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The basis
for payment for most service providers is what was done and not
why the patient needed the care. Generally the diagnosis does
not contribute to the payment calculation beyond this general
test of appropriateness. Thus occasionally diagnoses are not accurate,
but they have to fit the bill well enough for routine audit. Diagnoses
may well be more problematic when a patient has many co-morbidities
because, in such cases, several diagnoses could justify the claim.
The major
exception to the pattern of paying for services (with diagnoses
as a check on appropriateness) is hospitals, where payment is
based on Diagnostic Related Group (DRG). DRGs group together patients
with similar diagnoses and health care needs. DRGs take into account
diagnosis, procedures, and whether a patient received medical
or surgical services. Often, the same patient can have their condition
coded several different ways, all of which are correct. Click
here for a case study illustrating this situation.
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