Physician claims are paid based on the fee schedule associated with the CPT® or HCPCS code that is submitted. Diagnosis coding can be a reason for a denial.
Physicians use CPT® or HCPCS codes to tell the payer what was done (colonoscopy, office visit) and modifiers to describe special circumstances (assistant at surgery, bilateral procedure.) We use diagnosis codes to tell the payer:
- The reason the service was performed,
- And, to establish the medical necessity for the service.
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The CodingIntel Guide to Hierarchical Condition Categories provides a comprehensive list of HCC and Risk Adjusted Diagnosis Coding resources available on CodingIntel.