On reimbursement: Nurse practitioners have at least 4 reasons for attending to ICD-9 (diagnosis) codes, when billing physician services:
- A claim submitted without an ICD-9 code (along with a procedure code) will be denied.
- Claims submitted with incompatible diagnosis and procedure codes will be denied.
- If a diagnosis has 5 digits in the ICD-9 system, and only 3 are supplied on HCFA 1500 form, Medicare will deny the claim.
- In managed care, rates are determined using calculations provide higher fees for complicated diagnoses. This is in contrast to fee-for-service, where the procedure code, rather than the diagnosis code, determines the fee.Therefore, a clinician who does not use appropriate diagnosis codes to give a complete picture of a patient may find that capitated payments do not accurately reflect the work involved in caring for a patient. Get familiar with the ICD-9 manual.
This tip is excerpted from The Green Sheet, a monthly newsletter on compensation and reimbursement for NPs, published by the Law Office of Carolyn Buppert.
For a 12-month subscription, send a check for $30 to The Green Sheet, Law Office of Carolyn Buppert, 1419 Forest Drive, Suite 205, Annapolis, MD 21403. A companion newsletter, The Gold Sheet, offers the latest information on quality issues.
Updated March 18, 2001
Copyright 1994-2003 NP Central