Introduction | Diabetes coding in HCC
In fee-for-service medicine:
Diagnosis coding establishes the medical necessity for a service. At times, it may be the reason for a denial, particularly for diagnostic tests or procedures. Services with national or local coverage policies often have specific diagnosis codes that are required for payment.
In risk based contracts or Accountable Care Organizations (ACOs):
Payers assess the acuity of a panel of patients, and use that acuity along with age/gender distribution, cost, quality and outcomes, to provide incentive payments or decrease payments at the end of a contract year.
What should physicians and other practitioners do?
Follow ICD-10 rules. The General Guidelines for outpatient visits say, “Code all documented conditions which exist at the time of the visit that require or affect patient care or treatment.” If the patient’s underlying medical problems that require or affect treatment, document them in the assessment/plan and use those codes on the claim form.