AAPC CPC Coding Guidelines
Questions And Answers.
Finding main dx term--try reading dx right to left -
\EX: COPD (chronic obstructive pulmonary disease) can be found under "disease" as
well as "obstruction"
Ex2: URI (upper respiratory infection) can be found under "infection"
Always code to the highest degree of specificity. -
\Ex: aged related Osteoporosis with current fracture of left shoulder, follow up visit;
M80.012D:
M80 (osteoporosis with current fracture) +
M80.0 (age related) +
M80.012 (age related w/current fracture of left shoulder +
M80.012D (subsequent visit)
Outpatient visits--SUSPECTED Dx NEVER coded.
If a definitive Dx has not been reported then code:
1--Signs
2--Sx
3--Abnormal Test results -
\Terms of suspected Dx:
Probable
Suspected
Questionable
Rule Out
Differential
Working
Inpatient Visits--SUSPECTED Dx MAY BE CODED, with exception to HIV.
HIV Dx must be confirmed before coding. -
\
Sx that are an INTEGRAL part of a disease do NOT need to be coded. -
\Ex: Pt presents w/severe AB pain, nausea, vomiting. Diagnosed w/acute appendicitis.
Code only acute appendicitis K35.80.
Sx that are NOT INTEGRAL part to a disease DO NEED TO BE CODED. -
\Ex: Patient presents with runny nose & cough as well as Rt shoulder pain. Physician
diagoses URI. Code URI as well as Sx of Rt Shoulder pain.
URI--J06.9
Rt Shldr Pn--M25.511
, MULTIPLE CODING FOR A SINGLE CONDITION--
Some Diseases require multiple Dx codes and will indicate ETIOLOGY &
MANIFESTATION. It will appear in the alphabetic index as one code followed by
another code in brackets. -
\Ex: Amyloid Heart Disease E85.4 [I43]
BOTH etiology AND manifestation codes are required to record this condition.
ACUTE & CHRONIC CONDITIONS DOCUMENTED AT THE SAME TIME--
when both are documented, code acute first then chronic -
\EX: Acute and chronic cystitis
N30.00 Acute cystitis w/o hematuria
N30.20 Other Chronic cystitis w/o hematuria
CHRONIC CONDITIONS--
can be coded as many time as applicable to treatment, but after resolution will appear
as z-codes if history of condition affects CURRENT reason for care. -
\EX: colon cancer
(look under "history, personal of"--not "cancer")
Pt w/ personal hx of colon cancer presents for colonoscopy. Z85.038
Sequelae--late or residual effects after an acute illness/injury. TWO codes are often
required. Residual condition 1st, then cause for sequelae 2nd. If no residual effects are
documented, use cause for sequelae as prinicpal Dx. -
\Look up "sequelae" in alphabetic index.
EX:
Due to an old injury
Due to previous illness
Due to illness/injury 1 yr or more from current encounter
Impending or Threatened Conditions -
\--Can be found under main term then subterm "impending."
--If subterm impending not listed, look under "Impending or Threatened" as main term
w/condition as subterm.
--If no code is suitable, use signs and symptoms codes.
Therapeutic Services as primary reason for encounter will be coded with REASON
therapeutic services are being rendered (IE code Dx, condition, problem).
**If service is for chemo, radiation, or rehab, then code z-code for the service 1st and
the underlying condition 2nd.** -
\EX: Outpatient chemotherapy visit
Z51.11 --chemo...
C19 --malignant neoplasm...
Pre-Op Exams -
\Look under "Examination/pre-procedural"
1st-Code for preop (Z01.818)
Questions And Answers.
Finding main dx term--try reading dx right to left -
\EX: COPD (chronic obstructive pulmonary disease) can be found under "disease" as
well as "obstruction"
Ex2: URI (upper respiratory infection) can be found under "infection"
Always code to the highest degree of specificity. -
\Ex: aged related Osteoporosis with current fracture of left shoulder, follow up visit;
M80.012D:
M80 (osteoporosis with current fracture) +
M80.0 (age related) +
M80.012 (age related w/current fracture of left shoulder +
M80.012D (subsequent visit)
Outpatient visits--SUSPECTED Dx NEVER coded.
If a definitive Dx has not been reported then code:
1--Signs
2--Sx
3--Abnormal Test results -
\Terms of suspected Dx:
Probable
Suspected
Questionable
Rule Out
Differential
Working
Inpatient Visits--SUSPECTED Dx MAY BE CODED, with exception to HIV.
HIV Dx must be confirmed before coding. -
\
Sx that are an INTEGRAL part of a disease do NOT need to be coded. -
\Ex: Pt presents w/severe AB pain, nausea, vomiting. Diagnosed w/acute appendicitis.
Code only acute appendicitis K35.80.
Sx that are NOT INTEGRAL part to a disease DO NEED TO BE CODED. -
\Ex: Patient presents with runny nose & cough as well as Rt shoulder pain. Physician
diagoses URI. Code URI as well as Sx of Rt Shoulder pain.
URI--J06.9
Rt Shldr Pn--M25.511
, MULTIPLE CODING FOR A SINGLE CONDITION--
Some Diseases require multiple Dx codes and will indicate ETIOLOGY &
MANIFESTATION. It will appear in the alphabetic index as one code followed by
another code in brackets. -
\Ex: Amyloid Heart Disease E85.4 [I43]
BOTH etiology AND manifestation codes are required to record this condition.
ACUTE & CHRONIC CONDITIONS DOCUMENTED AT THE SAME TIME--
when both are documented, code acute first then chronic -
\EX: Acute and chronic cystitis
N30.00 Acute cystitis w/o hematuria
N30.20 Other Chronic cystitis w/o hematuria
CHRONIC CONDITIONS--
can be coded as many time as applicable to treatment, but after resolution will appear
as z-codes if history of condition affects CURRENT reason for care. -
\EX: colon cancer
(look under "history, personal of"--not "cancer")
Pt w/ personal hx of colon cancer presents for colonoscopy. Z85.038
Sequelae--late or residual effects after an acute illness/injury. TWO codes are often
required. Residual condition 1st, then cause for sequelae 2nd. If no residual effects are
documented, use cause for sequelae as prinicpal Dx. -
\Look up "sequelae" in alphabetic index.
EX:
Due to an old injury
Due to previous illness
Due to illness/injury 1 yr or more from current encounter
Impending or Threatened Conditions -
\--Can be found under main term then subterm "impending."
--If subterm impending not listed, look under "Impending or Threatened" as main term
w/condition as subterm.
--If no code is suitable, use signs and symptoms codes.
Therapeutic Services as primary reason for encounter will be coded with REASON
therapeutic services are being rendered (IE code Dx, condition, problem).
**If service is for chemo, radiation, or rehab, then code z-code for the service 1st and
the underlying condition 2nd.** -
\EX: Outpatient chemotherapy visit
Z51.11 --chemo...
C19 --malignant neoplasm...
Pre-Op Exams -
\Look under "Examination/pre-procedural"
1st-Code for preop (Z01.818)
