How to code 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.

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Coding Examples

Patient had an outpatient phlebotomy performed for polycythemia vera.
ICD 10 code ; D45 polycythemia vera.

Female patient received outpatient chemotherapy for breast cancer with metastasis to the axillary lymph nodes.
ICD 10 code ; Z51.11 encounter for chemotherapy, C50.919 breast cancer, and C77.3 metastasis to axillary lymph nodes.

Patient had monthly B12 shot for pernicious anemia.
ICD 10 code ; D51.0 pernicious anemia, congenital.

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Author

  • Jitendra M.Sc CPC

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