If a patient comes in for an office visit and had an EM, what is the first diagnosis?

• A. Inpatient-principle diagnosis
• B. Outpatient-primary diagnosis
• C. Emergency diagnosis
• D. Family history

Answer: (B)

In an office visit, the encounter is outpatient. The first diagnosis coded for an outpatient encounter is the primary diagnosis—the main condition being addressed during that visit. It wouldn’t be an inpatient principal diagnosis, which is used only when someone is admitted to the hospital. It wouldn’t be an emergency diagnosis, which is used for Emergency Department visits. Family history is not a current diagnosis, so it wouldn’t be the first diagnosis either.