ED Coding and Reimbursement Alert

Question: Thank you for your Q&A last month about workers’ compensation coding. I have a follow-up question. When the patient has workers compensation and Medicare, and workers’ comp doesn’t cover the whole visit, can we bill Medicare for the balance?

Codify Subscriber

Answer: Yes you can. The workers’ compensation insurer will always be the primary payer, but “If workers’ compensation insurance denies payment, and you give Medicare proof that the claim was denied, Medicare will pay for Medicare-covered items and services as appropriate,” CMS says in its “Medicare and Other Health Benefits: Who Pays First” document.

For example, suppose a Medicare patient is working at a store part-time as a cashier. He falls while carrying a bag to a patient’s cart and is taken to the ED. The claim is sent to the workers’ compensation insurer, which denies paying for the service. The ED can send Medicare the claim along with a copy of the workers’ comp denial. Medicare will pay the ED physician for the Medicare-covered items and services administered as part of the service, but the patient has to pay for any services non-covered by Medicare.