For patients receiving diagnostic services only during an encounter/visit, sequence first the diagnosis, condition, problem, or other reason for encounter/visit shown in the medical record to be chiefly responsible for the outpatient services provided during the encounter/visit. Codes for other diagnoses (e.g., chronic conditions) may be sequenced as additional diagnoses.
For encounters for routine laboratory/radiology testing in the absence of any signs, symptoms, or associated diagnosis, assign Z01.89, Encounter for other specified special examinations. If routine testing is performed during the same encounter as a test to evaluate a sign, symptom, or diagnosis, it is appropriate to assign both the Z code and the code describing the reason for the non-routine test.
For outpatient encounters for diagnostic tests that have been interpreted by a physician, and the final report is available at the time of coding, code any confirmed or definitive diagnosis(es) documented in the interpretation. Do not code related signs and symptoms as additional diagnoses.
Note: This differs from the coding practice in the hospital inpatient setting regarding abnormal findings on test results.
Coding Examples:
Patient encounter for blood typing prior to outpatient surgery tomorrow.
ICD-10 code : Z01.83 encounter for blood typing.
Patient is having an MRI of the head to monitor the progression of brain tumor.
ICD-10 code : D49.6 brain tumor.
Patient without any symptoms had a CBC (complete blood count).
ICD-10 code : Z01.89 laboratory examination without any sign or symptom documented.
Patient was seen for shortness of breath and fever with a negative x-ray. Patient returned the next day for a CT of chest, which confirmed the presence of pneumonia.
ICD-10 code : J18.9 pneumonia.