Inpatient and Outpatient Coding The similarities and differences

Inpatient and Outpatient Coding The similarities and differences

Basic differences • Inpatient coders use the 10 -PCS for procedure coding. • Outpatient coders use CPT and HCPCS Level II for procedure and service coding. The codes sets are unique and have different guidelines. • Inpatient coders review the entire medical record. • Outpatient coders focus on a particular date of service. • CMS inpatient reimbursement is based on IPPS which is determined by MS-DRGs • CMS outpatient reimbursement is based on OPPS and APCs

Inpatient Coding: Steps • Review Medical Documentation • Abstract procedure performed • Identify Min Term • Locate Term in the CPT Index • Verify Codes in the CPT Tabular Section • Determine the Need for Modifiers • Assign the Code

Outpatient: Steps in Coding • Locate the main term • Scan for Instructional Notes • Identify Terms that Modify the Main Term • Follow Any Cross-Reference Notes • Always Verify the Code in the Tabular List.

Inpatient Coding: Key Differences • Additional lengths of stay caused by hospital complications use the complication as the principle diagnosis • In an inpatient facility, medical coders must determine the principle diagnosis for the admission, as well as present on admission (POA) indicators on all diagnoses. • Uncertain diagnosis that are not documented at the time of discharge are not coded. Ex: “appears to be” • Medical/surgical procedures use ICD-10 -PCS • Code assignment is based on entire admission

Outpatient Coding: Key Differences • Signs and symptoms are an acceptable for coding • Many outpatient procedures lack definitive diagnosis • Uncertain diagnosis in the Outpatient setting do not get assigned a code. • Coders can code up to absolute degree of certainty. • Code assignment is based on the encounter or visit • Medical/surgical procedures use CPT and HCPCS level II codes

Similarities between systems • Locating the correct code requires the following of certain steps. • Both require checking both the alphabetic index as well as the tabular section. • Guidelins must be followed in both systems. • These guidelines do however, provide a separate list of rules.