Response to the following True or False:
1. If the preoperative and postoperative diagnosis are different, the preoperative diagnosis should be reported
2. For an outpatient service, a history code (Z80-Z87) may be assigned as a secondary code if the historical condition or family history has an impact on the current care or has an influence on the treatment.
3. In the outpatient setting, a diagnosis that is documented as "rule out" should not be reported.
4. You should code all of the documented conditions that coexist at the time of an encounter/visit and require or affect patient care, treatment, or management.
5. Z codes may be assigned as first-listed or a secondary diagnosis.
6. Assign Z01.89 (i.e., Encounter for other specified special examinations) for encounters for routine laboratory/radiology testing in the absence of any signs, symptoms, or associated diagnosis.
7. In the inpatient hospital setting, probable, suspected, and rule-out diagnosis cannot be reported by the facility as though the condition exists.
8. The term "primary diagnosis" is the same as the first-listed diagnosis.
9. When an encounter is for a therapeutic service, the first-listed code is the diagnosis, condition, or problem shown to be chiefly responsible for the therapeutic services.
10. Section IV of the official Coding and Reporting Guidelines can be used to code both the inpatient and outpatient settings when coding diagnostic and therapeutic services.
Response to the following multiple choice questions:
11. Identify the first-listed diagnosis in the following outpatient encounter. An established patient is seen for redness and sensitivity to light in her right eye. The documentation states the diagnosis is iritis.
* Acute appendicitis
* Chest pain
* Hypothyroidism, diabetes
* Iritis
12. Identify the first-listed diagnosis in the following encounter. An established patient experiences chest pain. He has a history of previous myocardial infarction and coronary artery bypass surgery.
* Acute appendicitis
* Chest pain
* Hypothyroidism, diabetes
* Iritis
13. Identify the first-listed diagnosis in the following outpatient encounter. An established patient is seen for management of diabetes and hypothyroidism, and the physician spends equal time on each diagnosis.
*Acute appendicitis
* Chest pain
* Hypothyroidism, diabetes
* Iritis
14. Identify the first-listed diagnosis in the following outpatient encounter. A patient makes an initial office visit for nausea and vomiting. The physician documented that the nausea and vomiting were due to acute appendicitis.
* Acute appendicitis
* Chest pain
* Hypothyroidism, diabetes
* Iritis
Response to the following must be 75 words in length:
15. When coding, if you come to the terms "cross reference" and "see also," what should you do? Why is this important? What will happen if this is not done correctly?