Coding, Classification & Reimbursement

Primary Diagnosis in Outpatient Setting (Primary Care)

  • 1.  Primary Diagnosis in Outpatient Setting (Primary Care)

    Posted 9 days ago
    Can someone please explain how to assign the primary diagnosis in the outpatient setting. I thought it was the patient's chief complaint but is this not so? What if patient's chief complaint is an R code and provider documents another diagnosis that would be the cause of the R code but does not specifically document the relationship? What if the chief complaint is an R code but there are more specific diagnoses for the secondary reasons the patient is seeking treatment? I need some guidance!

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    Heather Mayes
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  • 2.  RE: Primary Diagnosis in Outpatient Setting (Primary Care)

    Posted 9 days ago

    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. List additional codes that describe any coexisting conditions. In some cases the first-listed diagnosis may be a symptom when a diagnosis has not been established (confirmed) by the physician.



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    Chrystel Barron
    Coding Education Instructor
    Cleveland Clinic Health System
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