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Section 1
COC blueprint: ICD-10-CM diagnosis coding — outpatient uncertain diagnoses (Item 1)
Preview
Preview: ICD-10-CM diagnosis coding
Preview includes- 4 of 5 lesson topics
- 1 overview segment
- 3 core concepts
- 2 exam tips
Lesson Topics
- Apply the controlling rule
- Identify the decisive documentation clue
- Differentiate the nearest competing concept
- Verify code, modifier, units, or payment status when applicable
Overview
This card covers ICD-10-CM diagnosis coding — outpatient uncertain diagnoses.
Core Concepts
- For hospital outpatient encounters, do not code a diagnosis documented as probable, suspected, questionable, rule out, compatible with, consistent with, working diagnosis, or similar uncertainty. Report the highest degree of certainty known at the end of the encounter, such as signs, symptoms, abnormal findings, or another documented reason for the visit.
- Inpatient uncertain-diagnosis rules do not carry over to outpatient facility coding.
- Use the current-year code set and the CMS file effective for the date of service when the answer depends on a code descriptor, edit, status indicator, or payment policy.
Exam Tips
- AAPC estimates 15 ICD-10-CM questions; prioritize outpatient guidelines, sequencing, specificity, combination codes, and documentation.
- Read the stem for setting, reason for encounter, exact service performed, route/approach, time, contrast, tissue depth, units, and date of service before looking at answer choices.
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Section 2
COC blueprint: ICD-10-CM diagnosis coding — outpatient uncertain diagnoses (Item 2)
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Section 3
COC blueprint: ICD-10-CM diagnosis coding — definitive diagnosis vs symptoms (Item 3)
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Section 4
COC blueprint: ICD-10-CM diagnosis coding — additional symptoms (Item 4)
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Section 5
COC blueprint: ICD-10-CM diagnosis coding — preprocedural examination sequencing (Item 5)
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Section 6
COC blueprint: ICD-10-CM diagnosis coding — follow-up and history coding (Item 6)
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Section 7
COC blueprint: ICD-10-CM diagnosis coding — active malignancy vs history (Item 7)
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Section 8
COC blueprint: ICD-10-CM diagnosis coding — screening encounters (Item 8)
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Section 9
COC blueprint: ICD-10-CM diagnosis coding — screening vs diagnostic services (Item 9)
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Section 10
COC blueprint: ICD-10-CM diagnosis coding — observation for suspected condition ruled out (Item 10)
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Section 11
COC blueprint: ICD-10-CM diagnosis coding — hypertensive chronic kidney disease (Item 11)
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Section 12
COC blueprint: ICD-10-CM diagnosis coding — hypertensive heart disease (Item 12)
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Section 13
COC blueprint: ICD-10-CM diagnosis coding — hypertensive heart and CKD (Item 13)
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Section 14
COC blueprint: ICD-10-CM diagnosis coding — diabetes with CKD (Item 14)
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Section 15
COC blueprint: ICD-10-CM diagnosis coding — type 2 diabetes with hyperglycemia (Item 15)
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Section 16
COC blueprint: ICD-10-CM diagnosis coding — diabetic polyneuropathy (Item 16)
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Section 17
COC blueprint: ICD-10-CM diagnosis coding — long-term insulin use (Item 17)
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Section 18
COC blueprint: ICD-10-CM diagnosis coding — COPD with acute exacerbation (Item 18)
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Section 19
COC blueprint: ICD-10-CM diagnosis coding — COPD with acute lower respiratory infection (Item 19)
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Section 20
COC blueprint: ICD-10-CM diagnosis coding — asthma specificity (Item 20)
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Section 21
COC blueprint: ICD-10-CM diagnosis coding — old myocardial infarction (Item 21)
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Section 22
COC blueprint: ICD-10-CM diagnosis coding — CAD with angina combination coding (Item 22)
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Section 23
COC blueprint: ICD-10-CM diagnosis coding — definitive diagnosis in outpatient ED (Item 23)
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Section 24
COC blueprint: ICD-10-CM diagnosis coding — adverse effects (Item 24)
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Section 25
COC blueprint: ICD-10-CM diagnosis coding — poisoning sequencing (Item 25)
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Section 26
COC blueprint: ICD-10-CM diagnosis coding — underdosing sequencing (Item 26)
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Section 27
COC blueprint: ICD-10-CM diagnosis coding — injury seventh character (Item 27)
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Section 28
COC blueprint: ICD-10-CM diagnosis coding — sequela coding (Item 28)
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Section 29
COC blueprint: ICD-10-CM diagnosis coding — laterality and specificity (Item 29)
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Section 30
COC blueprint: ICD-10-CM diagnosis coding — coding from laboratory results (Item 30)
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Section 31
COC blueprint: ICD-10-CM diagnosis coding — conflicting documentation (Item 31)
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Section 32
COC blueprint: ICD-10-CM diagnosis coding — controlled chronic conditions (Item 32)
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Section 33
COC blueprint: ICD-10-CM diagnosis coding — BMI documentation (Item 33)
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Section 34
COC blueprint: ICD-10-CM diagnosis coding — integral signs and symptoms (Item 34)
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Section 35
COC blueprint: ICD-10-CM diagnosis coding — nonintegral signs and symptoms (Item 35)
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Section 36
COC blueprint: ICD-10-CM diagnosis coding — diagnostic test results (Item 36)
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Section 37
COC blueprint: ICD-10-CM diagnosis coding — pathology diagnosis (Item 37)
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Section 38
COC blueprint: ICD-10-CM diagnosis coding — personal history after completed treatment (Item 38)
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Section 39
COC blueprint: ICD-10-CM diagnosis coding — screening with abnormal findings (Item 39)
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Section 40
COC blueprint: ICD-10-CM diagnosis coding — screening vs symptom-driven colonoscopy (Item 40)
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Section 41
COC blueprint: CPT coding — laparoscopic cholecystectomy (Item 41)
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Section 42
COC blueprint: CPT coding — laparoscopic cholecystectomy with cholangiography (Item 42)
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Section 43
COC blueprint: CPT coding — open vs laparoscopic approach (Item 43)
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Section 44
COC blueprint: CPT coding — diagnostic colonoscopy (Item 44)
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Section 45
COC blueprint: CPT coding — colonoscopy with biopsy (Item 45)
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Section 46
COC blueprint: CPT coding — colonoscopy with snare removal (Item 46)
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Section 47
COC blueprint: CPT coding — multiple colonoscopy techniques (Item 47)
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Section 48
COC blueprint: CPT coding — diagnostic EGD (Item 48)
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Section 49
COC blueprint: CPT coding — EGD with biopsy (Item 49)
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Section 50
COC blueprint: CPT coding — routine cataract surgery (Item 50)
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Section 51
COC blueprint: CPT coding — complex cataract surgery (Item 51)
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Section 52
COC blueprint: CPT coding — knee arthroscopy meniscectomy one compartment (Item 52)
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Section 53
COC blueprint: CPT coding — knee arthroscopy meniscectomy two compartments (Item 53)
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Section 54
COC blueprint: CPT coding — total hip arthroplasty (Item 54)
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Section 55
COC blueprint: CPT coding — total knee arthroplasty (Item 55)
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Section 56
COC blueprint: CPT coding — major joint aspiration/injection (Item 56)
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Section 57
COC blueprint: CPT coding — tendon sheath injection (Item 57)
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Section 58
COC blueprint: CPT coding — debridement to subcutaneous tissue (Item 58)
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Section 59
COC blueprint: CPT coding — debridement additional surface area (Item 59)
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Section 60
COC blueprint: CPT coding — debridement to muscle/fascia (Item 60)
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Section 61
COC blueprint: CPT coding — debridement to bone (Item 61)
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Section 62
COC blueprint: CPT coding — chest radiography views (Item 62)
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Section 63
COC blueprint: CPT coding — two-view chest radiography (Item 63)
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Section 64
COC blueprint: CPT coding — CT head without contrast (Item 64)
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Section 65
COC blueprint: CPT coding — CT head with contrast (Item 65)
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Section 66
COC blueprint: CPT coding — CT head without and with contrast (Item 66)
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Section 67
COC blueprint: CPT coding — CT chest without contrast (Item 67)
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Section 68
COC blueprint: CPT coding — CT chest with contrast (Item 68)
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Section 69
COC blueprint: CPT coding — CT chest without and with contrast (Item 69)
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Section 70
COC blueprint: CPT coding — CT abdomen and pelvis without contrast (Item 70)
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Section 71
COC blueprint: CPT coding — CT abdomen and pelvis with contrast (Item 71)
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Section 72
COC blueprint: CPT coding — CT abdomen and pelvis without and with contrast (Item 72)
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Section 73
COC blueprint: CPT coding — basic metabolic panel (Item 73)
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Section 74
COC blueprint: CPT coding — comprehensive metabolic panel (Item 74)
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Section 75
COC blueprint: CPT coding — CBC with automated differential (Item 75)
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Section 76
COC blueprint: CPT coding — venipuncture (Item 76)
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Section 77
COC blueprint: CPT coding — surgical pathology level IV (Item 77)
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Section 78
COC blueprint: CPT coding — ECG technical component (Item 78)
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Section 79
COC blueprint: CPT coding — ECG professional interpretation (Item 79)
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Section 80
COC blueprint: CPT coding — initial therapeutic infusion (Item 80)
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Section 81
COC blueprint: CPT coding — additional infusion hour (Item 81)
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Section 82
COC blueprint: CPT coding — therapeutic injection (Item 82)
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Section 83
COC blueprint: CPT coding — chemotherapy infusion (Item 83)
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Section 84
COC blueprint: CPT coding — inhalation treatment (Item 84)
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Section 85
COC blueprint: CPT coding — therapeutic exercise timed units (Item 85)
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Section 86
COC blueprint: CPT coding — therapeutic activities (Item 86)
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Section 87
COC blueprint: CPT coding — modifier 25 (Item 87)
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Section 88
COC blueprint: CPT coding — modifier 59 (Item 88)
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Section 89
COC blueprint: CPT coding — discontinued outpatient procedure modifiers (Item 89)
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Section 90
COC blueprint: HCPCS Level II — CPAP equipment (Item 90)
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Section 91
COC blueprint: HCPCS Level II — bilevel respiratory assist device (Item 91)
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Section 92
COC blueprint: HCPCS Level II — bilevel device with backup rate (Item 92)
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Section 93
COC blueprint: HCPCS Level II — PAP full face mask (Item 93)
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Section 94
COC blueprint: HCPCS Level II — PAP nasal interface (Item 94)
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Section 95
COC blueprint: HCPCS Level II — PAP headgear (Item 95)
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Section 96
COC blueprint: HCPCS Level II — PAP tubing (Item 96)
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Section 97
COC blueprint: HCPCS Level II — PAP disposable filter (Item 97)
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Section 98
COC blueprint: HCPCS Level II — BLS nonemergency ambulance (Item 98)
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Section 99
COC blueprint: HCPCS Level II — BLS emergency ambulance (Item 99)
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Section 100
COC blueprint: HCPCS Level II — ambulance mileage (Item 100)
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Section 101
COC blueprint: HCPCS Level II — fixed-wing air ambulance (Item 101)
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Section 102
COC blueprint: HCPCS Level II — rotary-wing air ambulance (Item 102)
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Section 103
COC blueprint: HCPCS Level II — ketorolac units (Item 103)
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Section 104
COC blueprint: HCPCS Level II — ceftriaxone units (Item 104)
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Section 105
COC blueprint: HCPCS Level II — ondansetron units (Item 105)
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Section 106
COC blueprint: HCPCS Level II — dexamethasone units (Item 106)
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Section 107
COC blueprint: HCPCS Level II — vitamin B12 injection (Item 107)
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Section 108
COC blueprint: HCPCS Level II — infliximab drug coding (Item 108)
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Section 109
COC blueprint: HCPCS Level II — DME purchase/rental modifiers (Item 109)
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Section 110
COC blueprint: HCPCS Level II — KX modifier (Item 110)
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Section 111
COC blueprint: HCPCS Level II — GA modifier (Item 111)
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Section 112
COC blueprint: HCPCS Level II — GZ modifier (Item 112)
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Section 113
COC blueprint: HCPCS Level II — GY modifier (Item 113)
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Section 114
COC blueprint: HCPCS Level II — JW and JZ modifiers (Item 114)
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Section 115
COC blueprint: Facility reimbursement — OPPS scope (Item 115)
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Section 116
COC blueprint: Facility reimbursement — ASC vs OPPS (Item 116)
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Section 117
COC blueprint: Facility reimbursement — critical access hospitals (Item 117)
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Section 118
COC blueprint: Facility reimbursement — APC grouping (Item 118)
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Section 119
COC blueprint: Facility reimbursement — diagnosis vs APC assignment (Item 119)
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Section 120
COC blueprint: Facility reimbursement — Addendum B (Item 120)
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Section 121
COC blueprint: Facility reimbursement — status indicator N (Item 121)
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Section 122
COC blueprint: Facility reimbursement — comprehensive APC J1 (Item 122)
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Section 123
COC blueprint: Facility reimbursement — comprehensive observation J2 (Item 123)
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Section 124
COC blueprint: Facility reimbursement — observation hours (Item 124)
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Section 125
COC blueprint: Facility reimbursement — observation vs inpatient status (Item 125)
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Section 126
COC blueprint: Facility reimbursement — MS-DRG vs APC (Item 126)
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Section 127
COC blueprint: Facility reimbursement — C-APC packaging (Item 127)
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Section 128
COC blueprint: Facility reimbursement — packaged vs separately payable (Item 128)
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Section 129
COC blueprint: Facility reimbursement — revenue codes and HCPCS (Item 129)
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Section 130
COC blueprint: Facility reimbursement — revenue code purpose (Item 130)
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Section 131
COC blueprint: Facility reimbursement — institutional vs professional claim forms (Item 131)
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Section 132
COC blueprint: Facility reimbursement — hospital outpatient bill type (Item 132)
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Section 133
COC blueprint: Facility reimbursement — Integrated Outpatient Code Editor (Item 133)
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Section 134
COC blueprint: Facility reimbursement — NCCI edits in outpatient facilities (Item 134)
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Section 135
COC blueprint: Facility reimbursement — Medically Unlikely Edits (Item 135)
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Section 136
COC blueprint: Facility reimbursement — status indicator C (Item 136)
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Section 137
COC blueprint: Facility reimbursement — quarterly OPPS updates (Item 137)
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Section 138
COC blueprint: Facility reimbursement — packaged drugs (Item 138)
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Section 139
COC blueprint: Facility reimbursement — JW/JZ and packaged drugs (Item 139)
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Section 140
COC blueprint: Facility reimbursement — C-APC reporting (Item 140)
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Section 141
COC blueprint: Facility reimbursement — facility vs professional payment (Item 141)
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Section 142
COC blueprint: Facility reimbursement — professional and technical components (Item 142)
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Section 143
COC blueprint: Facility reimbursement — pass-through payment concept (Item 143)
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Section 144
COC blueprint: Facility reimbursement — multiple-procedure discounting (Item 144)
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Section 145
COC blueprint: Facility reimbursement — J1 vs J2 comprehensive logic (Item 145)
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Section 146
COC blueprint: Facility reimbursement — hospital outpatient clinic visit (Item 146)
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Section 147
COC blueprint: Facility reimbursement — ED facility level selection (Item 147)
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Section 148
COC blueprint: Facility reimbursement — facility E/M resources (Item 148)
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Section 149
COC blueprint: Facility reimbursement — coverage vs payment status (Item 149)
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Section 150
COC blueprint: Facility reimbursement — NCD vs LCD in outpatient coverage (Item 150)
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Section 151
COC blueprint: Compliance and billing rules — False Claims Act — knowingly false claims (Item 151)
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Section 152
COC blueprint: Compliance and billing rules — upcoding (Item 152)
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Section 153
COC blueprint: Compliance and billing rules — unbundling (Item 153)
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Section 154
COC blueprint: Compliance and billing rules — identified Medicare overpayment (Item 154)
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Section 155
COC blueprint: Compliance and billing rules — Medicare 60-day overpayment rule (Item 155)
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Section 156
COC blueprint: Compliance and billing rules — Advance Beneficiary Notice — expected denial (Item 156)
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Section 157
COC blueprint: Compliance and billing rules — ABN specificity (Item 157)
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Section 158
COC blueprint: Compliance and billing rules — medical necessity vs code validity (Item 158)
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Section 159
COC blueprint: Compliance and billing rules — coder alteration of documentation (Item 159)
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Section 160
COC blueprint: Compliance and billing rules — compliant provider query (Item 160)
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Section 161
COC blueprint: Compliance and billing rules — modifier 59 documentation (Item 161)
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Section 162
COC blueprint: Compliance and billing rules — compliance auditing and monitoring (Item 162)
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Section 163
COC blueprint: Compliance and billing rules — reporting compliance concerns (Item 163)
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Section 164
COC blueprint: Compliance and billing rules — HIPAA minimum necessary (Item 164)
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Section 165
COC blueprint: Compliance and billing rules — HIPAA treatment exception to minimum necessary (Item 165)
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Section 166
COC blueprint: Compliance and billing rules — CLIA waived testing and QW (Item 166)
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Section 167
COC blueprint: Compliance and billing rules — test result does not change procedure code (Item 167)
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Section 168
COC blueprint: Compliance and billing rules — MUE and units of service (Item 168)
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Section 169
COC blueprint: Compliance and billing rules — claim correction after duplicate billing (Item 169)
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Section 170
COC blueprint: Compliance and billing rules — accurate date of service and documentation (Item 170)
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Section 171
COC blueprint: Anatomy, terminology and integrated outpatient cases — gallbladder and biliary anatomy (Item 171)
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Section 172
COC blueprint: Anatomy, terminology and integrated outpatient cases — intraoperative cholangiography anatomy (Item 172)
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Section 173
COC blueprint: Anatomy, terminology and integrated outpatient cases — cecum and complete colonoscopy (Item 173)
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Section 174
COC blueprint: Anatomy, terminology and integrated outpatient cases — terminal ileum anatomy (Item 174)
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Section 175
COC blueprint: Anatomy, terminology and integrated outpatient cases — sigmoid colon and rectum (Item 175)
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Section 176
COC blueprint: Anatomy, terminology and integrated outpatient cases — upper GI endoscopy route (Item 176)
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Section 177
COC blueprint: Anatomy, terminology and integrated outpatient cases — pancreatic and biliary drainage (Item 177)
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Section 178
COC blueprint: Anatomy, terminology and integrated outpatient cases — cardiac valve anatomy — mitral (Item 178)
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Section 179
COC blueprint: Anatomy, terminology and integrated outpatient cases — cardiac valve anatomy — aortic (Item 179)
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Section 180
COC blueprint: Anatomy, terminology and integrated outpatient cases — pulmonary artery anatomy (Item 180)
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Section 181
COC blueprint: Anatomy, terminology and integrated outpatient cases — coronary artery anatomy (Item 181)
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Section 182
COC blueprint: Anatomy, terminology and integrated outpatient cases — pleura vs peritoneum (Item 182)
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Section 183
COC blueprint: Anatomy, terminology and integrated outpatient cases — urinary flow sequence (Item 183)
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Section 184
COC blueprint: Anatomy, terminology and integrated outpatient cases — ureter vs urethra (Item 184)
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Section 185
COC blueprint: Anatomy, terminology and integrated outpatient cases — prostate anatomy (Item 185)
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Section 186
COC blueprint: Anatomy, terminology and integrated outpatient cases — nephron terminology (Item 186)
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Section 187
COC blueprint: Anatomy, terminology and integrated outpatient cases — rotator cuff anatomy (Item 187)
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Section 188
COC blueprint: Anatomy, terminology and integrated outpatient cases — carpal tunnel anatomy (Item 188)
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Section 189
COC blueprint: Anatomy, terminology and integrated outpatient cases — ulnar nerve anatomy (Item 189)
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Section 190
COC blueprint: Anatomy, terminology and integrated outpatient cases — knee arthroplasty anatomy (Item 190)
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Section 191
COC blueprint: Anatomy, terminology and integrated outpatient cases — skin layers and debridement depth (Item 191)
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Section 192
COC blueprint: Anatomy, terminology and integrated outpatient cases — debridement to muscle/fascia (Item 192)
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Section 193
COC blueprint: Anatomy, terminology and integrated outpatient cases — proximal vs distal terminology (Item 193)
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Section 194
COC blueprint: Anatomy, terminology and integrated outpatient cases — ipsilateral vs contralateral (Item 194)
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Section 195
COC blueprint: Anatomy, terminology and integrated outpatient cases — percutaneous approach terminology (Item 195)
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Section 196
COC blueprint: Anatomy, terminology and integrated outpatient cases — laparoscopic vs open approach (Item 196)
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Section 197
COC blueprint: Anatomy, terminology and integrated outpatient cases — diagnostic vs therapeutic terminology (Item 197)
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Section 198
COC blueprint: Anatomy, terminology and integrated outpatient cases — integrated screening colonoscopy case (Item 198)
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Section 199
COC blueprint: Anatomy, terminology and integrated outpatient cases — integrated outpatient uncertain diagnosis case (Item 199)
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Section 200
COC blueprint: Anatomy, terminology and integrated outpatient cases — integrated facility/professional components (Item 200)
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