Using standardizing formats related to coding will improve the
efficiency by making sure everyone involved is on the same page. All
information that is standardized through various formats can be read
and understood no matter what system is being used. This will allow
better patient care, better understanding between healthcare team
members, and lead to more accurate coding resulting less errors
which will generate better reimbursement for the healthcare
facilities. Reading chapter eight and ten of our text demonstrates this
by elaborating on RxNorm and LOINC. RxNorm is an online tool that
uses standardized vocabulary relating to pharmaceutical drugs
(Giannangelo, 2019). RxNorm provides a way for various systems
that use different names or versions of drugs to communicate with
each other using similar nomenclature (Giannangelo, 2019). LOINC
(Logical Observation Identifiers, Names, and Codes) standardizes
specific health related identifiers for, "health measurements,
observations, and documents", to be used universally for exchange of
information across electronic health information systems using
structured medical vocabulary (Giannangelo, 2019). LOINC is readily
available online and is free to download. The only requirement is an
appropriate license for use. (Giannangelo, 2019)
The rules for inpatient and outpatient coding are similar with the
exception of three rules. With outpatient coding, the first-listed
diagnosis/condition, or symptoms and signs when there is no
diagnosis is what should be coded instead of the principal diagnosis
that is used in inpatient setting (Jurek & Mosay, 2017). This is
because the principal diagnosis is used "after study" and it could take
multiple visits before a diagnosis is made in the outpatient setting
(Jurek & Mosay, 2017). An inconclusive diagnosis such as a rule out
or suspicion should only be used with inpatient coding and only a
definitive diagnosis or symptoms/signs when there is not a diagnosis
are used with outpatient coding (Jurek & Mosay, 2017). In the
outpatient setting, a coder can apply codes from test results that
have been interpreted by a physician (Jurek & Mosay, 2017).
References
Giannangelo, K. (2019). Healthcare code sets, clinical terminologies, and
Classification Systems. Chicago, IL: AHIMA, American Health
Information Management Association.
Jurek, J., & Mosay, S. (2017). Conquer medical coding 2018 : A critical
thinking approach with coding simulations. F. A. Davis Company.
