1. Employee Training Presentation
This is my Employee Training Presentation on Inpatient, Outpatient, and Physician Medical Coding Guidelines and Conventions
Inpatient and Outpatient Guidelines, Conventions, and Steps.
Samantha Muncy
7/25/18

2. Differences in Inpatient vs. Outpatient Coding
X+7th character placeholders are more likely in an inpatient setting where a definite diagnosis has been made with need for more specification.
Uncertain diagnosis's should be coded as if they were established or exist if they were present at the time of discharge.
Signs and symptoms as part of the primary diagnosis should not be coded unless a definite diagnoses is not included.
If complications from condition lengthen the inpatient stay the n the complication should be listed as the principal diagnosis, if it lacks the specify then additional codes may be assigned.
(Gibson, 2015)
In the outpatient setting its less likely to have to assign a 7th character or X placeholder than in an inpatient setting.
Uncertain diagnosis and conditions in outpatient settings do not warrant any sort of code , but should code to absolute degree of certainty.
Signs and symptoms are acceptable in outpatient settings when there is a lack of a definite diagnosis
If admitted after outpatient surgery or procedure due to a complication then the complication is listed as the principal diagnosis for inpatient admission. If the admission is not from a complication of surgery then list the reason for the surgery as the principal diagnosis.
(Gibson, 2015)
Some of the important differences between inpatient and outpatient coding are for starters, that the X placeholder and the &th character are more likely in an inpatient setting, and also that whereas signs and symptoms are acceptable in the outpatient setting they should not be coded as part of the primary diagnosis in an inpatient setting unless a definite diagnosis has not been in included. Also, uncertain diagnosis do not warrant any sort of code in an outpatient setting but in a inpatient setting they should be coded as if the y were established if they exist at the tie of discharge. Complications from both settings however, if they lengthen a hospital stay or if a patient is admitted from outpatient surgery due to a complication the complication should be listed as the principal diagnosis.

3. Inpatient Guidelines and Conventions
Inpatient Coding Guidelines
Codes for symptoms, signs, and ill-defined conditions from Chapter 18 are not to be used as principal diagnosis when a related definitive diagnosis has been established. (ICD-10 Guidelines, 2018)
When there are two or more interrelated conditions (such as diseases in the same ICD10-CM chapter or manifestations characteristically associated with a certain disease) potentially meeting the definition of principal diagnosis, either condition may be sequenced first, unless the circumstances of the admission, the therapy provided, the Tabular List, or the Alphabetic Index indicate otherwise.  (ICD-10 Guidelines, 2018)
In the unusual instance when two or more diagnoses equally meet the criteria for principal diagnosis as determined by the circumstances of admission, diagnostic workup and/or therapy provided, and the Alphabetic Index, Tabular List, or another coding guidelines does not provide sequencing direction, any one of the diagnoses may be sequenced first. (ICD-10 Guidelines, 2018)
In those rare instances when two or more contrasting or comparative diagnoses are documented as “either/or” (or similar terminology), they are coded as if the diagnoses were confirmed and the diagnoses are sequenced according to the circumstances of the admission. If no further determination can be made as to which diagnosis should be principal, either diagnosis may be sequenced first.  (ICD-10 Guidelines, 2018)
Some of the main guidelines for inpatient coding are firstly to code for symptoms signs and conditions and when there is 2 or more interrelated conditions that either potentially meet the definition of the a principal diagnosis or equally meet the definition either can be sequenced first. If they contract then they are coded as established and are sequenced according to the circumstances.

4. Inpatient Coding Guidelines Continued….
Sequence as the principal diagnosis the condition, which after study occasioned the admission to the hospital, even though treatment may not have been carried out due to unforeseen circumstances.  (ICD-10 Guidelines, 2018)
When the admission is for treatment of a complication resulting from surgery or other medical care, the complication code is sequenced as the principal diagnosis. If the complication is classified to the T80-T88 series and the code lacks the necessary specificity in describing the complication, an additional code for the specific complication should be assigned.  (ICD-10 Guidelines, 2018)
If the diagnosis at the time of discharge is qualified as “probable”, “suspected”, “likely”, “questionable”, “possible”, or “still to be ruled out”, or terms indicating uncertainty, code the condition as if it existed or established. (ICD-10 Guidelines, 2018)
Admission Following Medical Observation When a patient is admitted to an observation unit for a medical condition, which either worsens or does not improve, and is subsequently admitted as an inpatient of the same hospital for this same medical condition, the principal diagnosis would be the medical condition which led to the hospital admission.  (ICD-10 Guidelines, 2018)
Admission Following Post-Operative Observation When a patient is admitted to an observation unit to monitor a condition (or complication) that develops following outpatient surgery, and then is subsequently admitted as an inpatient of the same hospital, hospitals should apply the Uniform Hospital Discharge Data Set (UHDDS) definition of principal diagnosis as "that condition established after study to be chiefly. responsible for occasioning the admission of the patient to the hospital for care.“(ICD-10 Guidelines, 2018)
Codes qualifying as probable, or likely are to be coded as if they were established at the time of discharge. Most of the time the reason for the patient being admitted to the hospital will be listed as the principal diagnosis even when they are admitted after an outpatient surgery or after being in an observation unit.

5. Inpatient Coding Continued….
When a patient receives surgery in the hospital's outpatient surgery department and is admitted for inpatient care at the same hospital, the following guidelines should be followed in selecting the principal diagnosis:
If the reason for the inpatient admission is a complication, assign the complication as the principal diagnosis.
If no complication is documented for the inpatient admission, assign the reason for the outpatient surgery as the principal diagnosis.
If the reason for the inpatient admission is another condition unrelated to the surgery, assign the unrelated condition as the principal diagnosis. (ICD-10 Guidelines, 2018)
When the purpose for the admission is rehabilitation, code for the condition for which the service is being performed. If the condition is no longer present, report the appropriate aftercare code as the principal diagnosis, unless the rehabilitation service is following an injury. For rehabilitation services following treatment of injury, assign the injury code with the appropriate seventh character as principal diagnosis. (ICD-10 Guidelines, 2018)
If the provider has included a diagnosis in the discharge summary or the face sheet, it should ordinarily be coded. History codes (categories Z80-Z87) may be used as secondary codes if the historical condition or family history has an impact on current treatment. (ICD-10 Guidelines, 2018)
Abnormal findings are not coded unless the provider indicates their clinical significance. (ICD-10 Guidelines, 2018)
The circumstances that surround an inpatient being admitted to the hospital die to complications is one of the few times that the reason for the original admission would not be sequenced first and you would code the complication as the primary diagnosis. Abnormal Conditions are usually not coded unless the provider finds them to be significant and advices that they be included.

6. Outpatient guidelines and conventions
In the outpatient setting, the term first-listed diagnosis is used in lieu of principal diagnosis. (ICD-10 Guidelines, 2018)
The appropriate code(s) from A00.0 through T88.9, Z00-Z99 must be used to identify diagnoses, symptoms, and conditions. (ICD-10 Guidelines, 2018)
Codes that describe symptoms and signs are acceptable for reporting purposes when a diagnosis has not been established. (ICD-10 Guidelines, 2018)
ICD-10-CM provides codes to deal with encounters for circumstances other than a disease or injury.
1. ICD-10-CM codes with 3, 4, 5, 6 or 7 characters ICD-10-CM is composed of codes with 3, 4, 5, 6 or 7 characters. Codes with three characters are included in ICD-10-CM as the heading of a category of codes that may be further subdivided by the use of fourth, fifth, sixth or seventh characters to provide greater specificity.
2. Use of full number of characters required for a code A three-character code is to be used only if it is not further subdivided. A code is invalid if it has not been coded to the full number of characters required for that code, including the 7th character, if applicable. (ICD-10 Guidelines, 2018)
List first the ICD-10-CM code for the diagnosis, condition, problem, or other reason for encounter, to be chiefly responsible for the services provided. List additional codes that describe any coexisting conditions. In some cases the first-listed diagnosis may be a symptom when a diagnosis has not been established. (ICD-10 Guidelines, 2018)
Another important rule is to make sure that regardless of the circumstances revolving around the encounter to always code any diagnosis at the highest level of certainy.

7. Outpatient Coding Guidelines continued………
Do not code diagnoses documented as “probable”, “suspected,” “questionable,” “rule out,” or “working diagnosis” or words indicating uncertainty. Rather, code the condition(s) to the highest degree of certainty. (ICD-10 Guidelines, 2018)
Chronic diseases treated on an ongoing basis may be coded and reported as many times as the patient receives treatment. (ICD-10 Guidelines, 2018)
Code all documented conditions that coexist at the time of the encounter and require or affect patient care, treatment, or management. Do not code conditions that no longer exist. However, history codes (categories Z80- Z87) may be used as secondary codes. (ICD-10 Guidelines, 2018)
For patients receiving diagnostic services only during an encounter, sequence first the diagnosis, condition, problem, or reason shown in the medical record to be chiefly responsible. Codes for other diagnoses sequenced as additional diagnoses. For routine laboratory/radiology testing in the absence of any signs, symptoms, or associated diagnosis, assign Z01.89, Encounter for other specified special examinations. If routine testing is performed during the encounter as a test to evaluate a sign, symptom, or diagnosis, assign both the Z code and the code describing the reason for the non-routine test. For outpatient diagnostic tests that the final report is available at the time of coding, code any confirmed or definitive diagnosis. (ICD-10 Guidelines, 2018)
Always refer to the guidelines to determine what category to code or if the use of Z codes are needed and always code a definite diagnosis.

8. Outpatient Coding Guidelines continued………
For patients receiving therapeutic services during a visit, sequence first the diagnosis, condition, problem, or other reason to be chiefly responsible .Codes for other diagnoses may be sequenced as additional diagnoses. The only exception to this rule is when the primary reason for the encounter is chemo or radiation, the appropriate Z code for the service is listed first, and the diagnosis for which the service is being performed listed second. (ICD-10 Guidelines, 2018)
For patients receiving pre-op evaluations only, sequence first a code from category Z01.81, Encounter for pre-procedural exams, then a code for the condition to describe the reason for the surgery as an additional diagnosis. (ICD-10 Guidelines, 2018)
For ambulatory surgery, code the diagnosis for which the surgery was performed. If the post-op diagnosis is different from the pre-op diagnosis when the diagnosis is confirmed, select the post-op diagnosis for coding. (ICD-10 Guidelines, 2018)
The categories for encounters for general medical exams Z00.0- and encounter for routine child health exam, Z00.12-, provide codes for with and without abnormal findings. Should a general medical exam result in an abnormal finding, the code for general medical exam with abnormal finding should be assigned. An exam with abnormal findings refers to a diagnosis that is newly identified or a change in severity of a chronic condition during a physical exam. A secondary code for the abnormal finding should also be coded.  (ICD-10 Guidelines, 2018)
If an abnormal finding is located during the patient encounter then it should be assigned along with the diagnostic code and sequenced as a secondary code. The diagnosis code should always be sequenced first if confirmed for a surgical procedure and z codes are used for coding various examinations.

9. Steps to Inpatient and Outpatient Coding
Review the medical record and abstract all key elements. Identify the reason for the encounter.
Always refer to the alphabetical index and only use the tabular list to verify the codes.
Determine the diagnosis as documented in the medical record. If more than one determine the sequence as outlined by the ICD-10-CM guidelines and conventions.
Determine the procedures, supplies, or additional services provided.
Locate the main terms (diagnosis, procedure, treatment) and locate them in the alphabetical index.
Review entries for any modifiers. Interpret abbreviations, cross reference, symbols and brackets.
Verify the chosen code from the alphabetical index in the tabular list and determine if code is at its highest level of specificity , and consult the official coding guidelines and conventions.
Assign the correct code.
The main steps for locating any of these codes is the review the medical record, abstract the main terms from the medical record regarding to the diagnosis, procedures , or other findings and refer to the alphabetical index to find the code. Then review any modifiers and cross references, notations, and abbreviations and verify the code in the tabular list. Then lastly assign the code.

10. References
Gibson, Harold. (2015, October, 15). Inpatient Coding vs. Outpatient Coding: Medical Coding Explained. Retrieved from: scribe.com/blog/inpatient-coding-vs-outpatient-coding-medical-coding- explained
Pickett, Donna. (2018, August, 11) Coding Guidelines. [PDF File] . Ahima: Retrieved from: CM-Coding-Guidelines.pdf#page=117&zoom=auto,-39,782

11. Script for narrations.
Slide 1: This is my Employee Training Presentation on Inpatient, Outpatient, and Physician Medical Coding Guidelines and Conventions
Slide 2: Some of the important differences between inpatient and outpatient coding are for starters, that the X placeholder and the &th character are more likely in an inpatient setting, and also that whereas signs and symptoms are acceptable in the outpatient setting they should not be coded as part of the primary diagnosis in an inpatient setting unless a definite diagnosis has not been in included. Also, uncertain diagnosis do not warrant any sort of code in an outpatient setting but in a inpatient setting they should be coded as if the y were established if they exist at the tie of discharge. Complications from both settings however, if they lengthen a hospital stay or if a patient is admitted from outpatient surgery due to a complication the complication should be listed as the principal diagnosis
Slide 3: Some of the main guidelines for inpatient coding are firstly to code for symptoms signs and conditions and when there is 2 or more interrelated conditions that either potentially meet the definition of the a principal diagnosis or equally meet the definition either can be sequenced first. If they contract then they are coded as established and are sequenced according to the circumstances.
Slide 4: Codes qualifying as probable, or likely are to be coded as if they were established at the time of discharge. Most of the time the reason for the patient being admitted to the hospital will be listed as the principal diagnosis even when they are admitted after an outpatient surgery or after being in an observation unit.
Slide 5: The circumstances that surround an inpatient being admitted to the hospital die to complications is one of the few times that the reason for the original admission would not be sequenced first and you would code the complication as the primary diagnosis. Abnormal Conditions are usually not coded unless the provider finds them to be significant and advices that they be included.
Slide 6: Another important rule is to make sure that regardless of the circumstances revolving around the encounter to always code any diagnosis at the highest level of certainty.
Slide 7: Always refer to the guidelines to determine what category to code or if the use of Z codes are needed and always ode a definite diagnosis.
Slide 8: If an abnormal finding is located during the patient encounter then it should be assigned along with the diagnostic code and sequenced as a secondary code. The diagnosis code should always be sequenced first if confirmed for a surgical procedure and z codes are used for coding various examinations.
Slide 9: The main steps for locating any of these codes is the review the medical record, abstract the main terms from the medical record regarding to the diagnosis, procedures , or other findings and refer to the alphabetical index to find the code. Then review any modifiers and cross references, notations, and abbreviations and verify the code in the tabular list. Then lastly assign the code.