COC · AAPC
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In the outpatient setting, how should a diagnosis documented as 'probable' or 'suspected' be coded?
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Answer:
For outpatient encounters, uncertain diagnoses are not coded as confirmed. Code to the highest degree of certainty, such as symptoms, signs, or abnormal findings.
Source: ICD-10-CM Official Guidelines, Section IV.H
For an outpatient encounter, what is the first-listed diagnosis?
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Answer:
The first-listed diagnosis is the condition chiefly responsible for the outpatient services provided.
Source: ICD-10-CM Official Guidelines, Section IV.G
Under which Medicare method are hospital clinic services grouped into Ambulatory Payment Classifications (APCs)?
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Answer:
OPPS groups hospital outpatient services into APCs for payment. IPPS uses diagnosis-related groups for inpatient stays.
Source: CMS Hospital Outpatient Prospective Payment System
Exam outline
Exam details are taken from AAPC's published materials. Always check the issuer for the latest rules.
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