Question

multiple choice question

what is the second step in outpatient diagnosis coding?

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

Explanation:

Analyze the coding process

In medical billing and coding (specifically ICD-10-CM outpatient diagnosis coding), the standard sequential steps to assign diagnostic codes from documentation are:

1. Review complete medical documentation to understand the patient's visit.
2. Abstract the medical conditions (diagnoses, signs, symptoms, or reasons for the encounter) from the visit documentation.
3. Identify the main term for each condition to look up in the Alphabetic Index.
4. Locate the main term in the Alphabetic Index and verify the code in the Tabular List, checking compliance with official guidelines.

Identify the second step

Using the Outpatient Coding Guidelines process:

• Step 1: Review complete medical documentation.
• Step 2: Abstract the medical conditions from the visit documentation.
• Step 3: Identify the main term for each condition.
• Step 4: Locate the term in the Alphabetic Index, verify in the Tabular List, and check compliance with guidelines.

Therefore, the second step is "Abstract the medical conditions from the visit documentation."

Answer:

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