Inpatient Hospital Coding Services
MedCodex delivers accurate inpatient hospital coding with a focus on principal diagnosis selection, DRG assignment, CC/MCC capture, and Present on Admission (POA) reporting. Our inpatient coders are trained to optimize reimbursement under the Medicare Severity Diagnosis Related Group (MS-DRG) system while maintaining strict compliance.
Core Competencies
- Principal and secondary diagnosis coding (ICD-10-CM)
- Procedure coding (ICD-10-PCS)
- MS-DRG and APR-DRG assignment
- CC/MCC identification and capture
- Present on Admission (POA) indicator assignment
- Discharge disposition and patient status coding
Our Inpatient Coding Process
Our certified inpatient coders perform a thorough review of the entire medical record — including H&P, progress notes, operative reports, lab results, and discharge summary — before assigning codes.
- Complete Chart Review: All documentation reviewed holistically.
- Code Assignment: ICD-10-CM/PCS codes with correct sequencing.
- DRG Optimization: Ensure all CCs and MCCs are captured.
- Compliance Check: Codes validated against MCC, CC lists, and grouper logic.
- QA & Feedback: Detailed coder feedback and educational reports.
DRG Optimization
Missed CCs and MCCs represent significant revenue leakage for hospitals. Our coders are specifically trained to identify all secondary diagnoses that qualify as complications or comorbidities, maximizing appropriate DRG weight and reimbursement without compromising compliance.
Compliance Assurance
We follow Official Coding Guidelines, Uniform Hospital Discharge Data Set (UHDDS) definitions, and CMS IPPS rules. Our multi-level QA process catches coding errors before claims are submitted, reducing your risk of audits and takebacks.
Why Choose MedCodex for Inpatient Coding?
Frequently Asked Questions
How does MedCodex handle CC/MCC capture and POA reporting specifically for inpatient cases?
Our coders review clinical documentation thoroughly to identify all supporting diagnoses that qualify as CCs or MCCs, and validate POA indicators against admission notes and H&P documentation before finalizing the DRG assignment. This process is performed by AAPC- or AHIMA-certified coders holding CPC or CCS credentials with dedicated inpatient coding experience. A multi-level QA review then checks every chart for DRG accuracy before the coded record is returned to your team.
What turnaround time can we expect for inpatient charts, and how is that maintained under high census volumes?
Standard turnaround for inpatient charts is 24 to 48 hours from the time a chart is made available in your system. We scale coder capacity to match your census volume, and your dedicated account manager monitors queue status daily to flag any risk of delay before it affects your billing cycle. For facilities with seasonal spikes or backlog, we can adjust staffing within the engagement without renegotiating the contract.
How does MedCodex access our EHR and billing systems, and what safeguards protect PHI?
Our coders work directly inside your existing EHR or billing platform using secure remote access, so no PHI is downloaded or transferred to external systems. MedCodex executes a signed Business Associate Agreement before any work begins, and all access is governed by role-based permissions, encrypted connections, and audit logging to meet HIPAA requirements. Your IT team retains full control over access provisioning and can revoke credentials at any time.
Can we run a pilot before committing to a full inpatient coding engagement, and what does that involve?
Yes, MedCodex offers a free pilot at no cost and with no commitment, during which we code a representative sample of your inpatient charts so you can evaluate DRG accuracy, CC/MCC capture rates, and turnaround against your current benchmarks. The pilot is structured to reflect your actual payer mix and case complexity, not a curated selection, so the results are directly comparable to your live performance. There is no obligation to continue after the pilot concludes.
How is inpatient coding priced, and does the model change if we need ongoing FTE-equivalent support versus occasional overflow?
MedCodex offers both per-chart and FTE-equivalent pricing models, allowing you to choose based on whether your need is ongoing volume support or periodic overflow during census peaks or staff absences. Per-chart pricing works well for variable volumes where you want cost to track directly with output, while FTE-model engagements suit facilities that need consistent daily coverage aligned to a predictable budget. Your account manager can walk through both options during the pilot review so you can select the structure that fits your revenue cycle workflow.