Each section has a certain number of elements that needs to be documented. Even though the MDM drives the level, the number of elements has to be documented in order to assign that level. If the documentation is not there to support the level, then you have to down code to the level that the documentation does support. Below is a graph with the number of elements required per CMS guidelines:. The interventions include, but are not limited to, diagnostic tests performed, medication administration, discharge instructions, etc.
Share your thoughts in the comment below! Consequently, complete and accurate assignment of ICDCM codes is essential to the outpatient reimbursement process. Note that Medicare has identified certain other facilities, such as critical access hospitals, that may use C codes at their discretion. Official coding guidelines provide detailed instructions on how to code correctly; however, it is important for facility coders to understand that guidelines may differ based on who is billing inpatient facility, outpatient facility, or physician office.
B, General Coding Guidelines, as well as sections that apply only to specific settings. For instance, Section IV, Diagnostic Coding and Reporting Guidelines for Outpatient Services, is relevant to coding and reporting hospital-based outpatient services and provider-based office visits.
Guidelines in this section do not apply to inpatient hospital services. Let's review a major difference between inpatient and outpatient coding guidelines specific to coding an uncertain diagnosis:.
These guidelines are essentially opposite of each other. For example, suppose a patient presents to the outpatient clinic with a complaint of chest pain and shortness of breath SOB. After a full assessment and work-up, a final diagnosis of rule-out acute myocardial infarction AMI is documented. According to outpatient-focused Section IV. H, the encounter should be coded based on the signs or symptoms, which in this case are chest pain and SOB.
Because the AMI is an unconfirmed diagnosis, it cannot be coded for an outpatient encounter. Conversely, if this same scenario were related to an inpatient admission, Section II. To avoid incorrect coding and reduce the likelihood of denied or rejected claims and inaccurate reimbursement, the best practice is to refer only to the guideline sections including general sections that apply to the healthcare setting where the encounter is being coded.
Our focus is on outpatient facility coding and reimbursement, but facility coders and pro-fee coders need to be aware that the facility is not the only entity that can submit claims for services performed in facilities. Physicians and other providers also report the services they perform in facilities to be reimbursed for their work. For instance, suppose a specialist, such as a cardiologist or gastroenterologist, provides a consultation for a patient in the emergency department of a hospital.
Medicare, for instance, no longer accepts the consult codes, and providers and coders should check with their individual payers to determine the appropriate codes for billing consultations. Many private practice physicians have admitting privileges with hospitals and can admit their patients for more acute care when warranted. This is a billable service for the physician. The outpatient and inpatient scenarios above discuss capturing the professional work of the physician.
However, the facility coders also would submit claims to bring in reimbursement for the facility resources used such as the room cost, nursing personnel, drugs, supplies, etc.
The inpatient and outpatient hospital facilities bill using the UB institutional claim form also called the CMS , shown in Figure 1. The professional fee services are billed on the CMS professional claim form, shown in Figure 2.
Typically, the more complex medical services and procedures are soft-coded. This means a coding professional manually codes the medical service or procedure. To ensure complete and accurate coding of services, outpatient hospital facility coders must understand and reference outpatient hospital coding guidelines and payer-specific guidelines. There are many outpatient hospital departments that have specific guidelines on how to code and bill for certain services, such as intravenous IV injection and infusion, chemotherapy, and radiation therapy, all of which require in-depth knowledge usually obtained by a certified coder.
The facility coder, unlike the pro-fee coder, also must understand relevant payment methodologies, such as the OPPS, and be aware of how government and payer rules and policies may affect facility reporting.
The type of code to use for a specific service is another area that sometimes differentiates professional fee coding from facility coding.
For example, Medicare has guidelines on how to code outpatient hospital clinic visits for Medicare beneficiaries. There also are major differences between inpatient and outpatient facility coding. Navigating the healthcare coding and reimbursement sector can be complex as there are varying rules and guidelines that are not always transparent.
The examples above demonstrate how the guidelines can differ depending on the payer-specific rules and the healthcare setting. They follow your coding policies and procedures. Since they work remotely and are paid using a totally different paradigm, there is no employee friction with your staff. Plus, with no required minimums, your management has much greater decision-making flexibility.
With our accuracy guaranteed, you can try us for a while to see if TCN is a suitable solution for your hospital. If not, you can revise your staffing plan and recuruit coders without creating a human resources nightmare. If you are offering your HIM staff training, mentoring, and a coding career path, what is to prevent misunderstandings and mistakes from being passed down from one coder to the next?
Our coding accuracy audits address this issue as well as compliance and revenue optimization. Your staff will get an outside expert peer review with a complete and educational analysis of our findings. CMS selects primary care payment model participants According to Becker's Hospital Review, "CMS chose primary care practices and 37 regional health plan partners as participants in its new payment model called Primary Care First. Medical Center failed to comply with Medicare billing requirements for three of inpatient and outpatient claims reviewed by HHS' Office of Inspector General, according to [ Decades of experience in hospital coding and training hospital coders.
Manager of a team of certified coders. Hospital Facility Coding Need Well trained hospital facility coding specialists are difficult to find. Coder turnover is extremely high across the nation.
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