Medical Coding Service
Inpatient
What is inpatient?
An inpatient is someone who has been formally admitted to the hospital based on a physician’s directive. The individual retains the status of an inpatient until the day before being discharged.
Note:
Simply spending a night in the hospital doesn’t automatically categorize the patient as an inpatient.
Inpatient Medical Coding
Inpatient coding pertains to services rendered during a patient’s prolonged hospital stay. Examples of inpatient facilities encompass acute and long-term care hospitals, skilled nursing facilities, hospices, and home health services.
Here’s the significance:
Throughout the duration of the stay, the patient may undergo various tests and experience changes in diagnosis and treatments. A protracted stay typically leads to comprehensive and intricate patient records, underscoring the importance of having a skilled medical inpatient coder handling the task.
Furthermore, it utilizes ICD-10-CM diagnostic codes for billing and ensuring appropriate reimbursement, while ICD-10-PCS serves as the procedural coding system. The Inpatient Prospective Payment System (IPPS) constitutes the reimbursement methodology employed by Medicare to facilitate reimbursement for hospital inpatient services.
Outpatient
What is Outpatient Medical Coding?
Outpatient medical coding is the systematic translation of healthcare procedures and diagnoses into standardized codes for billing and record-keeping purposes. Unlike inpatient coding, which applies to hospital stays, outpatient coding is specific to services provided in settings such as clinics or surgical centers. The coding process involves using codes such as ICD-10-CM for diagnoses and CPT or HCPCS for procedures. Accurate outpatient coding is essential for healthcare providers to receive proper reimbursement for services rendered during outpatient visits. Certified medical coders ensure precision in code assignment, contributing to the efficiency and compliance of the healthcare billing process.
Outpatient Medical Coding
Outpatient Medical Coding in the evolving landscape of healthcare reflects the shift of numerous services from inpatient to outpatient settings. The coding process for outpatient services relies on ICD-10-CM diagnostic codes for billing and accurate reimbursement, while procedures are reported using the CPT or HCPCS coding system. The precision of documentation is pivotal in determining appropriate CPT and HCPCS codes for services.
The reimbursement framework for outpatient services is structured around Ambulatory Payment Classifications (APCs). Consequently, our team of medical coders holds essential credentials, including an AHIMA certification as a Certified Coding Specialist – Physician-based (CCS-P), as well as AAPC certifications such as Certified Professional Coder (CPC), Certified Anesthesia Professional Coder (CANPC), among others, to ensure proficiency in outpatient coding.
Home Health Coding
Home health coding is the segment of coding that enables home health agencies to complete coding for patients admitted to enhance their medical condition.
Clinical Documentation Review
Our team comprises seasoned home health professionals and certified coding specialists. To maintain a high level of precision and uniformity, our dedicated coding team meticulously examines clinical documentation.
A home health service agency may encounter various challenges if the clinical documentation fails to effectively communicate an accurate, patient-specific care plan. Issues such as inadequate care coordination, suboptimal referral source quality, patient safety concerns, higher takebacks, diminished reimbursement, and an elevated risk of audits are common repercussions of inaccurate clinical documentation.
Home Health Coding Types and Levels
Various types of home health care, including Start of Care (SOC), Re-certification (REC), Resumption of Care (ROC), Significant Change in Condition (SCIC), Discharge (D/C), and Hospice, are subject to multiple coding levels. These coding processes adhere to CMS guidelines and Patient Driven Groupings Model (PDGM) rules, contributing to improved Star ratings for home health agencies. The coding levels are categorized as follows:
1. Level 1 – Coding Only
2. Level 2 – Coding & OASIS Review
3. Level 2.5 – Coding & Comprehensive OASIS Review
4. Level 3 – Coding, Comprehensive OASIS Review & Plan of Care (POC)
5. Level 3.5 – Coding, Comprehensive OASIS Review, POC & Pre-Billing QA
HEDIS
HEDIS, which stands for Healthcare Effectiveness Data and Information Set, serves as a tool for employers and individuals to gauge the quality of health plans. It assesses the effectiveness of health plans in providing services and care to their members.
HEDIS Measures
CMS collaborated with NCQA to formulate a strategy for assessing the quality of care delivered by Special Needs Plans (SNPs). Specifically tailored for SNPs, NCQA developed the Healthcare Effectiveness Data and Information Set (HEDIS) measures. HEDIS is a comprehensive set of standardized performance metrics aimed at offering purchasers and consumers reliable information for comparing health plan performance. Covering significant public health concerns such as cancer, heart disease, smoking, asthma, and diabetes, HEDIS measures serve as a valuable resource. SNPs can leverage HEDIS performance data to pinpoint improvement opportunities, monitor the effectiveness of quality enhancement initiatives, track progress, and establish measurement standards for comparisons with other plans. This data-driven approach facilitates the identification of performance gaps and the setting of realistic targets for improvement.
HEDIS measures in 2022:
- Childhood Immunization Status (CIS)
- Immunizations for Adolescents (IMA)
- Weight Assessment and Counselling for Nutrition and Physical Activity for Children/ Adolescents (WCC)
- Cervical Cancer Screening (CCS)
- Prenatal and Postpartum Care (PPC)
- Controlling High Blood Pressure (CBP)
- Blood Pressure Control for Patients with Diabetes (BPD)
- Hemoglobin A1C Control for Patients with Diabetes (HBD)
- Eye Exam for Patients with Diabetes (EED)
- Care for Older Adults (COA)
- Colorectal Cancer Screening (COL)
- Transitions of Care (TRC)
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