Module-1- DRG Basics

Inpatient Coding Basics

What is inpatient?

An inpatient is an individual who has been officially admitted to the hospital under a physician’s order. The patient will remain classified as an inpatient until one day before discharge. 

Staying in the hospital overnight does not necessarily mean that the patient is considered an inpatient.

Inpatient Medical Coding

Inpatient coding is related to the patient’s extended stay service.  Examples of Inpatient facilities include acute and long-term care hospitals, skilled nursing facilities, hospices, and home health services.

Here’s why this matters:

During the stay, the patient may have a variety of tests run, will have changes in diagnosis and treatments. A lengthy stay usually results in extensive and intricate patient records which makes it important to have an experienced medical inpatient coder doing the job.

So what is outpatient care, who is an outpatient and what is outpatient services?

Outpatient

A patient that comes to the ER or practice, and is being treated or undergoing tests, but has not been admitted is considered an outpatient, even if the patient spends the night.

Outpatient Medical Coding

Outpatient coding focuses on the direct treatment offered in a single visit, which is usually a few hours.  A basic rule of thumb is that outpatient care has a duration of 24 hours or less. 

With the increased development in the medical field, many services that used to be considered inpatient treatments are being assigned to outpatient services.

Payments

Original Medicare inpatient claims are paid under Part A, whereas outpatient claims are paid under Medicare Part B. 

Inpatient medical coding is reported using ICD-10-CM and ICD-10-PCS codes, which results in payments based on Medicare Severity-Diagnosis Related Groups (MS-DRGs).  Outpatient medical coding requires ICD-10-CM and CPT®/HCPCS Level II codes to report health services and supplies. 

Examples of Medicare Part B services include hospital care, emergency department services, lab tests, X-rays, outpatient surgeries, and doctors’ office visits.

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. 

Diagnoses listed as “probable,” “suspected,” “likely,” “questionable,” and other such terms, may be coded when documented as existing at the time of discharge and no definitive diagnosis has been established.

The diagnostic workup, arrangement for further workup or observation, etc. needs to relate to the established diagnosis.

That’s not all…

A common mistake is to code uncertain diagnoses that are not documented at the time of discharge/on the discharge summary – do not do that as they may have been ruled out during the stay.  

Module-2 ICD-10-PCS Coding

ICD-10-PCS (ICD-10 Procedure Coding System) TheICD-10-PCS is a procedure classification published by the US for classifying procedures performed in hospital inpatient healthcare settings. It is developed by 3M Health Information Systems with the support of the Centers for Medicare and Medicaid Services (CMS)

ICD-10-PCS has a 7 character alpha-numeric code structure that provides a unique code for all substantially different procedures, and allows new procedures to be incorporated as new codes. All procedures currently performed can be specified in ICD-10-PCS.

Module-3 - Principal Diagnosis and Procedure

Principal diagnosis is defined as the condition, after study, which occasioned the admission to the hospital, according to the ICD-10-CM Official Guidelines for Coding and Reporting.

The attending physician is responsible for listing the patients principal and secondary diagnoses on the attestation or discharge face sheet when a patient is discharged from the hospital.

Selecting the principal diagnosis is the most important factor in the assignment of the diagnosis-related group (DRG) number. This assignment ultimately affects the amount of payment received by the hospital.

The principal diagnosis, as defined in the NUBC Official UB-04 Data Specifications Manual, is "the condition established after study to be chiefly responsible for occasioning the admission of the patient for care."

Note: There are instances when the principal diagnosis and the admitting diagnosis are not the same.

For example, a patient admitted with chest pain may be subsequently diagnosed with an anterior wall myocardial infarction (MI). In this case, the principal diagnosis would be MI, while the admitting diagnosis would be chest pain. The principal diagnosis code should be for services rendered, not for the member's historical diagnosis.

Module-4 PCS Guidelines

The ICD-10-PCS Guidelines are printed in PCS manual.

Refer guidelines in PCS Manual. Make note of important Points

Always refer guidelines for accuracy.