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Sandeep Posted Mon 08th of January, 2018 01:40:49 AM
What is the criteria for selecting Primary ICD codes when procedures are performed in office/outpatient basis in hospital? As per Official coding guidelines page no 34, section A .1 mentions under outpatient surgery heading , ' the reason for surgery (reason for encounter) should be the primary Dx. However section G states that "List first the ICD 10 CM code for the diagnosis, condition, problem, or other reason for encounter/visit shown in the medical record to be chiefly responsible for the services provided. This statement mentiones that 'diagnosis' may be reported as first code. How does above two statments balance each other? If diagnosis can be the reported as primary, in which circumstances it should be reported as primary and in which circumstances reason for encounter(which may be only signs/symptoms, not diagnosis) should be reported as first listed diagnosis code. If reason for encounter code is not part of LCD/NCD guidelines of that state, should it be still reported as priamry ICD code?
SuperCoder Answered Tue 09th of January, 2018 01:28:19 AM


In order for selection of primary dx, there are multiple rules depending on the documentation and place of service.

  • When a patient receives surgery in the hospital's outpatient surgery department and is subsequently admitted for continuing inpatient care at the same hospital, the following guidelines should be followed in selecting the principal diagnosis for the inpatient admission:    • If the reason for the inpatient admission is a complication, assign the complication as the principal diagnosis.   • If no complication, or other condition, is documented as the reason for the inpatient admission, assign the reason for the outpatient surgery as the principal diagnosis.    • If the reason for the inpatient admission is another condition unrelated to the surgery, assign the unrelated condition as the principal diagnosis.
  • In the outpatient setting, the term first-listed diagnosis is used in lieu of principal diagnosis. In determining the first-listed diagnosis the coding conventions of ICD-10-CM, as well as the general and disease specific guidelines take precedence over the outpatient guidelines. Diagnoses often are not established at the time of the initial encounter/visit. It may take two or more visits before the diagnosis is confirmed. The most critical rule involves beginning the search for the correct code assignment through the Alphabetic Index. Never begin searching initially in the Tabular List as this will lead to coding errors.   1. Outpatient Surgery: When a patient presents for outpatient surgery (same day surgery), code the reason for the surgery as the first-listed diagnosis (reason for the encounter), even if the surgery is not performed due to a contraindication.   2. Observation Stay When a patient is admitted for observation for a medical condition, assign a code for the medical condition as the first-listed diagnosis. When a patient presents for outpatient surgery and develops complications requiring admission to observation, code the reason for the surgery as the first reported diagnosis (reason for the encounter), followed by codes for the complications as secondary diagnoses.
  • If reason for encounter code is not part of LCD/NCD guidelines of that state, you need to change your ICD, you must choose the most appropriate ICD as per documentation which is allowable with that CPT code as per LCD/NCD guidelines. You may also refer to LCD/NCD tool that is provided in SuperCoder for cross reference of CPT to ICD-10 codes.



Sandeep Posted Thu 11th of January, 2018 06:08:26 AM
Hello, We have encountered many claims wherein we had billed based on reason for encounter as primary ICD code, but these claims were denied, however when primary ICD code was selected from LCD guidelines, the claims got paid. But this contradicts with ICD guidelines stating primary ICD code has to be reason for encouner. How should be the primary ICD selected? Can we use LCD/NCD guidelines for selecting primary ICD code?
SuperCoder Answered Fri 12th of January, 2018 00:17:33 AM


The first preference for choosing primary dx should be followed as per ICD-10 guidelines but when insurance denies the claims due to LCD/NCD guidelines, you need to refer to LCD/NCD guidelines and choose the appropriate dx from the LCD/NCD list. For medicare patients, most of the time it is preferred to select as per LCD/NCD guidelines.


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