Legal Tips
Provided by Carolyn Buppert, MSN, JD, ANP

On reimbursement: Nurse practitioners have at least 4 reasons for attending to ICD-9 (diagnosis) codes, when billing physician services:

  1. A claim submitted without an ICD-9 code (along with a procedure code) will be denied.

  2. Claims submitted with incompatible diagnosis and procedure codes will be denied.

  3. 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.

  4. 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


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