Wiki diagnosis ranking for physician reimbursement

[bungalowgirl]

does anyone know if medicare (or any of the large payers) reimburses physicians MORE for billing certain diagnoses over others (ie: type 1 diabetes complications vs type 2 diabetic complications)? Or do other financial incentives exist for billing one type vs the other?

 

[Pam Warren]

Fee-for service billing is reimbursed based on RVUs. So the CPT code drives the reimbursement in those cases. Diagnosis codes that don't meet medical necessity based on LCDs or NCDs, will be denied, and of course that impacts your reimbursement.

Diagnosis codes impact reimbursement on the facility side, through the calculation of the DRG. The sicker the patient, the more the hosptial gets paid (generally).

I'm unaware of any reimbursement model from a FFS perspective that changes based on diagnosis.

For pay-for-performance models, the diagnosis coding will be critical as our providers attempt to show care plan improvement for certain chronic conditions--that's on the horizon!

 

[bungalowgirl]

thanks Pam!