Question

multiple choice question

what is the second step in outpatient diagnosis coding?

abstract the medical conditions from the visit documentation.
review complete medical documentation.
identify the main term for each condition.
check compliance with any applicable official guidelines and list codes in appropriate order.

Explanation:

Identify the first step in coding

Using the ICD-10 Coding Steps and Outpatient Coding Guidelines knowledge points, the very first step in the diagnostic coding process is to review the complete medical documentation of the patient's visit to understand the clinical picture.

Determine the second step in coding

Using the ICD-10 Coding Steps and Outpatient Coding Guidelines knowledge points, once the documentation is reviewed, the second step is to abstract the specific medical conditions, diagnoses, or reasons for the encounter from that documentation.

Evaluate the remaining options

Using the ICD-10 Coding Steps knowledge point, identifying the main term for each condition is a subsequent step used to look up codes in the Alphabetic Index, and checking compliance with guidelines is one of the final steps in the coding process.

Answer:

• (A) Abstract the medical conditions from the visit documentation. (Correct answer)
• (B) Review complete medical documentation.
• (C) Identify the main term for each condition.
• (D) Check compliance with any applicable official guidelines and list codes in appropriate order.