Way back when, when I was working in California for Sutter Health,
the EHR design and usage was one of the priorities the organization
was working on. I initially thought putting everyone’s most intimate
details – health records – online was a recipe for disaster. Since EHR
is now everywhere, I have certainly had a complete reversal of that
opinion.
From a personal standpoint, I can say that electronic heath records
have been an essential component of my health care. I have several
chronic conditions (i.e., diabetes, thyroid, DVT, etc.) for which I see a
variety of medical providers. Back in the “olden days” when I was in
my 20s and 30s, the EHR was non-existent. One physician could not
see my health records from a different treating specialist I was
seeing. Often, that meant that I needed to be better at
understanding medical conditions to be able to update the variety of
doctors I was seeing. Now, not only can I access my medical records,
schedule appointments, print bloodwork orders for upcoming
appointments and other aspects of my healthcare through the
patient portal, but I can follow up with my primary care physician
telephonically or through Zoom and she has instant access to
uploaded reports from the other specialists I see. Everyone is now
literally “on the same page” as the old catch phrase denotes. In fact,
two days ago this exact scenario was a godsend. I had a recent
problem with a possible DVT in my left calf and needed testing to
see what progress, if any, I had made with a recent treatment plan.
The vein specialist I saw explained things to me, but when I tried to
relay those same explanations to the PCP, I was not as eloquent or
clear about those results. My PCP was able to look up those results
on my EHR and we were able to make a change in treatment plan
accordingly. It saved me an hour of round-trip travel out of my day,
afforded the physician’s office to handle the meeting by phone, and
further follow COVID protocols by not having me put at risk by other
patients in the office setting.
EHR has become mainstream and for good reasons. It allows for
more accurate and timely reporting (and easy reading – no bad
handwritten notes to have to decipher.) Having a standardized and
uniform way of reporting medical procedures and health records also
allows for a more efficient and accurate way of keeping medical
records. The ability for a group of physicians to access the patients
complete medical records also allows a safety feature, in that
providers can easily see what medications have been prescribed for
the patient and helps the providers make sure that contraindicating
medications are not doled out to the patient, possibly putting them in
harm's way physically.
From a processing perspective, having a uniform system to code
medical diagnoses and procedures not only brings an efficiency and
higher accuracy rate, but it also decreases the rejection of medical
claims submissions and increases the capacity for maximum
reimbursement. It also gives a guideline for treatment plans that are
followed nationwide, which in some circumstances can assure a
patient is receiving the best treatment plans in improving their health
problems. This also helps with the scientific community – as we have
seen with the development of COVID and its variants – Public Health
officials and agencies can track the way a disease progresses. Much
like Omicron that we are currently dealing with, the latest news is
that this tracking done my NIH, WHO, and other organizations, has
given us the information that although Omicron is a lot more
contagious than the original COVID virus, it is also peaking faster and
the future outlook of containing this variant is promising. It allows
scientists to get a sense of what patterns the disease is following and
how they can get ahead of the curve by updating vaccines as needed.
Inpatient medical coding uses ICD-10-CM and ICD-10-PCS codes.
These result in insurance coverage, payments, and reimbursements
based on Medicare Severity-Diagnosis Related Groups (MS-DRGs).
“Inpatient” refers to a patient who has been admitted to the hospital
for extended stay treatments or services (generally longer than 24
hours), such as hospice, acute and/or long-term hospital visits, skilled
nursing facilities, and home health services. Inpatient payments and
reimbursements are covered under Part A of Medicare. (Key
Differences Between Inpatient Coding and Outpatient Coding, 2018)
In the alternative, outpatient medical coding requires ICD-10-CM
and CPT®/HCPCS Level II codes to report health services and
supplies. Outpatient status and its subsequent coding is used for
single visit treatments (even if those treatments – such as physical
therapy are ongoing), and the usual rule is that outpatient coding
covers doctor visits or care that are less than 24 hours in duration.
An exception to that would be outpatient surgeries or care that is
equal to or less than 24 hours. Outpatient payments and
reimbursements are covered under Part B of Medicare. (Key
Differences Between Inpatient Coding and Outpatient Coding, 2018)
While researching this topic, I found a neat little chart that shows the
differences between Inpatient and Outpatient coding. I include it
below for your perusal.
(Key Differences Between Inpatient Coding and Outpatient Coding,
2018)
References
Key Differences Between Inpatient Coding and Outpatient Coding.
(2018, June 1). Retrieved from MedConverge:
https://medconverge.com/key-differences-between-inpatient-
coding-and-outpatient-coding/
