Tutorial - How to Code a Hospital Inpatient Record.docx -...

TUTORIAL: How to Code a Hospital Inpatient Record
Welcome!
Assigning ICD-10-CM and ICD-10-PCS codes to diagnoses and procedures for inpatient records can be
somewhat intimidating to students at first. No fear! I am going to walk you through this entire process, page-by-
page, so you learn how to assign codes to diagnosis and procedures.
You will also see where the codes are entered on a UB-04 claim, which is submitted to third-party payers for
processing, resulting in reimbursement being provided to the hospital (for inpatient stays).
NOTE: Chapter 19 of your 3-2-1 Code It! textbook contains content about the purpose of the UB-04, which
you can review. You will also use the Understanding Health Insurance textbook in a future course where you
will learn how to complete the UB-04 claim.
At the end of this tutorial, you will be able to view results of entering ICD-10-CM and ICD-10-PCS codes in a
diagnosis-related group (DRG) grouper, which determines reimbursement provided to the hospital (for inpatient
hospital stays). When assigning codes and DRG groups to inpatient records, use the 3M Coding and
Reimbursement product (or a similar product provided by your school).
All claims submitted for inpatient admissions to hospitals are required to report the present on admission
(POA) indicator , which is assigned by the coder to principal and secondary diagnoses codes and external cause
of injury codes reported on the UB-04 claim, which is also called the 837 institutional electronic claim.
o The coder reviews the inpatient record to determine whether a condition was present on admission or
not.
o Issues related to inconsistent, missing, conflicting, or unclear documentation are resolved by the
provider as a result of the physical query process.
In this context, present on admission is defined as “present at the time the order for inpatient admission occurs.”
Thus, conditions that develop during an outpatient encounter, including emergency department, observation, or
outpatient surgery are considered as present on admission upon admission of the patient as a hospital inpatient.
CMS reporting options and definitions include the following:
o Y = Yes (diagnosis was present at the time of inpatient admission)
o N = No (diagnosis was not present at the time of inpatient admission)
o U = Unknown (documentation is insufficient to determine if the condition was present at the
time of inpatient admission)
o W = Clinically undetermined (provider is unable to clinically determine whether the condition
was present at the time of inpatient admission)
o Blank = Unreported/not used (exempt from POA reporting) (the field is left blank for factors that
do not represent a current disease or for a condition that is always present on admission)
NOTE: Before entering ICD-10-CM and ICD-10-PCS codes in the Submission assignment for each inpatient
case (IPCase), be sure that you have also determined the diagnosis-related group (DRG) number. An example of
a DRG display is included at the end of this tutorial, and each element of DRG results is explained.