The outpatient primary diagnosis of the patient is determined when the medical assistant verifies their registration form, the encounter form, any notes regarding the visit, lab and radiology reports as well as operative reports pertaining to outpatient procedures. Most times the physician will specify what code to be used on the encounter form, however the medical assistant has to verify and compare it to that of the patient’s medical record. The medical assistant looks for the definitive diagnostic code given by the physician regarding the patient visit. The diagnosis is then indicated under Impressions or in SOAP (Subjective, Objective, Assessment, and (Plan) under A (Assessment). This is the primary diagnosis, the reason responsible for the services that were provided.

Principal diagnosis …show more content…
Summarize what it means to perform quality ICD-10-CM coding for the physicians' office.
Performing quality ICD-10-CM coding for the physicians office is crucial because that is how payment is ensured. The patient is billed for the services provided at the hospital/clinic by the physician. The coder has to ensure that they are certified coders. Performing quality ICD-10-CM coding is when the coder codes everything properly. For a doctors visit, you could possibly have multiple symptoms where the physician has to run tests and examine you and then perhaps prescribe medication. If a coder were to try and write down every detail of the diagnosis then that report would be too long. With codes, diagnosis and procedures could be reported with sufficient information for the billers to then do their job efficiently. And because every code is verified a second time to ensure proper coding it makes it possible for the physician to receive reimbursement for the services provided. Because this information is in the UHDDS, this means that uniform information allows for research and analysis that in turn help the government track health