The Differences Between Inpatient And Outpatient Coding

All hospital settings require a comprehensive healthcare coding and billing system. Thousands of professionals are hired by a hospital to ensure its efficiency and effectiveness, beginning with the billing and reimbursement processes for patients. Making sure the billing process is completed and that reimbursement is successfully claimed on time is a difficulty in and of itself.

One of the many functions of coding is to facilitate the retrieval and reporting of data based on criteria such as diagnosis and procedure. Moreover, coding provides unique numerical or alphanumeric identifiers to every part of a patient’s medical record, both in and out of the hospital. Therefore, determining whether a patient is an outpatient or an inpatient is crucial to the hospital’s coding and billing procedure.

Difference Between Outpatient And Inpatient Coding


1. Basics: Outpatient Vs. Inpatient Coding

The term “outpatient” describes someone who visits the emergency room for medical attention but need not stay in the hospital overnight for their recovery. Typically, patients are discharged from the hospital within 24 hours. Outpatient CDI reviews medical data in an ambulatory, emergency department, same-day, observation, or clinic setting to document diagnoses, hierarchical condition categories (HCCs), and chronic conditions.

Whereas an inpatient is someone who has been formally admitted to a hospital per a doctor’s orders and will stay there for a prolonged period. In contrast to inpatient coding, which describes a patient’s diagnosis and services based on his lengthy stay, outpatient coding refers to a complete diagnosis report where the patient is generally treated in a single visit.

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2. Coding For Outpatient Vs. Inpatient

ICD-9/10-CM diagnosis and procedure codes are used exclusively in the inpatient coding system to facilitate accurate billing and payment. It is the universally accepted method for classifying and coding medical diagnoses and is utilised by doctors and other medical professionals. The ICD-10-PCS is used for statistical reporting. Finding the correct ICD-9/10-CM diagnosis codes for outpatient care is the same as inpatient care, but payment for outpatient care is determined by the CPT and HCPCS codes assigned to the procedures performed. The CPT and HCPCS service codes rely heavily on supporting documentation.


3. Principal Diagnosis

A patient’s primary diagnosis is the ailment for which hospitalisation was initially sought. Inpatient coding always begins with the primary diagnosis. Full compensation is contingent on making sure the right primary diagnosis is given. In a nutshell, the primary diagnosis is the deciding factor in how much care a patient needs. However, the term principal diagnosis is not used for outpatient reasons because diagnoses are not always established at the initial visit; instead, the first-listed disease is generally used to signify the primary reason for the visit.


4. Length Of Stay

Coding for inpatients is more difficult than for outpatients. All the care a patient receives while in the hospital is documented by their inpatient code. There is a requirement for reporting a patient’s POA when classifying an inpatient stay. Conditions that are “present on admission” are already present when the inpatient admission order is made. The purpose of the POA indicator is to differentiate between pre-existing problems and those that emerge during a patient’s hospital stay.

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Assigning a code in outpatient coding is done during the patient’s visit or encounter. If a patient receives care but is only going to stay at the facility for less than 24 hours, they are considered an outpatient.


5. Payment Involved

Healthcare providers and government programmes reimburse hospital inpatient services according to the Inpatient Prospective Payment System (IPPS), which considers the patient’s diagnosis and the care they received while hospitalised. Patients are classified into DRGs (diagnosis-related groups) based on their clinical similarities or their required hospital resources. However, the Outpatient Prospective Payment System (OPPS) is a prospective payment system that reimburses hospitals for outpatient care. Ambulatory Payment Classifications is the name for the system used by this payment system.


Final Thoughts!

To sum up, the basics are the same, but coders must keep up with changing hospital coding laws to follow inpatient and outpatient guidelines. Hospitals must submit claims and use the right billing and coding systems to get paid for services. Hospital capacity is measured by the number of inpatients and beds. Since codes vary by facility and practitioner, coders must ensure accuracy. Inpatient and outpatient coding differ greatly in methodology, norms, payment structure, etc.

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