Wiki CRG & coding guidelines

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kumeena

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Hi Everyone,

1) I think hospital Outpatient clinics get reimbursement (CRG methodology)

2) Primary clinic Providers document the diagnosis without any work up and refer the patient to specialty clincs. (Ex: Premature ejaculation, chronic hematuria etc.,) Is is OK to code for hospital billing?

3) I was told by consutant it is OK to code. But the doctors disagree . As per physcians they are not treating the condtion they do not want to code/bill including CAD & DM manifestations

Thank you
 
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Mabe it is one of those days for me but I truly am not understanding your question. What is CRG methodology? I have worked op for years and I have not ever heard this expression.
For #2 are you asking if the facility can code something other than the dx for the reason for the referral?
#3 are you asking if it ok to bill just the complication and not the diabetes?
Like I said mabe it is just me and for that I apologize!
 
mitchellde said:
Mabe it is one of those days for me but I truly am not understanding your question. What is CRG methodology? I have worked op for years and I have not ever heard this expression.
For #2 are you asking if the facility can code something other than the dx for the reason for the referral?
#3 are you asking if it ok to bill just the complication and not the diabetes?
Like I said mabe it is just me and for that I apologize!
Click to expand...

Hi Debra,

Sorry. My writing is no good.

1) CRG (Clinical risk group) methodology is a type of reimbursment to hospital by the insurance. You can find more info., thru internet.

2) No. I would like to code for the condition. But the provider disagree.

3) As a primary physician he/she knows patient's condtion (DM retinopathy) and documented in the chart. But bill only Diabetes not for the manifestation. Leave out the manifestation for specialty .

Thank you once again for your time Debra.
 
Hospital outpatient is paid based on APC which is determined by the CPT code. The CRG is used mainly for capitation programs which is why I have not been familiar with it. The OPPS is based on the APC system for payment since August of 2000.
If the provider documents a dx then we code it, unless it is stated as possible probably suspected or rule out.
If the provider documents the patient has say diabetic retinopathy then then you must code the condition as specified by the coding guidelines which is code the diabetes with the 4th character for the complication and code also the complication.
 
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