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!