered directly to your inbox. ```json { "@context" : "https://schema.org", "@type" : "BlogPosting", "author" : { "@type" : "Person", "name" : "HIAcode", "url" : "https://hiacode.com/blog/author/hiacode" }, "dateModified" : "2024-01-31T16:36:49.361Z", "datePublished" : "2022-07-26T14:32:14.000Z", "headline" : "Diagnosis Reporting on Outpatient Records", "image" : [ "https://hiacode.com/hubfs/iStock-1356206631.jpg" ], "mainEntityOfPage" : { "@id" : "https://hiacode.com/blog/education/coding-tip-diagnosis-reporting-on-outpatient-records", "@type" : "WebPage" }, "publisher" : { "@type" : "Organization", "logo" : { "@type" : "ImageObject", "url" : "https://hiacode.com/hubfs/HIA_RGB_AlternativeLogo%20(1)%20(1).png" }, "name" : "Health Information Associates" } } ``` ```json { "@context" : "http://schema.org", "@type" : "Article", "author" : { "@type" : "Person", "name" : "Kim Boy, RHIT, CDIP, CCS, CCS-P", "url" : "https://hiacode.com/blog/author/kim-boy" }, "dateModified" : "2023-03-17", "datePublished" : "2022-07-26", "description" : "In outpatient coding, coders are allowed to code from the pathology and radiology reports without the treating physician confirming the diagnosis.", "headline" : "Diagnosis Reporting on Outpatient Records", "image" : "https://20824215.fs1.hubspotusercontent-na1.net/hubfs/20824215/iStock-1356206631.jpg", "mainEntityOfPage" : { "@id" : "https://hiacode.com/blog/education/coding-tip-diagnosis-reporting-on-outpatient-records", "@type" : "WebPage" }, "publisher" : { "@type" : "Organization", "logo" : { "@type" : "ImageObject", "height" : "60", "url" : "https://hiacode.com/hubfs/Logos/Health%20Information%20Associates%20Medical%20Coding%20Company.png", "width" : "60" }, "name" : "Health Information Associates" }, "url" : "https://hiacode.com/blog/education/coding-tip-diagnosis-reporting-on-outpatient-records" } ``` ```json { "@context" : "http://schema.org", "@type" : "BlogPosting", "author" : { "@type" : "Person", "name" : "Kim Boy, RHIT, CDIP, CCS, CCS-P", "url" : "https://hiacode.com/blog/author/kim-boy" }, "dateModified" : "2023-03-17", "datePublished" : "2022-07-26", "description" : "In outpatient coding, coders are allowed to code from the pathology and radiology reports without the treating physician confirming the diagnosis.", "headline" : "Diagnosis Reporting on Outpatient Records", "image" : "https://20824215.fs1.hubspotusercontent-na1.net/hubfs/20824215/iStock-1356206631.jpg", "mainEntityOfPage" : { "@id" : "https://hiacode.com/blog/education/coding-tip-diagnosis-reporting-on-outpatient-records", "@type" : "WebPage" }, "publisher" : { "@type" : "Organization", "logo" : { "@type" : "ImageObject", "height" : "60", "url" : "https://hiacode.com/hubfs/Logos/Health%20Information%20Associates%20Medical%20Coding%20Company.png", "width" : "60" }, "name" : "Health Information Associates" }, "url" : "https://hiacode.com/blog/education/coding-tip-diagnosis-reporting-on-outpatient-records" } ```