Do ICD-9 (Diagnosis codes) play a role in APC payments?
No, ICD-9 codes do not determine ED facility reimbursement and since 2007 they are no longer required for observation coding. ICD-9 codes do establish medical necessity for the level of services or procedures billed and Medicare’s edit system thus looks for certain ICD-9 codes for some services. These ICD-9s can be identified by looking up CMS’s local and national coverage decision (LCDs and NCDs) documents for each procedure. See the Observation FAQ for additional information on any 2010 OPPS changes for Observation services.
