White Paper: Outpatient vs. Inpatient Knowledge and Credentials
September 17th, 2008
Providers benefit from using coders with the skills and credentials that best address the type of services they report. The CCS and CCS-P credentials from the American Health Information Management Associate (AHIMA) focus primarily on inpatient coding, while the CPC® and CPC-H® credentials, awarded by the American Academy of Professional Coders (AAPC), stress a mastery of outpatient coding.1
All healthcare providers rely on medical coders to translate medical records into billable claims. Accurate coding ensures that providers capture every legitimate reimbursement opportunity, while improving data collection and reducing compliance burdens. Providers have likewise learned that careless, uninformed coding has serious compliance and reimbursement consequences.
In 2002, 3M Health Information Systems Consulting Services studied 1 million pre-scrubbed Outpatient Prospective Payment System (OPPS) claims collected from 80 hospitals. The analysis uncovered errors in as many as one-third of all claims. A full 80 percent of hospitals 3M reviewed had significant incidence of compliance or cash-flow problems.” The largest majority of problem claims — 56 percent — were the result of coding errors.2 Recent Recovery Audit Contractor (RAC) hospital audits indicate similar results.
Faulty coding is also responsible for a significant portion of the billions of dollars that Medicare recovers against improperly filed health care claims each year, including $2.2 billion in 2006.3 Worse still, a pattern of careless or inappropriate coding can lead to accusations of fraud and abuse, along with possible civil and criminal penalties.
The 3M analysis called revenue losses due to improper claims reporting “staggering,” and identified several key areas in which hospitals must improve performance, including “repeated problems with incorrect or missing codes,” “struggling to keep pace with the speed of change” and a lack of staff “with the necessary constellation of skills” to code and handle claims correctly.
Knowledgeable, certified coding professionals can help solve these problems. A skilled coder will identify all billable services in the medical record, and assign the appropriate codes to describe and support payment for each of those services. Through continuing education and a commitment to professionalism, the certified coder stays abreast of changing guidelines and regulatory requirements.
Although all certified coders demonstrate a higher level of expertise than their uncertified peers, the various credentialing programs are not interchangeable.
AHIMA, which awards the Registered Health Information Administrator (RHIA) and Registered Health Information Technician (RHIT) credentials familiar to many hospital administrators, also certifies the majority of inpatient coders. To become a Certified Coding Specialist (CCS) or Certified Coding Specialist-Physician (CCS-P), the applicant must pass a rigorous examination and complete continuing professional education each year. Over 35,000 coders currently hold a CCS designation.
The CCS and CCS-P, which appropriately focus on developing the ICD-9-CM coding skills essential to inpatient services, are the most respected inpatient coding credentials in the U.S. Yet, for those hospitals that require coders with a thorough understanding of outpatient procedure coding, the familiar and esteemed CCS or CCS-P credentials are not necessarily the optimum choice.
A strong grasp of CPT® coding principles is essential for coding outpatient services successfully, yet neither the CCS nor the CCS-P emphasizes mastery of procedural (CPT®) coding.4 The CCS exam includes CPT® coding on only 10 percent of its questions, for instance. The CCS-P exam includes CPT® coding on less than 30 percent of its questions.5
Many hospitals already provide more outpatient than inpatient services. With continued advancements in medical technology, and with continued pressure from government, insurers and patients for cost savings, outpatient services will likely make up even a greater part of hospital claims in the years to come.
Outpatient coding demands a level of accuracy and specialized knowledge uncommon among inpatient coders. The 3M analysis, for instance, warned repeatedly that the rate of regulatory changes for outpatient billing — including quarterly national Correct Coding Initiative updates, frequent Medicare program memoranda and yearly revisions to the CPT®, ICD-9-CM and HCPCS Level II coding manuals — represents a special challenge for hospitals. In addition, inpatient coders work almost exclusively with ICD-9-CM codes, whereas hospitals must claim outpatient services using CPT® codes.
AAPC coders are the outpatient coding specialists. All AAPC-credentialed Certified Professional Coders (CPC®) and Certified Professional Coders-Hospital (CPC-H®) must undergo a thorough examination to verify their medical and coding knowledge. More than 60 percent of the CPC® and CPC-H® certification exam questions measure the coder’s knowledge of outpatient CPT® coding. The remainder of the exam covers HCPCS Level II, diagnosis and practice management issues, with less focus on ICD-9-CM coding issues than the CCS and CCS-P exams.
AAPC members commit themselves to continued learning, and must earn 18 continuing education units (CEUs) per year to maintain a CPC® credential. There are 53,000 CPCs® in the U.S. today.
The AAPC wants facility administrators and human resource personnel to understand the difference between professional coding credentials. For improved compliance and a better bottom line, here’s the plain truth: If you need a professionally certified coder for inpatient services, a CCS credential is ideal.
The AAPC respects AHIMA and what it has done for inpatient administration, information technology and coding. If you need a certified coder for outpatient services, however, a CPC® credential demonstrates the highest level of outpatient coding expertise.
Certified Medical Coding PDF version.