This lesson discusses the coding guidelines for outpatient encounters and services in the most recent version of ICD-10-CM Official Guidelines for Coding and Reporting. The guidelines are designated for use by physicians, other health care professionals, and hospitals for coding and reporting of outpatient diagnoses in Section IV. Diagnostic Coding and Reporting Guidelines for Outpatient Services are covered. The ICD-10-CM conventions, general guidelines, and chapter-specific guidelines applicable to all health care settings are also discussed. Before beginning this lesson, you should have access to the most recent version of ICD-10-CM (International Classification of Diseases, Tenth Revision, Clinical Modification). If you do not have the most recent version of an ICD-10-CM code book, click the Resources tab for a link to the necessary documents. Be sure to download both the index and tabular listing of ICD-10-CM, as well as the External Cause of Injuries Index, the Table of Drugs and Chemicals, and the Table of Neoplasms.
This activity is approved for 0.50 contact hours.
“This program has been approved for 0.50 continuing education unit(s) for use in fulfilling the continuing education requirements of the American Health Information Management Association (AHIMA). Granting prior approval from AHIMA does not constitute endorsement of the program content or its program sponsor.”
This activity is approved for 0.50 contact hours.
Section 1: Introduction
About This Course
Section 2: Outpatient Diagnosis Coding Guidelines
ICD-10-CM Coding Guidelines
ICD-10-CM Outpatient Coding Guidelines
Other Coding Guidelines
Section 3: Coding Outpatient Diagnosis
Sign and Symptom Codes
Outpatient Prenatal Visits
Outpatient Encounters Guidelines
Section 4: Coding Outpatient Encounters
Coding Practice: Outpatient Encounters
Section 5: Conclusion
Expert Reviewer: Jane Conway, RHIA, CCS, CRC, CDIP, CPhT, ICD-10-CM/PCS Trainer
Sarah is a Subject Matter Expert/Writer for Relias's Revenue Cycle and Coding online education. Sarah is credentialed by AHIMA as a Certified Coding Specialist (CCS) and Certified Coding Specialist Physician-based (CCS-P), as well as an approved ICD-10-CM/PCS Trainer. She is also credentialed by AAPC as a Certified Professional Coding Instructor (CPC-I), a certified coder of physician/professional (CPC) and outpatient hospital services (COC), and a Certified Risk Adjustment Coder (CRC), with specialty certification in Evaluation and Management Services (CEMC). Sarah has extensive experience in both professional and facility ICD-10-CM/PCS, CPT and HCPCS coding, auditing, and revenue cycle management and as an educator of hospital and professional medical coding curriculum. She has served as Director of Physician Billing and Reimbursement for a regional health system, Manager of Coding and Compliance for a hospital and cancer center, and Business Manager of Physician Practices at a teaching hospital, as well as a coding auditor and consultant. Sarah has also authored coding textbooks and instructional resources.Disclosure: Sarah A. Serling, CCS, CPC, CRC, COC, CCS-P, CEMC, CPC-I, ICD-10-CM/PCS Trainer has declared that no conflict of interest, Relevant Financial Relationship or Relevant Non-Financial Relationship exists.
Jane Conway is a Revenue Cycle, Coding, and CDI subject matter expert, content writer for Relias. She has ten years of experience in writing and maintaining ICD-10-CM/PCS eLearning curricula for inpatient and outpatient hospital settings. She is also an author and peer reviewer for other revenue cycle eLearning products. She has extensive knowledge in risk adjustment for CMS, HHS, and commercial payers. Jane has worked in healthcare for almost 30 years both in Health Information Management and pharmacy. Her pharmacy background adds a depth of knowledge to her courses. Jane is a Registered Health Information Administrator (RHIA), Certified Documentation Improvement Practitioner (CDIP), a Certified Risk Adjustment Coder (CRC), Certified Coding Specialist (CCS), and an AHIMA approved ICD-10-CM and ICD-10-PCS trainer. She is also a Certified Pharmacy Technician (CPhT). Jane earned a Bachelor's degree in Health Information Management from the State University of New York Polytechnic Institute where she was the recipient of the New York Health Information Management Association (NYHIMA) Academic Achievement Award.
Jane is active in NYHIMA, where she has served on the program planning committee and the education committee. Jane has also served as a credentials officer for NYHIMA. She recently was a keynote speaker at the NYHIMA annual conference and presented to both AAPC and CNYHIMA local meetings on several pertinent topics. She has also written several articles about new medical treatments for the NYHIMA newsletter.Disclosure: Jane Conway, RHIA, CCS, CRC, CDIP, CPhT, ICD-10-CM/PCS Trainer has declared that no conflict of interest, Relevant Financial Relationship or Relevant Non-Financial Relationship exists.
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