What is the second step in outpatient diagnosis coding?

The second step in outpatient diagnosis coding is to abstract the medical conditions from the visit documentation. This step involves carefully reviewing the patient's medical records to identify and extract relevant diagnoses that need to be coded. This process is crucial because it ensures that all pertinent information related to the patient's visit is considered, which can directly impact the accuracy of the coding.

In outpatient coding, following the abstraction process, coders move on to locate the main term in the Alphabetic Index, which is essential for finding potential codes. After identifying the main term, coders then verify the selected code in the Tabular List to ensure it is used correctly and is appropriate for the specific circumstances of the visit. The final step typically involves checking the medical documentation to ensure that everything is complete and accurate, reinforcing the importance of thorough documentation throughout the coding process.