DIAGNOSIS codes explain except: What the insurance carrier should pay for it all

DIAGNOSIS codes explain except: What the insurance carrier should pay for it all

• A. The insurance carrier payment amount
• B. The severity of the illness
• C. The prognosis
• D. The affected body system

Answer: (A)

Diagnosis codes describe the patient’s condition and where it affects the body, and they can convey information about how severe the illness is. They also help form the clinical picture that informs prognosis, and they support medical necessity for the services billed. What the insurer will pay for a service, however, is not determined by the diagnosis code itself. Payment amount is mainly driven by the CPT/HCPCS procedure codes, modifiers, and the payer’s reimbursement rules and contracts. That’s why the statement about what the insurance carrier should pay for it all is the one that diagnosis codes do not explain.

Diagnosis codes describe the patient’s condition and where it affects the body, and they can convey information about how severe the illness is. They also help form the clinical picture that informs prognosis, and they support medical necessity for the services billed. What the insurer will pay for a service, however, is not determined by the diagnosis code itself. Payment amount is mainly driven by the CPT/HCPCS procedure codes, modifiers, and the payer’s reimbursement rules and contracts. That’s why the statement about what the insurance carrier should pay for it all is the one that diagnosis codes do not explain.