What coding guidelines should be followed for outpatient vs inpatient coding?

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Outpatient and inpatient medical coding follow different guidelines due to differences in care settings and billing rules. Here are key coding guidelines for each:

Outpatient Coding Guidelines

(Follow CPT®, HCPCS, and ICD-10-CM)

• Code to the highest level of specificity: Use the most specific diagnosis available at the time of the encounter.

• Use only confirmed diagnoses: Do not code "rule out," "suspected," or "probable" diagnoses—code only what is known after the visit.

• Focus on reason for the visit: Code only diagnoses relevant to that encounter.

• Use CPT/HCPCS codes for procedures and services (e.g., office visits, minor surgeries).

• Code each encounter separately: Outpatient visits are billed per visit.

• Modifiers may be needed to clarify procedures (e.g., modifier -25 for E/M with a procedure).

Inpatient Coding Guidelines

(Follow ICD-10-CM and ICD-10-PCS)

• Code all conditions affecting care: Include confirmed and suspected diagnoses, including "rule out" or "probable" ones documented at discharge.

• Use ICD-10-PCS for procedures performed during the inpatient stay.

• Principal diagnosis is the condition chiefly responsible for admission.

• Comorbidities and complications (CC/MCC): Code additional diagnoses that affect patient care, as they can impact DRG and reimbursement.

• Follow UHDDS guidelines: Used for determining reportable diagnoses and procedures.

• Sequence diagnoses properly: Based on coding conventions and documentation.

Summary:

• Outpatient: Code only confirmed diagnoses; use CPT/HCPCS; visit-based.

• Inpatient: Include suspected diagnoses; use ICD-10-PCS; stay-based with focus on full documentation and sequencing.

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