Coding Corner: The future is now: CDI in office/outpatient settings

By Lori-Lynne A. Webb, CPC, CCS-P, CHDA, CDIP, COBGC
Back in 2016, I wrote the following synopsis for HCPro about outpatient/office diagnosis reporting, clarifying some of the misunderstood procedural guidelines between inpatient and outpatient services.

“For those who code for outpatient or office based services; instead of reporting a ‘principal’ diagnosis, you would code the firstlisted diagnosis, as well as signs and symptoms that are documented by the provider of care. In some cases, it may take more than one visit or encounter to arrive at and/or confirm a specific ’diagnosis.’ ICD-10-CM guidelines allow us to continue to report signs and symptoms over the course of the outpatient workup. The majority of the signs and symptom codes are found in Chapter 18 of the ICD-10-CM diagnosis codes, however, other signs and symptom codes can be found in many of the other sections and chapters of ICD-10-CM.”