The learner will: Explain the key differences between inpatient and outpatient billing processes, including workflows and claim submission requirements. Identify essential documentation elements required for compliant inpatient and outpatient billing. Evaluate coding and billing variations based on care type, payer rules, and regulatory requirements. Analyze reimbursement patterns and payment structures across inpatient and outpatient settings to determine financial impact. Apply appropriate billing rules, claim formats, and payer-specific policies to ensure accuracy and compliance. Create visual workflow maps demonstrating the complete billing process for inpatient and outpatient encounters.

Before beginning this unit, learners should have: Working knowledge of charge capture, coding, and claims management. Familiarity with payer reimbursement systems and claim submission formats. Completion of Unit 3.5: Revenue Code and DRG/APC Assignments or equivalent healthcare billing experience.

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This unit is ideal for professionals aiming to enhance their understanding of billing processes and reimbursement methodologies across different care settings. It benefits: Billing and Coding Specialists – who manage claims for both inpatient and outpatient services. Revenue Cycle Analysts and Coordinators – seeking to optimize financial performance through accurate billing workflows. Compliance and Audit Officers – ensuring claims meet CMS and payer documentation requirements. Healthcare Administrators and Finance Managers – responsible for managing reimbursement operations across departments. Students and Entry-Level Healthcare Professionals – preparing for roles in billing, claims processing, or hospital finance.