How Medical Coders Can Accurately Support Inpatient Diagnosis

Accurate inpatient coding is the key that ensures healthcare providers get the appropriate reimbursement along with maintaining the compliances with federal regulations. Medical Coders play a pivotal role in translating complex inpatient diagnoses into standardized codes and streamlining the entire processes. Shoreline Medical Billing Company specializes in delivering precise inpatient coding services, helping physicians focus on patient care while maintaining financial efficiency. This article explores how medical coders can support accurate inpatient diagnoses and why Shoreline Medical Billing is the ideal partner.

Key Considerations for Inpatient Coding

Accurately Identifying the Principal Diagnosis

The first step of inpatient coding begins with the accurate identification of the principal diagnosis, as it directly influences reimbursement, along with taking care of the compliances as per ICD-10 guidelines. The principal diagnosis is defined by the ICD-10-CM Official Guidelines for Coding and Reporting as “the condition established after study to be chiefly responsible for occasioning the admission of the patient to the hospital for care.”This can be done by reviewing the discharge summary, admission notes, and clinical findings.

What is MDC and MS-DRG?

MDC (Major Diagnostic Category) is broad classification of principal diagnoses into 25 major categories each covering a specific organ system or etiology. Few examples are

MDC Code	Category: Diseases & Disorders	Primary Diagnoses
01	The Nervous System	Cerebrovascular diseases (e.g., stroke), Seizures and epilepsy, Degenerative disorders (e.g., Parkinson’s disease, multiple sclerosis) Meningitis, Encephalitis, Traumatic brain injury, brain tumors.
05	The Circulatory System	Acute Myocardial, Heart Failure, Hypertensive Heart Disease, Cardiomyopathy, Peripheral Vascular Disorders, Pericarditis, Chronic Ischemic Heart Disease, Cardiac Arrest, Deep Vein Thrombosis.
08	Musculoskeletal System and Connective Tissue	Osteoarthritis, Hip fracture, Spinal stenosis, Rheumatoid arthritis, Osteomyelitis, Degenerative disc disease.
11	Kidney and Urinary Tract	Acute kidney failure, chronic kidney disease (CKD), Urinary tract infection (UTI), Kidney stones (renal calculi), Hydronephrosis, Bladder cancer.
14	Pregnancy, Childbirth & the Puerperium	Normal delivery, Pre-eclampsia, Eclampsia, Preterm labor, Postpartum hemorrhage, Cesarean section complications
19	Mental Diseases and Disorders	Major depressive disorder, Schizophrenia, Bipolar disorder, Generalized anxiety disorder, Alcohol dependence, Dementia
21	Injuries, Poisonings, and Toxic Effects	Traumatic brain injury, Rib fracture, Drug overdose, Poisoning by prescription medication, Open wound of the head, Accidental fall with injury

MS-DRG (Medicare Severity Diagnosis-Related Group) is a refined system of classification of inpatient hospital stays into specific groups based on diagnoses, procedures, and patient characteristics for reimbursement under the IPPS.

They account for the severity of illness (SOI) and risk of mortality (ROM) by incorporating complications and comorbidities. Most MS-DRGs are split into three tiers based on severity:

▪ With MCC: Major complications/comorbidities (highest severity, highest payment).

▪ With CC: Complications/comorbidities (moderate severity, moderate payment).

▪ Non-CC/MCC: No complications/comorbidities (lowest severity, lowest payment).

Comprehensive Coding of Secondary Diagnoses

We at Shoreline Medical billing use advanced software to identify and code relevant secondary diagnoses, optimizing MS-DRG assignments.

Assigning the Procedure Codes

• We use ICD-10-PCS for coding Inpatient procedures, such as surgeries or interventions, which impacts whether an MS-DRG is classified as surgical or medical.
• Go through the operative reports and procedure notes to get details about the root operation (e.g., resection, fusion), body part operated, approach used (e.g., open, percutaneous), and devices used.
• Care should be taken to see that codes cover the full scope of the procedure to avoid unbundling (coding components separately when a single code applies).
• Verify if procedures qualify as major operating room procedures, as these will shift the MS-DRG to a surgical category with higher reimbursement.

Looking for the Present on Admission (POA) Indicators

POA indicators specify whether a diagnosis was present at the time of admission, affecting reimbursement and quality metrics, especially for Hospital Acquired Conditions (HACs).

Assign POA indicators for each diagnosis:

Code	Meaning
Y	Yes (present on admission)
N	No (hospital-acquired)
U	Unknown (insufficient documentation)
W	Clinically undetermined
1	Exempt from POA reporting

Review admission notes to confirm POA status, as HACs (e.g., pressure ulcers ) not present on admission may reduce payment.

Adhering to ICD-10 Guidelines and Compliance

To get in Compliance with ICD-10 guidelines , and National Correct Coding Initiative (NCCI) edits we must look into the following aspects.

• Check for ICD-10-CM and ICD-10-PCS guidelines for specificity, sequencing, and code selection.
• Improper code combinations must be avoided.
• Ensure that all medical necessities are documented correctly and are aligning with the Medicare, Medicaid, or other private payer requirements.
• Protecting patient data under HIPAA during coding and billing.

We at Shoreline Medical Biling Company is fully HIPAA compliant, implementing robust safeguards to protect PHI and ePHI during inpatient coding and billing processes. Through, quarterly staff training, encryption, role-based access controls, regular audits, and adherence to billing standards like HIPAA 5010 and ICD-10 guidelines, we ensures compliance with HIPAA’s Privacy, Security, and Breach Notification Rules. Beyond HIPAA, we also aligns with CMS, OIG, NCCI, and FCA standards to prevent fraud and optimize reimbursement.

Ensuring Coding Matches Clinical Documentation

We at Shoreline Medical Billing Company implements CDI into their workflow, working with providers to improve documentation and coding accuracy.

Assingning the Correct MS-DRG

Looking for Payer-Specific Requirements

At Shoreline Medical Billing Company, we help healthcare providers by providing skilled inpatient coding services, with trained coders, CDI integration, and advanced technology and make sure to abide by accuracy and compliance.