Medical Coding Inpatient vs. Outpatient Coding


Q: [Inpatient vs Outpatient Coding] I’m
having a difficult time distinguishing between how coding is done for each side (Inpatient
vs Outpatient). Are we coding everything, (e.g. Signs & Symptoms) in outpatient and
just the definitive diagnosis on the inpatient, or do I have them confused? A: So, yes, it’s a little bit confused.
I wanted to address two issues with this question. One, do we code for signs and symptoms plus
the definitive diagnosis? And two, can outpatient coders code rule out diagnosis?
Let’s take a look at the first one – Coding Signs and Symptoms. This applies to inpatient
and outpatient, so that’s the first answer to the question there. If you have a definitive
diagnosis, and what that means is yup they definitely have it. Maybe the physician, like
in my case, I had right-sided weakness. I was getting some tingling in my arm, the side
of my face was feeling numb, so I went to my doctor’s office right away and they started
to do a workup over the course of a week. I went to different specialists and they were
trying to rule out multiple sclerosis, MS. As it turned out, after everything was said
and done, I had a complicated migraine. My neck needed to be adjusted or whatever and
after a few chiropractic treatments, I was fine. But it was pretty scary because when
you work, I was an occupational therapist, and I worked with stroke patients and you
start seeing those symptoms, you get really scared. So, they did a rule out. I did all
these tests and labs and MRIs to rule out multiple sclerosis. My signs and symptoms
were the numbness and the weakness and all those other things. So, the definitive diagnosis,
had I been diagnose with it would have been multiple sclerosis. In the end, my definitive
diagnosis was complicated migraines. OK? So, that’s what definitive means. Now, when you’re dealing with signs or symptoms
as whether or not you code both, the signs and the symptoms and the definitive diagnosis,
depends on whether that sign or symptom is considered integral to that disease. If you
always have one with the other, then you don’t code the sign or symptom, OK?
Here’s an example: Patient comes in with wheezing and they’re diagnosed with asthma.
Well, wheezing always goes along with asthma, but you would not code the wheezing, you would
just code the asthma. There are many other examples out there, but that’s a pretty
good one. Now, if a sign or symptom is sometimes associated
with the definitive disease, but not always; then, in that case, it’s OK to code both
the sign and symptom and the definitive diagnosis. So, what that means is as coders you really
want to have a good understanding of the disease processes. Obviously when you’re first starting
out you can’t memorize everything, but once you get into your first job, or that’s the
specialty that you want to get into, become familiar with the common diagnosis for that
specialty and that will speed your diagnostic coding along. There’s this great article, this is another
link – hint, hint, Sylvia – to share and we’ll put that on a document that we’ll
share at the end of the webinar. But this is from AHIMA, goes into really great depth
of what I just discussed about, so I recommend checking that out. The second part of this I wanted to cover
was – Coding Rule-Out Conditions. That’s actually called equivocal language. It could
be suspected, it could be this diagnosis versus that diagnosis, probable; all of that is called
equivocal language. It’s not certain, it’s not definitive. So, that means the physician
is not ready to make it a definitive diagnosis yet. In outpatient coding, we do not code
rule-out type of diagnosis. We only code what they definitely have; if we don’t know that
they definitely have it. Like, in my case with the ruling out MS, no
one should have coded me as having MS. They should have coded my signs and symptoms – the
weakness, the numbness, and the other things. Unfortunately, they did, in one office coded
me as having it, and when I went to get life insurance or some other type of insurance
and I was denied, I’m like “Why?” Come to find out is they thought I had MS. So,
I had to get that straightened out and it was a big deal. And so, as coders, it’s
very important that we are careful in our coding. Now, for inpatient coders, they CAN code rule-outs.
So, if a physician suspect something like MS, etc., then they can code it. The reason
is, if you think about it, on the physician side, the payments are normally based on what
was done for the patient. I say “normally” because things are starting to change with
risk adjustment coding. That’s another story. But on the inpatient side, they get paid by
the diagnosis. The diagnosis helps support certain diagnostic-related groups and some
of them pay more than others, and if you make a coding error, it could be thousands and
thousands of dollars. So, if a physician is working a patient up
for a particular thing, like, maybe possible stroke etc., they’re going to use the same
resources and treatment as if they had it; therefore, the cost is the same whether or
not they end up really being diagnosed with it. So, that’s why in the inpatient world,
they can code equivocal language, rule out probable suspected, etc. Just a P.S. we’re going to be having a “Payment
Methodologies” webinar, so if this type of topic is of interest to you, keep an eye
out for details on that. We’re going to go over – we all know basic CPT, ICD, HCPCS-type
coding, what happens after that? What’s the next layer with these payment methodologies?
For inpatient is DRGs, for physician- based, we’re starting to see more and more risk-adjustment-type
methodologies come in, like, with HCCs. So, look at that, it will be very, very interesting.
Chandra Stephenson is going to do that for us. We’re really – I’m looking forward
to it!

3 thoughts on “Medical Coding Inpatient vs. Outpatient Coding

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