Wiki Payor Grouper and Code Selections

[DennisW123]

What exactly is the current mindset around payors wanting new codes used when they are still using an old grouper version? Thanks

 

[sls314]

What exactly is the current mindset around payors wanting new codes used when they are still using an old grouper version? Thanks

When I worked in a hospital contracting department, we occasionally saw this happen - contracts would be tied to an old grouper, and the payer would manually map new codes to equivalent groupers.

Of course, that process was rarely quick. Early in the year, we would either hold claims with new codes until the grouper was updated, or track them separately so we could request reprocessing later.

Another possibility is that the payer treats the new codes as ungrouped and reimburses them based on your contract's methodology for ungrouped procedures.