Inpatient Coding Features and Characteristics

What is Inpatient?

Inpatient refers to a patient who is formally admitted to a hospital upon the orders of the physician who then admits the patient for an extended stay. The inpatient coding system is used to report a patient’s diagnosis and services based on his extended stay.

In Inpatient coding, same ICD 9/ICD10-CM codes are used for diagnosis coding. While ICD 10 PCS codes are used for reporting procedures. The Inpatient Prospective Payment System (IPPS) is the reimbursement methodology used by Medicare to provide reimbursement for hospital inpatient services.

The inpatient coding is totally different from outpatient coding.  Outpatient is referred to a patient who takes the treatment and leaves the clinic or hospital within 24 hours without getting admitted. For example, if a patient has a chest pain, he or she will visit the referred physician and the physician will take X-ray, CT or MRI depending on the condition and will leave the patient . Here, the patient is not admitted and is released after the procedure is done.

When a patient is formally admitted to a hospital upon the physician’s orders who then take care of your extended stay at the hospital stay, he is considered an inpatient.

Medical documents required for coding Inpatient report

The medical record for an inpatient patient will have different set of documents. Depending on the length of stay the patient will have a list of documents. Since, the admit date till the discharge date the patient will be under treatment, his or her progress will be written or document  in progress notes. Hence, more the length of stay more will be the progress notes.

Let us look at the list of documents present in Inpatient medical record.

• The history and physical examination report (H&P)
• Progress notes (PNs)
• Consultation(s)
• Operative report(s)
• Laboratory/pathology reports
• Radiology reports
• Minor procedure reports
• Physician orders
• Discharge summary

These are the key documents should be examined before reporting an diagnosis or ICD 10 PCS codes in Inpatient coding. Let us look at each of them.

Definition of Principle diagnosis

The principal diagnosis is defined in the Uniform Hospital Discharge Data Set (UHDDS) as “that condition established after study to be chiefly responsible for occasioning the admission of the patient to the hospital for care.” There are two important concepts within this definition that I would like to cover.

First, generally, the diagnosis must be present on admission to be considered the principal diagnosis. When working with new CDI professionals, I suggest first listing the diagnoses present on admission and then applying the rules of principal diagnosis assignment to that list. Remember that the principal diagnosis may not actually be identified on admission. The words “after study” tell us the patient may require workup first. Thus, the signs, symptoms, and patient presentation on admission can sometimes be tied to a more definitive diagnosis confirmed later in the stay.

The words “chiefly responsible for occasioning the admission” are also very important. The diagnosis chosen as the principal diagnosis should generally be one that requires an inpatient admission. A symptom such as abdominal pain or fever, a chronic condition such as chronic obstructive pulmonary disease or heart failure, or a condition that could easily be cared for in the outpatient setting would not “occasion an admission,” and such conditions should not be considered as the principal diagnosis. This is where CDI specialists will focus to identify an underlying etiology, a manifestation of acute exacerbation, a complication that would indeed occasion the admission.

The History and physical examination report (H&P)

The H&P report will help you to  know about the current diagnosis or Chief complaint, which is reason for admission.  This document will give you details  about the past history and family history. Also, it will give brief description about the reason for admission. You can even get to know about his or her current medications. Also you will know about allergies and review of systems. Finally at the end will the assessment and treatment plan.

Read also : Coding tips for Root operations used in ICD10 PCS coding

Progress notes

Progress notes plays a very important role in inpatient coding because it will give details about every day progress of the patient health. 

In acute care settings, the physician must see his patient daily and should update the treatment plan in the progress notes. The daily documentation is maintained in the progress notes. 

The progress notes can be also documents some minor procedures done during hospitalization period. These procedures may be performed bedside by the responsible procedure. Example of minor procedures are  debridement, paracentesis, thoracentesis, arthrocentesis etc. 

Consultations

Consultation may be provided to patient during hospitalization when there are getting some other symptom after admission. For example, a patient is admitted for abdominal pain and after admission he or she started getting headache.

In such case, the patient is consulted with a neurologist, to find out the exact cause of headache and then documents the final diagnosis in the consultation report.

The consultant report will be similar like H&P report but the reason for H&P and consultant will be different.

Operative report

Any surgery  procedure  performed should be documented. The operative report should consist of

• Preoperative diagnosis
• Postoperative diagnosis
• Procedure performed
• Detail description of procedures
• Findings

Operative report have direct effect on the DRG codes, which direct affect the reimbursement, hence the coders should document all the operative reports while coding a inpatient report.

Only, ICD 10 PCS codes should be used in Inpatient record.

 CPT codes are only for outpatient facility.

The coder’s needs to assign diagnosis based on postoperative diagnosis, because most of the times the preoperative diagnosis will not match will postoperative diagnosis.

Laboratory and Pathology Reports

 Lab test and pathology are important to find any bacterial infection. The microbiology report helps in find of any bacterial or viral infection.

Hence, laboratory and pathology reports are equally important in inpatient coding.

Radiology Reports

Radiology report consists of X-rays, CT , MRI scan etc. which can give more specific information about the diagnosis or disorder.

The radiology clinical diagnosis can have effect on overall diagnosis. Like if a patient have a unspecified right scapula fracture, S42.101A in H&P and the radiology report documents the presence of displaced fracture of neck of scapula, S42.151A, the medical coder can report the more specific diagnosis code.

The Discharge Summary

 A discharge summary is completed for all inpatient whose length of stay is 48 hours or more. Exceptions are patients admitted for normal deliveries and newborns. Some facilities may have a policy that a discharge summary be completed for all patients who have expired, regardless of length of stay. If a patient’s length of stay is fewer than 48 hours, the physician may be required to complete a short-stay form. 

Discharge summary includes details of patient’s stay and also documents the final diagnosis in the conclusion. The final impression or diagnosis will include the primary or principle diagnosis along with the secondary diagnosis.  

But, it is important to note that coders should not just choose the principle diagnosis on the basis of discharge summary, they have to go through all the medical document to finally choose a principle diagnosis.

The coder has to determine  the principle diagnosis and other diagnoses based on documentation in the entire medical record, not just he discharge summary.