General Surgery Coding Alert

Question: The surgeon saw a patient as a follow-up for a workers' compensation claim (burn injury). He identified a malignant mass on the skin, unrelated to the workers' comp case. If the majority of the visit relates to the workers' compensation claim, should we bill the whole visit to the workers' compensation carrier? Or should we bill the patient's private carrier?

Alabama Subscriber

Answer: Don't submit two claims for the same visit. If the visit primarily concerned the workers' compensation claim, report the appropriate work-related evaluation code (99455-99456) along with the condition that represents the patient's original illness.

"[A] physician/supplier is permitted under [workers' compensation] law to charge an individual or the individual's insurer for services which are not work-related," states the Medicare Carriers Manual, section 2370.2D. Therefore, in the scenario above, the physician could report both the workers' comp service (99455-99456) and the E/M service concerning the mass (99211-99215).

The physician should submit a separate bill for the E/M service. To ensure payment, make sure you fill in the appropriate check box in block 10 of the CMS-1500 form that indicates that the surgeon performed a nonwork-related service.