What is the Difference Between Outpatient and Inpatient Coding Guidelines?

Whenever you render medical health services to a patient, the first thing that you should keep in mind while billing is whether they are inpatient or outpatient. The coding and billing vary widely when it comes to inpatient and outpatient. The hospital coding and billing system is undoubtedly a complex process and to make this procedure in the right direction, following outpatient and inpatient coding guidelines is the key.

Every medical healthcare facility ensures that starting from systematic patient billing to the reimbursement process, every part needs to be smooth and organized. Although following outpatient and inpatient coding guidelines are challenging, to receive timely reimbursement and generate revenue, it is essential to submit error-free claims with adherence to the provided guidelines.

To have a complete idea of how inpatient and outpatient coding and billing work, let us explain why is inpatient and outpatient terms used for the patient in the healthcare industry.

Outpatient and Inpatient Coding Guidelines

Inpatient Coding

Inpatient is a term referring to patients who are properly admitted to the hospital after the prescription of their physician for a long stay in the hospital to treat a specific lingering disease. Here, the coding will be used from the inpatient coding system regulated by CMS according to the, stay of the patient, and the treatment provided in the duration.

The codes consist of ICD-10-CM diagnostic codes for billing and proper reimbursement. However, ICD-10-PCS (procedural coding system) can also be used in some cases. For hospital inpatient service, Medicare used a reimbursement process that refers to Inpatient prospective system (IPPS).

Inpatient provides with facilities include chronic ailment treatment and long-term hospital care that needs the services of skilled nurses, home health services, and hospices. In addition, during the stay of the patient, there can be a variety of tests, procedures, treatments, and diagnoses involved. As a result, the lengthy stay demands an extensive record and intricate patient treatment coding which requires an experienced medical inpatient coder who knows what to cover and how to code for every individual or extensive procedure provided.

Outpatient Coding

The outpatient term is referred to the patient who is not admitted to the hospital but receives the treatment and is released from the facility within 24 hours. Even if the patient stayed for more than 24 hours, they will consider outpatient as they are not suggested by their physician to get admitted.

The coding for outpatient is compiled under ICD-10-CM for appropriate reimbursement. However, depending on the procedures and coding system requirements, HCPCS or CPT coding systems can also be used to report the provided procedures. For a smooth transition of submitting claims to reimbursement, documentation, and error-free claims play a very crucial role. Plus, there are many treatments that can be provided to outpatients that are listed to provide or assigned to inpatients.

Coding Procedures for Inpatient and Outpatient Under Medicare

Inpatient and Outpatient Under Medicare

Impatient claims for Medicare are processed under Medicare Part A. On the other hand, outpatient claims are processed under Part B Medicare. As mentioned, the coding for inpatients is reported using ICD-10-CM and PCS codes where the payment are reimbursed according to MS-DRGs – Medicare Severity- Diagnosis Related Groups.

Similarly, ICD-10-CM and PCS code procedures for outpatients require HCPCS Level II codes for reporting supplies utilized and healthcare services. Outpatient services paid under Medicare Part B include emergency services provided in the emergency center or department, hospital care, X-rays, labs, surgeries, tests, and doctors’ visits.

Coding for Symptoms and Signs

Coding for signs and symptoms can be a challenge for coders. While there are some specific codes for certain symptoms, oftentimes coders must use their clinical judgment to determine the best code to use.

When coding for signs and symptoms, it is important to consider the following:

  • The severity of the symptom
  • Whether the symptom is chronic or acute
  • Whether the symptom is peculiar to the patient’s disease or condition
  • The location of the symptom
  • The timing of the symptom (e.g. onset, duration, frequency)

Keeping these factors in mind will help you choose the most appropriate code for the symptom.

Diagnosis Difference between Inpatient and Outpatient Facilities

When there is coding needed for an inpatient facility, the coder has to determine the principal disease or the diagnosis which advised them to get admitted to the hospital. Also, they need to report indicators for present in admission (POA) for all the diagnoses made at the time of admission.

In the medical reports, terms like suspected, questionable, likely, and probable will be coded as existing at the time of release if found, else no significant code will be established against them. This is because the arrangement of workup and observations etc. will be associated with the prior established diagnosis. 

The story doesn’t end here, a single error in the coding for the diagnosis which has not been held or was made but was not reported at the time of release can potentially decrease the chance of claim approval.

In comparison; Medicare does not allow coding for uncertain conditions. Here you can see the exact reporting that makes inpatient and outpatient coding differ from each other.

inpatient and outpatient coding guidelines

Key Takeaway Message

Regardless of the situation, the billers and coders need to remain informed about the outpatient and inpatient coding guidelines. Besides, they also need to find adhere to hospital facility protocols for the appropriate reimbursement for individual services rendered and physicians. 

After discussing such guidelines from the tip, one might have an idea that inpatient coding is more complex than outpatient, which is not necessarily true.

For regular, on-time, and accurate reimbursement, coders and billers experienced in outpatient and inpatient coding make a significant difference. If you are looking for medical coding and billing services for your practice, you must visit the contact section of the website to reach out to the experienced coders that we have at our facility. We have helped thousands of clients get a timely and complete reimbursement.

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