Diagnosis Reporting on Outpatient Records

Diagnoses in the Outpatient Setting 

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

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The information contained in this coding advice is valid at the time of posting. Viewers are encouraged to research subsequent official guidance in the areas associated with the topic as they can change rapidly.