Medical Coding Service

Healthcare Effectiveness Data and Information Set (HEDIS)


What is inpatient?

An inpatient is an individual who has been officially admitted to the hospital under a physician’s order. The patient will remain classified as an inpatient until one day before discharge. 


Staying in the hospital overnight does not necessarily mean that the patient is considered an inpatient.

What Is Clinical Documentation Improvement (CDI)

Inpatient Medical Coding

Inpatient coding is related to the patient’s extended stay service.  Examples of Inpatient facilities include acute and long-term care hospitals, skilled nursing facilities, hospices, and home health services.

Here’s why this matters:

During the stay, the patient may have a variety of tests run, will have changes in diagnosis and treatments. A lengthy stay usually results in extensive and intricate patient records which makes it important to have an experienced medical inpatient coder doing the job.

It also uses ICD-10-CM diagnostic codes for billing and appropriate reimbursement but uses ICD-10-PCS as the procedural coding system. The Inpatient Prospective Payment System (IPPS) is the reimbursement methodology used by Medicare to provide reimbursement for hospital inpatient services.

What codes are used for outpatient coding?


Outpatient Medical Coding 

With the increased development in the medical field, many services that used to be considered inpatient treatments are being assigned to outpatient services.

The outpatient coding is based on the ICD-10-CM diagnostic codes for billing and appropriate reimbursement but uses a CPT or HCPCS coding system to report procedures. Documentation plays a crucial role in the CPT and HCPCS codes for services.

Outpatient Reimbursement is based on Ambulatory Payment Classifications (APCs). Hence, for outpatient coding credentials, our medical coders have an AHIMA certification as a Certified Coding Specialist – Physician-based (CCS-P) and AAPC certifications as, Certified Professional Coder- CPC, Certified Anesthesia Professional Coder- CANPC, etc.

Home Health Care Coding Habits That Can Hurt Your Agency

Home Health Coding

Home health coding is the branch of coding which facilitates home health agencies to get the coding done for the patients admitted for improvement of their medical condition.

How to Improve Revenue Cycle Management ?

Clinical Documentation Review

We have experienced home health professionals and certified coding specialists. To ensure high accuracy and consistency, our specialized coding team reviews clinical documentations thoroughly. 

A wide range of potential issues may occur for a home health service agency, if the clinical documentation provided by them is not able to clearly convey an accurate patient specific care plan. Improper care coordination, poor quality of referral sources, issues with the safety of patient, increased takebacks, reduced reimbursement and increased risk of audits, are some of the common issues that occur due to incorrect clinical documentation.

Oasis Review

Our team of experts reviews the Oasis M items extensively to make sure all the patient conditions are correctly captured. We also provide recommendations and suggestions in coding depending on the Oasis review.

Home Health Coding Types and Levels

There are multiple types of home health care, such as; Start of Care (SOC), Re-certification (REC), Resumption of Care (ROC), Significant Change in Condition (SCIC), Discharge (D/C) and Hospice. For each of these types we perform multiple levels of coding adhering to CMS guidelines as well as the Patient Driven Groupings Model (PDGM) rules, which helps to improve the Star ratings for home health agencies. Different coding levels are as follows:

  • Level 1- Coding Only
  • Level 2- Coding & OASIS Review
  • Level 2.5- Coding & Comprehensive OASIS Review
  • Level 3- Coding, Comprehensive OASIS Review & Plan of Care (POC)
  • Level 3.5- Coding, Comprehensive OASIS Review, POC & Pre-Billing QA


HEDIS stands for Healthcare Effectiveness Data and Information Set. Employers and individuals use HEDIS to measure the quality of health plans. HEDIS measures how well health plans give service and care to their members.

HEDIS Measures

CMS contracted with NCQA to develop a strategy to evaluate the quality of care provided by Special Needs Plans (SNPs).  NCQA established Healthcare Effectiveness Data and Information Set (HEDIS) measures specifically for SNPs.  HEDIS is a comprehensive set of standardized performance measures designed to provide purchasers and consumers with the information they need for reliable comparison of health plan performance.  HEDIS Measures relate to many significant public health issues, such as cancer, heart disease, smoking, asthma, and diabetes.  SNPs can use HEDIS performance data to identify opportunities for improvement, monitor the success of quality improvement initiatives, track improvement, and provide a set of measurement standards that allow comparison with other plans.  Data allow identification of performance gaps and establishment of realistic targets for improvement.

2022 Quality Rating System Measure Technical Specifications

HEDIS measures in 2022:

  • Childhood Immunization Status (CIS)
  • Immunizations for Adolescents (IMA)
  • Weight Assessment and Counselling for Nutrition and Physical Activity for Children/ Adolescents (WCC)
  • Cervical Cancer Screening (CCS)
  • Prenatal and Postpartum Care (PPC)
  • Controlling High Blood Pressure (CBP)
  • Blood Pressure Control for Patients with Diabetes (BPD)
  • Hemoglobin A1C Control for Patients with Diabetes (HBD)
  • Eye Exam for Patients with Diabetes (EED)
  • Care for Older Adults (COA)
  • Colorectal Cancer Screening (COL)
  • Transitions of Care (TRC)


HEDIS’ digital future has begun. New digital measures reduce the burden of reporting quality results. Other changes assure that HEDIS will be useful, valid and reliable for a new era of medicine.