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 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.