Outpatient Claim Diagnosis

For outpatient claims, providers report the full diagnosis code for the diagnosis shown to be chiefly responsible for the outpatient services.

For instance, if a patient is seen on an outpatient basis for an evaluation of a symptom (e.g., cough) for which a definitive diagnosis is not made, the symptom is reported.

If, during the course of the outpatient evaluation and treatment, a definitive diagnosis is made (e.g., acute bronchitis), the definitive diagnosis is reported.

If the patient arrives at the hospital for examination or testing without a referring diagnosis and cannot provide a complaint, symptom, or diagnosis, the hospital reports the encounter code that most accurately reflects the reason for the encounter.

Examples include:

    • Encounter for general adult medical examination without abnormal findings 

    • Encounter for general adult medical examination with abnormal findings

    •  Encounter for examination of ears and hearing without abnormal findings

    • Encounter for examination of ears and hearing with other abnormal findings

For outpatient claims, providers report the full diagnosis codes for diagnoses that coexisted in addition to the diagnosis reported as the principal diagnosis.

For instance, if the patient is referred to a hospital for evaluation hypertension and the medical record also documents diabetes, diabetes is reported as another diagnosis.

Additional information and training is available on the CMS  website.