• Skip to main content
  • Skip to secondary menu
  • Skip to primary sidebar
  • Skip to footer
  • About Us
  • Medical Billing Process
  • Insurance Contacts & Addresses
    • with Alphabet A to E
      • Insurance Companies with Alphabet A
      • Insurance Companies with Alphabet B
      • Insurance Companies with Alphabet C
      • Insurance Companies with Alphabet D
      • Insurance Companies with Alphabet E
    • With Alphabet F to J
      • Insurance Companies with Alphabet F
      • Insurance Companies with Alphabet G
      • Insurance Companies with Alphabet H
      • Insurance Companies with Alphabet I
      • Insurance Companies with Alphabet J
    • With Alphabet K to O
      • Insurance Companies with Alphabet K
      • Insurance Companies with Alphabet L
      • Insurance Companies with Alphabet M
      • Insurance Companies with Alphabet N
      • Insurance Companies with Alphabet O
    • With Alphabet P to T
      • Insurance Companies with Alphabet P
      • Insurance Companies with Alphabet Q and R
      • Insurance Companies with Alphabet S
      • Insurance Companies with Alphabet T
    • With Alphabet U to Z
      • Insurance Companies with Alphabet U
      • Insurance Companies with Alphabet V
      • Insurance Companies with Alphabet W to Z
  • BCBS Prefix
    • BCBS Alpha Prefix
      • Prefix with Alphabet A to E
        • Prefix List (AAA to AZZ)
        • Prefix List (BAA to BZZ)
        • Prefix List (CAA To CZZ)
        • Prefix List (DAA To DZZ)
        • Prefix List (EAA to EZZ)
      • Prefix with Alphabet F to J
        • Prefix List (FAA to FZZ)
        • Prefix List (GAA to GZZ)
        • Prefix List (HAA to HZZ)
        • Prefix List (IAA to IZZ)
        • Prefix List (JAA to JZZ)
      • Prefix with Alphabet K to O
        • Prefix List (KAA to KZZ)
        • Prefix List (LAA to LZZ)
        • Prefix List (MAA to MZZ)
        • Prefix List (NAA to NZZ)
        • Prefix List (OAA to OZZ)
      • Prefix with Alphabet P to T
        • Prefix List (PAA to PZZ)
        • Prefix List (QAA to QZZ)
        • Prefix List (RAA to RZZ)
        • Prefix List (SAA to SZZ)
        • Prefix List (TAA to TZZ)
      • Prefix with Alphabet U to Z
        • Prefix List (UAA to UZZ)
        • Prefix List (VAA to VZZ)
        • Prefix List (WAA to WZZ)
        • Prefix List (XAA to XZZ)
        • Prefix List (YAA to YZZ)
        • Prefix List (ZAA to ZZZ)
    • BCBS Alpha Numeric Prefix
      • Prefix with Alphabet A to E
        • Prefix List (A2A To A9Z)
        • Prefix List (B2A To B9Z)
        • Prefix List (C2A To C9Z)
        • Prefix List (D2A To D9Z)
        • Prefix List (E2A to E9Z)
      • Prefix with Alphabet F to J
        • Prefix List (F2A to F9Z)
        • Prefix List (G2A to G9Z)
        • Prefix List (H2A to H9Z)
        • Prefix List (I2A to I9Z)
        • Prefix List (J2A To J9Z)
      • Prefix with Alphabet K to O
        • Prefix List (K2A To K9Z)
        • Prefix List (L2A To L9Z)
        • Prefix List (M2A To M9Z)
        • Prefix List (N2A To N9Z)
        • Prefix List (O2A To O9Z)
      • Prefix with Alphabet P to T
        • Prefix List (P2A To P9Z)
        • Prefix List (Q2A To Q9Z)
        • Prefix List (R2A To R9Z)
        • Prefix List (S2A To S9Z)
        • Prefix List (T2A To T9Z)
      • Prefix with Alphabet U to Z
        • Prefix List (U2A To U9Z)
        • Prefix List (V2A To V9Z)
        • Prefix List (W2A To W9Z)
        • Prefix List (X2A To X9Z)
        • Prefix List (Y2A To Y9Z)
        • Prefix List (Z2A To Z9Z)
  • CPT Codes
  • Modifiers
Billing Executive

Billing Executive

Medical Billing Knowledge Base

  • Medical Billing
  • Medical Coding
  • CMS
  • Private Payers
  • Billing Errors
  • Resources
  • Buy Books & Courses

What Do You Need To Know About Outpatient Facility Setting?

June 28, 2022 by Aamir247 Leave a Comment

What Do You Need To Know About Outpatient Facility Setting

Medical coding is the basic step in the medical billing process. It entails assigning standardized codes to medical diagnoses and procedures. Knowing the thousands of ICD-10 and CPT codes to notify the correct codes for the services provided is one of the most difficult challenges for healthcare organizations. Coding is used for various purposes, including obtaining and reporting information based on diagnosis and procedure. However, coding entails far more than simply systematically assigning codes. The documentation that follows is more complicated.

What Is Outpatient Coding?

Outpatient relates to a patient being treated but not admitted to the hospital for a stay and discharged within 24 hours. Even if a patient stay for more than 24 hours, they can be classified as an outpatient. Outpatient coding is based on ICD-9/10-CM diagnostic codes for billing and appropriate repayment, but procedures are reported using the CPT or HCPCS coding systems. Documentation is important in the CPT and HCPCS codes for services.
Coding Systems Used in Outpatient Facilities
ICD-10-CM, CPT®, and HCPCS Level II are the three main coding systems used in outpatient facilities. These are commonly known as code sets.

ICD-10-CM in the Outpatient Facility

The ICD-10-CM code set is used in all healthcare situations (including outpatient facilities, inpatient facilities, and physician offices) to obtain diagnoses and the purpose for a visit. The purpose of diagnosis codes in the outpatient reimbursement process is to assist the medical reason for the services offered. As a result, complete and accurate assignment of ICD-10-CM codes is critical to the outpatient reimbursement process.

CPT in the Outpatient Facility

The American Medical Association (AMA) established and maintained the CPT code set, used to collect medical services conducted in an outpatient hospital setting or to collect pro-fee benefits. Procedures represented by CPT codes include evaluation and management (E/M), surgery, radiology, laboratory, pathology, anesthesia, and medicine.

HCPCS in the Outpatient Facility Setting

The HCPCS Level II code set, which was originally designed for use with Medicare claims, mainly captures products and equipment. CPT codes do not cover services such as medications, durable medical equipment (DME), ambulance transport services, prosthetics, and orthotics. The HCPCS Level II code set includes an outpatient hospital reporting section. Medicare developed C codes for use by Outpatient Prospective Payment System (OPPS) hospitals. OPPS hospitals are not restricted to revealing C codes. Still, they use them to notify drugs, biologicals, devices, and the latest technological processes that do not have particular HCPCS Level II codes. It should be noted that Medicare has identified certain other facilities, such as critical access hospitals, as having the authority to use C codes.

The Fundamentals of Outpatient Vs Inpatient Coding

A patient who verifies into the ER and is handled but is not admitted to the hospital for an extended visit is referred to as an outpatient. Typically, the patient is discharged from the hospital the same day or within 24 hours. When a patient is officially admitted to a hospital at the request of a physician, who then takes care of your prolonged hospital stay, he is regarded as an inpatient. An outpatient coding system is used to notify a patient’s diagnosis and services based on his extended visit. In contrast, an inpatient coding system informs a patient’s diagnosis and services based on his extended stay.

Coding for Outpatient Vs Inpatient

The inpatient coding scheme is based purely on the assignment of ICD-9/10-CM diagnostic and operational codes for billing and timely reimbursement. It is the basic coding system medical providers use to classify and code all diagnoses and treatments. Procedures are reported using ICD-10-PCS. Finding the appropriate ICD-9/10-CM diagnostic codes for outpatient services stays the same, but outpatient facility services are compensated based on code tasks from the CPT and HCPCS systems. Documentation is essential in the CPT and HCPCS codes for offerings.

Reimbursement for Outpatient Vs Inpatient

Outpatient services are covered by Medicare Part B, whereas inpatient facilities are covered by Medicare Part A (hospital insurance). Many laws and regulations regulate Medicare reimbursements and any copays the patient may be required to pay.
Outpatient facility reimbursement is the money a hospital or other facility receives for providing the resources required for performing procedures or services in their institution. The resources typically include room, nursing staff, equipment, medications, and other objects and staffing the facility pays for. The facility records the fees and codes, typically on the UB-04 claim form, and submits the claim to the payer for reimbursement.

Typically, inpatient services are coded using Medicare Severity-Diagnosis Related Groups (MS-DRGs). DRGs categorize patients based on their diagnostic test, treatment, and length of hospitalization. A DRG is assigned based on factors such as the following: primary diagnosis, secondary diagnosis or diagnoses, surgical techniques performed, chronic conditions and problems, patient age and gender, and discharge status. Complications and comorbidities (CC) increase the severity and cost of care occurrences. MS-DRG task requires proper methods based on ICD-10-CM and PCS requirements and standards.

Outpatient Vs Inpatient Coding Comparison

The foundation remains the same, but coders must stay current with evolving hospital coding regulations to ensure compliance with inpatient and outpatient rules. The hospital facility provides a variety of setups for claiming services, billing, and coding adequately for reimbursement. The amount of inpatient admissions or rooms open for inpatient care is frequently used to determine hospital size. The rest is up to the coders, as codes differ from department to department and doctor to physician. Similarly, inpatient coding differs greatly from outpatient coding in terms of approach, rules, payment system, and other factors.
Professional knowledge is required for inpatient and outpatient coding. Collaboration with billing executive company can assist hospitals and practices in ensuring correct code-assigned tasks, effective claim submission, and efficient reimbursement.

About us

Billing Executive – a Medical Billing and Coding Knowledge Base for Physicians, Office staff, Medical Billers and Coders, including resources pertaining to HCPCS Codes, CPT Codes, ICD-10 billing codes, Modifiers, POS Codes, Revenue Codes, Billing Errors, Denials and Rejections.

We have more than 10 years experience in US Medical Billing and hand-on experience in Web Management, SEO, Content Marketing & Business Development with Research as a special forte.

Learn More

What Do You Need To Know About Medical Coding Modifiers?

Difference Between Prior Authorization And Predetermination

Surprise Medical Bill: New Protections for Consumers Starting 2022

How PA Residents can Save Through Pennie Health Insurance


Post Views: 6

Filed Under: Medical Billing, Medical Billing Process, Medical Coding, Posts Tagged With: medical billing, medical Coding, outpatient, outpatient Coding, Outpatient Facility

Reader Interactions

Leave a Reply Cancel reply

Your email address will not be published. Required fields are marked *

Primary Sidebar

Medical Billing & Coding Books

1 Stop Medical Billing Solutions

Save Time & Money by choosing “ONE STOP“ Solutions!

Revenue Cycle Management
Online Reputation
Virtual Staffing (RPO)

Free Standing Emergency Rooms, Micro Hospitals

www.rcmxpertz.com

Books for HCPCS & CPT Codes 2023

E-mail Newsletter

  • Facebook
  • GitHub
  • Instagram
  • Pinterest
  • Twitter
  • YouTube

Medical Jobs & Projects

  • Integrated Medical Services (IMS)

    Certified Medical Coder

    • Phoenix, AZ
    • Integrated Medical Services (IMS)
    • Full Time
  • Yeo & Yeo

    Medical Biller

    • Saginaw, Michigan
    • Yeo & Yeo
    • Full Time
  • UnitedHealth Group

    (OP) Medical Coder

    • HARTFORD, CONNECTICUT
    • UnitedHealth Group
    • Full Time
  • Aston Carter

    Medical Biller

    • Atlanta - Fulton County - GA Georgia - USA
    • Aston Carter
    • Full Time
  • Yeo & Yeo Affiliated Medical Billing

    Medical Biller

    • Saginaw, Michigan
    • Yeo & Yeo Affiliated Medical Billing
    • Full Time

Footer

Billing Executive – a “Medical Billing and Coding Knowledge Base” for Physicians, Office staff, Medical Billers and Coders, including resources pertaining to HCPCS Codes, CPT Codes, ICD-10 billing codes, Modifiers, POS Codes, Revenue Codes, Billing Errors, Denials and Rejections. Learn more about us!

Quick Links

  • Expert Advice for Medical Billing & Coding
  • Medical Billing and Coding Courses
  • List a Medical Billing Job or a Project
  • Medical Billing and Coding Jobs
  • Contact Us

Subscribe via Email

  • Privacy Policy

Proudly created by AJ Graphics

DISCLAIMER: Billing Executive does not claim ownership of all the informational content published or shared on this website, including any content shared by third parties. The content published or shared on this website, including any content shared by third parties is for informational/educational purposes.