Outpatients Coding
Outpatient Coding:
Outpatient coding, it involves assigning codes to medical procedures, diagnoses, and services provided to patients who receive care on an outpatient basis. Outpatient care refers to healthcare services that do not require an overnight stay in a healthcare facility.
The most significant difference between inpatient coding and outpatient coding is the setting in which the services are provided.
We have below commonly identified POS:
11: Office visit
19: Off campus outpatient
22: On campus outpatient
The E/M section is organized into broad categories:
Office visits
New patient
Established patient.
Consultations
Outpatient consultation: - 99242 to 99245
Office Visit
The following codes are used to report evaluation and management services provided in the office or in an outpatient or other ambulatory facility. A patient is considered an outpatient until inpatient admission to a health care facility occurs.
Determine the patient status as New or established: -
New Patient: A new patient is one who has not received any professional services from the physician or other qualified health care professional or another physician or other qualified health care professional of the exact same specialty and subspecialty who belongs to the same group practice, within the past three years.
Established Patient: An established patient is one who has received professional services from the physician or other qualified health care professional or another physician or other qualified health care professional of the exact same specialty and subspecialty who belongs to the same group practice, within the past three years.
New Patient note example:
Established Patient note:
Patient: Mr. Z
Age: 55
Presenting Complaint: Poorly controlled diabetes
History of Present Illness (HPI):
55 years of Mr. Z return to the office and has a history of type 2 diabetes mellitus. Despite medication, his blood glucose levels have been consistently high.
Review of Systems (ROS):
- Endocrine: As per HPI.
- Cardiovascular: No chest pain or palpitations.
- Gastrointestinal: No nausea, vomiting, or abdominal pain.
Past Medical History (PMH):
- Type 2 Diabetes Mellitus
- Hypertension
Physical Examination:
- General: Alert, oriented, in no apparent distress.
- Cardiovascular: Regular rate and rhythm. No murmurs.
Assessment:
The patient's diabetes is poorly controlled.
Plan:
- Adjust medication regimen (add Glipizide 5mg daily to current Metformin therapy)
- Recommend meeting with a dietitian
- Follow-up appointment in one week to assess response to treatment.
Office notes for established patient
Established Patient: An established patient is one who has received professional services from the physician or other qualified health care professional or another physician or other qualified health care professional of the exact same specialty and subspecialty who belongs to the same group practice, within the past three years.
In this type of encounter, the patient returns to his PCP or his doctor within 3 years, here it only requires to document the pertinent History and Exam. Level is decide based on the MDM alone.