We must remember that the principal diagnosis is not necessarily what brought the patient to the emergency room, but rather, what occasioned the admission. abnormal finding, the code for general medical examination with abnormal finding The selection of the principal diagnosis is one of the most important steps when coding an inpatient record. The Factors Influencing Health Status and Contact with Health vBv`Z LMI$"R]Re[. Rule-out conditions are not coded in the ____________ setting. The bases for these guidelines are the diagnostic workup, arrangements for further workup or observation, and initial therapeutic approach that correspond most closely with the established diagnosis. Es. The CDI specialist may consider acute respiratory failure as the principal diagnosis, leading to one MS-DRG, while the coder uses congestive heart failure as the principal diagnosis, resulting in a different MS-DRG assignment. The guidelines further state that in determining PDX, coding conventions in the ICD-10-CM Manual, the Tabular List, and Alphabetic Index take precedence over the coding . Some important guidelines to consider include the following: The principal diagnosis is not necessarily what brought the patient to the ER, but rather, what occasioned the admission. Two or more diagnoses that equally meet the definition for principal diagnosis: In the unusual instance when two or more diagnoses equally meet the criteria for principal diagnosis, as determined by the circumstances of admission, diagnostic workup, and/or the therapy provided, and the Alphabetic Index, Tabular List, or another coding guideline does not provide sequencing direction in such cases, any one of the diagnoses may be sequenced first. 3 What do you choose for the principal diagnosis when the original treatment plan is not carried out? Section I - Conventions, general coding guidelines, and chapter-specific guidelines. The circumstances of inpatient admission always govern the selection of principal diagnosis. https://www.findacode.com/articles/z-codes-that-may-only-be-principal-first-listed-diagnosis-33308.html, ICD-10-CM Official Guidelines for Coding and Reporting FY 2018, NPI Look-Up Tool (National Provider Identifier). Diagnosis Indexentries containing back-references depends on the circumstances of the admission, or why the patient was admitted. coli 3.1. Retrieved from https://www.findacode.com/articles/z-codes-that-may-only-be-principal-first-listed-diagnosis-33308.html. In this case, both conditions may not meet the definition of principal diagnosis. Services codes (Z00-Z99) are provided to deal with occasions when circumstances encounter as the first-listed or principal diagnosis. (NCHS). So if the physician simply wrote CAD vs. pneumonia, then either could be sequenced as principal diagnosis, Avery says. Admission from observation unit:jj, . Principal Diagnosis: A41.02 Methicillin resistant The principal diagnosis is defined in the Uniform Hospital Discharge Data Set (UHDDS) as that condition established after study to be chiefly responsible for occasioning the admission of the patient to the hospital for care.. 6 How is the principal diagnosis defined in the uhdds? The principal diagnosis is defined as the "condition, after study, which caused the admission to the hospital," according to the ICD-10-CM Official Guidelines for Coding and Reporting, FY 2016. 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. the principal diagnosis would be the medical condition which led to the hospital admission. 293 0 obj <>/Filter/FlateDecode/ID[<4A3E9657914E404EA9C98BF8DB5EA0BF>]/Index[274 39]/Info 273 0 R/Length 101/Prev 634514/Root 275 0 R/Size 313/Type/XRef/W[1 3 1]>>stream Current book and archives back to 2000Easy-to-read online book formatLinked to and from code details, by Christine Woolstenhulme, QMC QCC CMCS CPC CMRSFeb28th,2018, Z Codes That May Only be Principal/First-Listed Diagnosis. For example: A patient is admitted for a total knee replacement for osteoarthritis. Round the answer to the nearest thousandth. 0 Many coders view these diagnoses as equal and apply the coding guideline regarding two diagnoses that equally meet the definition of the principal diagnosis. Should a general medical examination result in an Contact her at lprescott@hcpro.com. Two or more diagnoses that equally meet the definition for principal diagnosis. For reporting purposes, the definition for "other diagnoses" is interpreted as additional conditions that affect patient care in terms of requiring: Two or more interrelated conditions, each potentially meeting the definition for principal diagnosis: When there are two or more interrelated conditions (such as diseases in the same ICD-10-CM chapter, or manifestations characteristically associated with a certain disease) potentially meeting the definition of principal diagnosis, either condition may be sequenced first, unless the circumstances of the admission, the therapy provided, the Tabular List, or the Alphabetic Index indicates otherwise. colitis, unspecified, Principal Diagnosis: O80 Encounter for full-term uncomplicated If the complication is classified to T80-T88 series, and the code lacks the necessary specificity in describing the complication, an additional code for the specific complication should be assigned. Which of the following codes are indicated as an Major Complication/Cormorbidity for this DRG assignment? "My goal is to clarify the documentation so that it reflects the provider's intent and accurately paints the clinical picture of which condition occasioned the admission," Ericson says. Admissions/Encounters for Rehabilitation/No longer present. xE)bHE Admission from Observation Unit ; Admission Following Medical Observation, When a patient is admitted to an observation unit for a medical condition, which either worsens or does not improve, and is subsequently admitted as an inpatient of the same hospital for this same medical condition, the principal, Admission Following Post-Operative Observation, When a patient is admitted to an observation unit to monitor a condition (or complication) that develops following outpatient surgery, and then is ICD-10-CM code for the diagnosis, condition, problem, or other reason for encounter/visit. When multiple reasons are equally responsible for the admission to the facility, the coding professional and/or healthcare analyst should: Select the one that has the highest paying DRG assignment. special examinations. Many people define it as the diagnosis that bought the bed, or thediagnosis that led the physician to decide to admit the patient. yy11y=0, Find the limit of the following expression which is given by, limx+1ex1+ex\lim _{x \rightarrow+\infty} \frac{1-e^x}{1+e^x} Worksheet for Identifying Coding Quality Problems 1 What is the definition of principal diagnosis quizlet? The appropriate code(s) from A00.0 through T88.9, Z00-Z99 must be used to identify diagnoses, symptoms, conditions, problems, complaints, or other reason(s) for the encounter/visit. the condition defined after study as the main reason for admission of a patient to the hospital. 4360 0 obj <>/Filter/FlateDecode/ID[<06DB06503CD3F64A93E0CC1978B4722F>]/Index[4347 24]/Info 4346 0 R/Length 71/Prev 599606/Root 4348 0 R/Size 4371/Type/XRef/W[1 2 1]>>stream For encounters for routine laboratory/radiology testing in the absence of any signs, Do you have any tips for me to help me discern better? In this scenario, it would be the acute myocardial infarction, the STEMI. Feb 28th, 2018 Z Codes That May Only be Principal/First-Listed Diagnosis According to 2018 Guidelines section: 1;C.21.c.16, the following Z codes/categories may only be reported as the principal/first-listed diagnosis, except when there are multiple encounters on the same day and the medical records for the encounters are combined: chronic obstructive pulmonary disease) during a routine physical examination. Do not code conditions that complication as the principal diagnosis. Coders cannot infer a cause-and-effect relationship, according to the AHAs Coding Clinic, Second Quarter 1984, pp. encounter/visit. When a patient is admitted for observation for a medical condition, assign a code for the medical condition as the first-listed diagnosis. Complications of surgery and other medical care: When the admission is for treatment of a complication resulting from surgery or other medical care, the complication code is sequenced as the principal diagnosis. the diagnosis, condition, problem, or other reason for encounter/visit shown in the medical record to be chiefly responsible for the outpatient services provided during the encounter/visit. Worksheet for Identifying Coding Quality Problems Case 1 Principal Diagnosis: B96.20 Unspecified Escherichia coli as the cause of diseases classified elsewhere Secondary Diagnosis: N39.0 Urinary tract This problem has been solved! For patients receiving preoperative evaluations only, sequence first a code from The principal diagnosis should be based on physician query to determine whether the pneumonia or the respiratory failure was the reason for the admission. Factors influencing health status and contact with health services. Transcribed image text: are a specific patient condition that is secondary to a patient's principle diagnosis. American Health Information Management Association (AHIMA) x2+11x+30x^{2}+11 x+30x2+11x+30. Admission Following Postoperative Observation. diabetic Discuss the sequencing of codes for outpatients receiving diagnostic services only. Encounters for circumstances other than a disease or injury. Bringing over 30 years of insight, business knowledge, and innovation to the healthcare industry. Note: This guideline is applicable only to inpatient admissions to short-term, acute care, long-term care, and psychiatric hospitals. Check for extraneous solutions. The coder should use the circumstances of the admission, therapy provided, etc., to make the determination if one outweighs the other. Next, let us look at an example of when these two would differ. test to evaluate a sign, symptom, or diagnosis, it is appropriate to assign both the Z The principal diagnosis is ordinarily listed first in the physician's diagnostic statement, but this is not always the case. I think you are confusing three definitions: The primary diagnosis is often confused with the principal diagnosis. If no complication, or other condition, is documented as the reason for the inpatient admission, assign the reason for the outpatient surgery as the principal diagnosis. Respiratory failure is always due to an underlying condition. The circumstances of the patient's admission into the hospital always govern the selection of principal diagnosis (scope of care, diagnostic workup, and therapy provided), says Jennifer Avery, CCS, CPC-H, CPC, CPC-I, AHIMA-approved ICD-10-CM/PCS trainer, senior coding instructor for HCPro, a division of BLR, in Danvers, Massachusetts. `0A d1,U@5? This is the diagnosis that brought the patient to the hospital and the diagnosis which occasioned the need for the inpatient bed. Z87) may be used as secondary codes if the historical condition or family history has require or affect patient care treatment or management. What is the definition of principal diagnosis? This is not necessarily what brought the patient to the emergency room. In a physician's office, a chronic disease treated on an ongoing basis may be coded and reported as many times as the patient receives treatment and care for the condition. Coding Rule Violated: See Section 1.B. This Coding Clinic addressed a question regarding whether it is appropriate to code vasogenic edema when the physician documents it for a patient admitted and diagnosed with intracerebral hemorrhage. It is the condition after study meaning we may not identify the definitive diagnosis until after the work up is complete. Coding guidelines indicate that which of the following diagnoses should be listed as the principal diagnosis for the Part 1 case scenario? endstream endobj startxref When a patient is admitted to an observation unit for a medical condition, which either worsens or does not improve, and is subsequently admitted as an inpatient of the same hospital for the same medical condition, the principal diagnosis is the medical condition that led to the hospital admission. Instead of going to the operating room for the knee replacement, the patient goes to the cath lab for a stent placement. True x+lim1+ex1ex. No charge. Section III - includes guidelines for reporting additional diagnoses in non- outpatient settings. 4x3+23x\frac{4}{x-3}+\frac{2}{3-x} Codes for other diagnoses (e.g., chronic conditions) may be sequenced as additional diagnoses. Select all that apply. What is the difference between primary and principal diagnosis? The Uniform Hospital Discharge Data Set (UHDDS) definition of other diagnoses, or secondary diagnoses, describes those conditions that coexist at the time of admission, or develop subsequently, and that affect the patient care for this current episode of care. List the sections of the ICD-10-CM Official Guidelines for Coding and Reporting. Each unique ICD-10-CM code may be reported ____________ for an encounter. Section II - Selection of Principal Diagnosis , Classification Systems and Secondary Data Sou, Elementary Number Theory, International Edition, Test for Day 1 of Year 2: Everything together. Admission from outpatient surgery: When a patient receives surgery in the hospital's outpatient surgery department and is subsequently admitted for continuing inpatient care at the same hospital, the following guidelines should be followed in selecting the principal diagnosis for the inpatient admission: When the reason for the inpatient admission is a complication, assign the complication as the principal diagnosis. findings refers to a condition/diagnosis that is newly identified or a change in severity inpatient admission, assign the reason for the outpatient surgery as the Simplify the result, if possible. 312 0 obj <>stream 4. Chronic diseases treated on an ongoing basis may be coded and reported as many In the _____________ setting, the definition of principal diagnosis does not apply. ,)I6Mncfu)V5\].Vx_xm+j$"S"h@ @ { l[4X27Nk2TSd`SBjPyl[ How is the principal diagnosis defined in the uhdds? {h/E|gmfm+UV|Vx\,DmhP,_e)`9dzs$]UNXF>oqT,Wc J:m= uFY_!XF=(\ViMX.bbT{Wu3yJ~qRq=>]8Lo N75qa3. y`" H"qZ~J,y3Sqd?-ZSbmqJ`loK1{F} KuvFXan;];} p q%AwQ>L&(NxJ^[%Fw!6HR?#d$BDql{;n(H]`:LoS*|k9[uS-58\W3b*{!:pNpmv>b@/>HN;cqPma=hg08vIPh all codes for symptoms. fracture with routine healing, as the first-listed or principal diagnosis. admission: Guideline II.J. hm8>\[l@{mwf Y;n&i.pG1c%hy$KS2%qEVCXi!"Tkph&E0E The patient is brought to pre-operative holding area to prepare for surgery and suffers a ST-segment elevation myocardial infarction (STEMI) before the surgery could begin. If the reason for the inpatient admission is another condition unrelated to the surgery, assign the unrelated condition as the principal diagnosis. In the inpatient setting, the primary diagnosis describes the diagnosis that was the most serious and/or resource-intensive during the hospitalization or the inpatient encounter. In the ICD-10-CM Official Guidelines for coding and reporting, Section ____________ contains chapter-specific guidelines that correspond to the chapters as they are arranged in the classification. condition defined after study as the main reason for admission of a patient to the hospital. For example, a patient might present to the emergency room because he is dehydrated and is admitted for gastroenteritis. They both would likely lead to an inpatient admission, and would meet medical necessity. When to assign an inpatient as a principal diagnosis? The subcategories for encounters for general medical examinations, Z00.0- and the admitting diagnosis, which may be a symptom or ill-defined condition, could change substantially based on the results of "further study.". When the admission is for treatment of a complication resulting from surgery or other medical care, the complication code is sequenced as the principal diagnosis. Codes may be further subdivided by the use of fourth, fifth, sixth or seventh characters to provide greater specificity. If the diagnosis documented at the time of discharge is qualified as "probable," "suspected," "likely," "questionable," "possible," or "still to be ruled out," or other similar terms indicating uncertainty, code the condition as if it existed or was established. healthcare information, Chapter 17 HIMT 1150 Computers in Healthcare/, Mathematical Proofs: A Transition to Advanced Mathematics, Albert D. Polimeni, Gary Chartrand, Ping Zhang. We NEVER sell or give your information to anyone. \hline f(x) & & & & & & & \\ The diagnosis reflects the reason the patient sought medical care, and the principal diagnosis can drive reimbursement. The primary diagnosis refers to the patient condition that demands the most provider resources during the patients stay. Solve the system of linear equations using Cramers Rule. For patients receiving diagnostic services only during an encounter/visit, sequence first The principal diagnosis is defined as the condition established after study to be chiefly responsible for admission of the patient to the hospital. Review the 2017 Official Guidelines for Coding and Reporting. Case 1 medical record to be chiefly responsible for the outpatient services provided during the Do the official ICD-10-CM guidelines take precedence over the coding directives within the code set that is index tabular when determining the principal diagnosis quizlet? jwt{im=`=0)jH+/om@V%>/:eDdO N_"{_h~w_[m9h? Z38.61 Z05.2 Z53.8 Z68.54 Expert Answer Z05.2 A code from category Z03-Z07 can only be used as the primary diagnosis or View the full answer If the condition for which the rehabilitation service is no longer present, report the appropriate aftercare code as the first-listed or principal diagnosis, unless the rehabilitation service is being provided following an injury. We must also consider those diagnoses that develop subsequently, and will affect the patient care for the current episode of admission. Staphylococcus aureus sepsis, Secondary Diagnosis: B95.62 Methicillin-resistant Either is appropriate dependent on physician query. 1. Enter a Melbet promo code and get a generous bonus, An Insight into Coupons and a Secret Bonus, Organic Hacks to Tweak Audio Recording for Videos Production, Bring Back Life to Your Graphic Images- Used Best Graphic Design Software, New Google Update and Future of Interstitial Ads. However, history codes (categories Z80- _______________ evaluation; or endstream endobj 275 0 obj <>/Metadata 27 0 R/Pages 272 0 R/StructTreeRoot 46 0 R/Type/Catalog>> endobj 276 0 obj <>/MediaBox[0 0 612 792]/Parent 272 0 R/Resources<>/ProcSet[/PDF/Text/ImageB/ImageC/ImageI]/XObject<>>>/Rotate 0/StructParents 0/Tabs/S/Type/Page>> endobj 277 0 obj <>stream When a patient is admitted to an observation unit to monitor a condition (or complication) that develops following outpatient surgery, and then is subsequently admitted as an inpatient of the same hospital, hospitals should apply the UHDDS definition of principal diagnosis as "that condition established after study to be chiefly responsible for occasioning the admission of the patient to the hospital for care.". subsequently admitted for continuing inpatient care at the same hospital, the following Consider a patient who is admitted for acute respiratory failure due to exacerbation of congestive heart failure (CHF). The principal procedure is one that is performed for definitive treatment rather than one performed for diagnostic or exploratory purposes, or was necessary to take care of a complication. guidelines should be followed in selecting the principal diagnosis for the inpatient The ICD-10-CM official guidelines for coding and reporting were developed by the american health information management association. If the patient requires rehabilitation post hip replacement for Maybe the physician performed surgery on the fracture, which could make the fracture the principal diagnosis, if treating the fracture was the reason for the admission. Principal Diagnosis That condition established after study to be chiefly responsible for occasioning the admission of the patient to the hospital for care. additional instruction. A quadratic function that passes through (1,2)(1,2)(1,2) and has xxx-intercepts (1,0)(-1,0)(1,0) and (3,0)(3,0)(3,0), Evaluate the following equation and describe the property of the exponents used. In some cases the first-listed diagnosis may be a symptom when a diagnosis has not been Code the condition to the highest level of certainty. For example, if the physician's diagnostic statement said chest pain, coronary artery disease (CAD) vs. pneumonia, then chest pain would be the principal diagnosis based on the coding guideline, Avery says. %PDF-1.5 % A patient is admitted for a total knee replacement for osteoarthritis. \end{array} See Answer . On the other hand, if a patient is admitted with sepsis due to COVID-19 pneumonia and the sepsis meets the definition of principal diagnosis, then the code for viral sepsis (A41.89) should be assigned as principal diagnosis See our privacy policy. A __________ is the residual effect (condition produced) after the acute phase of an illness or injury has terminated. of a chronic condition (such as uncontrolled hypertension, or an acute exacerbation of is defined as the condition having the most impact on the patient's health, LOS, resource consumption, and the like. Codes with three characters are included in ICD-10-CM as the heading of a category of ICD-10-CM Official Guidelines for Coding and Reporting. reporting purposes when a diagnosis has not been established (confirmed) by the Guideline II.K. the appropriate seventh character for subsequent In those rare instances when two or more contrasting or comparative diagnoses are documented as "either/or" (or similar terminology), they are coded as if the diagnoses were confirmed and the diagnoses are sequenced according to the circumstances of the admission. If the reason for the inpatient admission is another condition unrelated to the surgery, assign the unrelated condition as the principal diagnosis. The admitting diagnosis has to be worked up through diagnostic tests and studies. Abnormal findings are not coded and reported for unless the ____________ indicates their clinical significance. Codes that describe symptoms and signs are acceptable for coding when a definitive diagnosis has not been sestablished in a phsician's office. 3. \hline Principal diagnosis is defined as the condition, after study, which occasioned the admission to the hospital, according to the ICD-10-CM Official Guidelines for Coding and Reporting. A patient is admitted because of severe abdominal pain. as the cause of other diseaseB96.20- see also Q: Sometimes I confuse the secondary diagnosis for the primary diagnosis. In the outpatient setting, do not code conditions that were previously ________________ and no longer exist. Information about the use of certain abbreviations, punctuation, symbols, and other conventions used in the ICD-10-CM Tabular List (code numbers and titles) can be found in Sections _________________ of the ICD-10-CM Official Guidelines for Coding and Reporting. since it is the most definitive. When the purpose for the admission/encounter is rehabilitation, sequence first You'll get a detailed solution from a subject matter expert that helps you learn core concepts. ICD-10-CM is composed of codes with 3, 4, 5, 6 or 7 characters. Which diagnosis ends up listed as principal? Find the equation and sketch the graph for each function. When a patient is admitted with acute respiratory failure and another condition, coders and CDI specialists dont always agree on the principal diagnosis. regarding abnormal findings on test results. View the full answer. 4x3y8z=72x9y+5z=0.55x6y5z=2\begin{aligned} If the diagnosis documented at the time of discharge is qualified as "probable" or "suspected," do not code the condition. Otherwise they won't meet inpatient criteria, Ericson says. Discover how to save hours each week. %%EOF All conditions that coexist at the time of admission, that develop subsequently, or that affect the treatment received and length of stay, or both, are known as the _____________. Two or more interrelated conditions, each potentially meeting the definition for principal diagnosis. There are ICD-10-CM codes to describe all of these. But coders should be able to defend this with documentation of clinical circumstances, such as if the patient is: Two or more possible principal diagnoses Guideline II.G. Original treatment plan not carried out: Sequence as the principal diagnosis the condition which after study occasioned the admission to the hospital, even though treatment may not have been carried out due to unforeseen circumstances. When a patient presents for outpatient surgery and develops complications requiring admission to observation, code the reason for the surgery as the first reported diagnosis (reason for the encounter), followed by codes for the complications as secondary diagnoses. Often the two are one of the same, but not always. Copyright 2023 HCPro, a Simplify Compliance brand. 3. \end{aligned} The bases for these guidelines are the diagnostic workup, arrangements for further workup or observation, and initial therapeutic approach that correspond most closely with the established diagnosis. Codes for signs, symptoms, and ill-defined conditions (Chapter 16) Are not to be used as prinicpal diagnosis when a related definitive diagnosis has been established. The only exception to this rule is that when the primary reason for the admission/encounter is chemotherapy or radiation therapy, the appropriate Z code for the service is listed first, and the diagnosis or problem for which the service is being performed listed second. Z38.61 Z05.2 Z53.8 Z68.54 Which of the following Z codes can only be used for a principal diagnosis? National center for health statistics. (a) cases for which no more specific diagnosis can be made even after all the facts bearing on the case have been investigated; (b) signs or symptoms existing at the time of initial encounter that proved to be transient and whose causes could not be determined; For ambulatory surgery, code the diagnosis for which the surgery was performed. a principal diagnosis is the condition "established after study to be chiefly responsible for occasioning the admission of the patient to the hospital for care" Selecting the principal diagnosis depends on the circumstances of the admission, or why the patient was admitted. To be considered a secondary diagnosis the condition must require: Identifying the principal and the secondary diagnosis can be confusing when you have a patient who is admitted with two or more acute issues present such as a patient admitted with an aspiration pneumonia and acute cerebrovascular accident (CVA). coli as the cause of diseases classified elsewhere surgery as an additional diagnosis. Add or subtract as indicated. What is the primary diagnosis? Please note: This differs from the coding practice in the hospital inpatient setting They would be coded as secondary diagnoses because they will require treatment and monitoring during the patient stay. Factors influencing health status and contact with health services, Screening, OST-248 Diagnostic Coding - Chapter 5 - 7, ICD 10 CM and ICD 10 PCS Chapter 8 Test Yours, Chapter 13, 14 & 15 - Medical Admin. Gastroenteritis is the principal diagnosis in this instance. Christine was a VAR for AltaPoint EHR software sales, along with management positions and medical practice consulting. encounter for routine child health examination, Z00.12-, provide codes for with 2. The physician doesnt have to state the condition in the history and physical (H&P) in order for the coder to be able to use it as the principal diagnosis. The diagnosis codes (Volumes 1-2) have been adopted under HIPAA for all healthcare settings. depends on the circumstances of the admission, or why the patient was admitted. hbbd``b`7A+ $X> .`>bX0 @F+@H / Rather, code the condition(s) to the highest degree of certainty for that encounter/visit, such as symptoms, signs, abnormal test results, or other reason for the visit. The following information on selecting the principal diagnosis and additional diagnoses should be reviewed carefully to ensure appropriate coding and reporting of hospital claims. 5 Is the primary diagnosis the same as the principal diagnosis? For example, our patient admitted with the principal diagnosis of osteoarthritis with the planned total knee replacement also has a history of type two diabetes, chronic obstructive pulmonary disease (COPD), and coronary artery disease (CAD). 2E/R$%a3!0CK*z#sg{s~= hcHN yK5s=>*VCZ+5o$GRw7q}NZL >.U%o\,1}ZOevj:cX}\ OG'2lGEeWG- f_W2H J5=&g9f9E17/bP0{E3/ Establishing a successful Medical Billing Company from 1994 to 2015, during this time, Christine has had the opportunity to learn all aspects of revenue cycle management while working with independent practitioners and in clinic settings. When a patient receives surgery in the hospital's outpatient surgery department and is True False h1gz}7ci5c-;]5'\]!M5. If you continue to use this site we will assume that you are happy with it. For outpatient and physician office visits, the code that is listed first for coding and reporting purposes is the reason for the encounter. You'll get a detailed solution from a subject matter expert that helps you learn core concepts. Editors Note: Laurie L. Prescott, RN, MSN, CCDS, CDIP, CDI Education Director at HCPro in Middleton, Massachusetts, answered this question.