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.

Read also  Secret tips for ICD 10 code for cervical radiculopathy

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.

Read also  ICD-10-CM Heart Failure Coding Guide: Types, Ejection Fraction & Accurate Code Selection

Author

  • Jitendra M.Sc CPC

    Need expert coding advice?

    FREE CPT Code Search Tool (Click Here)

    MUST BUY CPT & ICD-10 CM  CODING EBOOKS 

    This article was written by Jitendra, CPC, a coding veteran with a decade of facility experience. Learn more about our mission on our About Us page.

    Connect with Jitendra: [%%AMCIL_PROTECT_2%%] | [%%AMCIL_PROTECT_3%%] | [%%AMCIL_PROTECT_4%%]

Read also  Nonischemic cardiomyopathy icd 10 code Coding Guide

Comments

No comments yet. Why don’t you start the discussion?

    Leave a Reply