Medical coding is a process that takes medical treatments, gear, and diagnoses and converts them into an alphanumeric code. It is up to professionals to accumulate data and get it turned into medical code. With these codes, it is easier for medical providers to communicate with other providers and make sure that everything gets done accurately during medical billing. To summarize, it makes the healthcare industry more efficient and safer. Two main kinds of medical coding exist, and each one has its distinctions.
Inpatient Medical Coding
Inpatient medical coding is done whenever physicians formally have patients admitted into medical facilities and have those patients stay at the facilities for a longer period of time. Because patients stay at facilities for extended durations, this makes inpatient medical coding a generally more complicated procedure than outpatient coding. Such facilities that use inpatient medical coding include rehabilitation centers, nursing homes, and facilities for long-term care. Because these are the facilities where patients stay, inpatient medical coders tend to work in these environments. Inpatient medical coding interprets the diagnosis of a patient and documents all the services that have been provided while they’re at the facility.
An overview of all of the treatments patients get during their stay is also provided. This helps accounting departments make sure that billing and reimbursement is done accurately.
There are two manuals on which inpatient coders depend, which are the ICD-10-PCS and the ICD-10-CM. Also, there will be a POA indicator, also known as a present on admission indicator, needed, which explains differences in a patient’s condition from when they arrived, compared to any new complications that come up while they are at the facility.
Outpatient Medical Coding
Outpatient medical coding has a few differences when compared to inpatient. A key difference is how the patient getting treatment does not end up staying at a facility for a long period of time. The patient does not usually stay for any longer than one day.
For outpatient situations, coders are not allowed to use terms like “likely” and “probable” when talking about the diagnosis of a patient. Instead, these coders must have an incredibly high amount of certainty for all their patients’ visits when getting their work done. Instead of trying to get a comprehensive overview of what the patient’s condition is, the physician is tasked with coming to a conclusion that is founded on whatever physical data they can access.
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