Outpatient Coding and Inpatient Coding

The hospital coding and billing is truly a complex system, considering the complexity of the hospital environment. Thousands of hospital employees make sure all things are well organized and systematic at the hospital, starting from the patient billing process to the reimbursement process. It’s a complex task in itself to make sure the patient billing process is completed error-free and successful reimbursement is claimed in a timely manner. Let’s understand what is Outpatient Coding and Inpatient Coding?

Outpatient Coding:

Outpatient refers to a patient who is being treated but not admitted under the care of the hospital for a duration of stay and is released from the hospital within 24 hours. Even if a patient stays for over 24 hours, he/she can be considered an outpatient.

The outpatient coding is based on the ICD-10-CM diagnostic codes for billing and appropriate reimbursement but uses a CPT or HCPCS coding system to report procedures. Documentation plays a crucial role in the CPT and HCPCS codes for services.

Inpatient Coding:

Inpatient refers to a patient who is properly admitted to a hospital upon the orders of the physician who then admits the patient for a long stay. The inpatient coding system is used to report a patient’s diagnosis and services based on his duration of stay.

It also uses ICD-10-CM diagnostic codes for billing and appropriate reimbursement but uses ICD-10-PCS as the procedural coding system. The Inpatient Prospective Payment System (IPPS) is the reimbursement methodology used by Medicare to provide reimbursement for hospital inpatient services.

Basics

Outpatient refers to a patient who checks into the ER and is being treated but is not admitted to the hospital for a long stay. The patient is usually discharged from the hospital the same day within 24 hours. When a patient is properly admitted to a hospital upon the physician’s advice who then takes care of your duration stay at the hospital stay, he is considered an inpatient.

Outpatient coding refers to a detailed diagnosis report in which the patient is generally treated in one visit, whereas an inpatient coding system is used to report a patient’s diagnosis and services based on his duration of stay.

Coding for Signs and Symptoms

If signs and symptoms are a given part of primary diagnosis, they should not be coded in inpatient settings. However, additional signs and symptoms may be coded when present if a definitive diagnosis is not included. For example, inpatient coding requires the coding of suspected conditions and abnormal signs and symptoms if the provider has not made a diagnosis.

Since many outpatient procedures lack a definitive diagnosis, signs, and symptoms are acceptable for coding purposes. However, coders should check for any new results and information from the provider about a definitive diagnosis prior to entering the codes for such signs and symptoms.

Complications

If a patient requires an additional length of stay in a hospital due to a complication, the complication should be listed as the principal diagnosis. However, if the complication lacks specificity to a diagnosis, additional code may need to be assigned.

Coding for Uncertain Diagnoses

Uncertain diagnoses should be coded at the time of discharge for inpatient admissions to short-term, long-term, acute care, and psychiatric hospitals. Coders should not include irregular findings unless the health care provider identifies the clinical importance of the symptoms.

However, some hospitals may have additional policies for the coding of uncertain conditions, and coders should maintain compliance with their facilities’ policies as well. The goal of coding suspected, probable, likely, or possible conditions are to identify them as a possible principal diagnosis for admission on future hospitalizations.

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