For outpatient encounters for diagnostic tests that have been interpreted by a physician, and the final report is available at the
time of coding, code any confirmed or definitive diagnosis(es) documented in the interpretation. Do not code related signs and
symptoms as additional diagnoses.
Please note: This differs from the coding practice in the hospital inpatient setting regarding abnormal findings on test results.
L. Patients receiving therapeutic services only
For patients receiving therapeutic services only during an encounter/visit, sequence first 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. Codes for other diagnoses (e.g., chronic conditions) may be sequenced as additional diagnoses.
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.
M. Patients receiving preoperative evaluations only
For patients receiving preoperative evaluations only, sequence first a code from subcategory Z01.81, Encounter for pre-procedural
examinations, to describe the pre-op consultations. Assign a code for the condition to describe the reason for the surgery as an
additional diagnosis. Code also any findings related to the pre-op evaluation.
n. Ambulatory surgery
For ambulatory surgery, code the diagnosis for which the surgery was performed. If the postoperative diagnosis is known to be
different from the preoperative diagnosis at the time the diagnosis is confirmed, select the postoperative diagnosis for coding,
since it is the most definitive.
o. Routine outpatient prenatal visits
See Chapter 15, Routine outpatient prenatal visits.
P. encounters for general medical examinations with abnormal findings
The subcategories for encounters for general medical examinations, Z00.0-, provide codes for with and without abnormal findings.
Should a general medical examination result in an abnormal finding, the code for general medical examination with abnormal
finding should be assigned as the first-listed diagnosis. A secondary code for the abnormal finding should also be coded.
Q. encounters for routine health screenings
See Chapter 21, Factors influencing health status and contact with health services, Screening
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