General Surgery Coding Alert

WC insurers expect information about the accident or disease's cause

If your surgeon is seeing patients for workers' compensation (WC) claims, you'll want to pay special attention to diagnosis coding. Specifically, coding experts advise that to have your WC claims paid the first time, you should provide information with the claim (using ICD-9 E codes) that describes how, and sometimes where, the injury the surgeon is treating occurred.
 
Payers require E codes: Suppose a patient suffers severe burns while working near the engine of a running bulldozer at his construction job.
 
Your surgeon sees the patient for debridement and skin grafts. You report 943.31 (Burn of upper limb, except wrist and hand; full-thickness skin loss [third degree NOS], forearm) and 948.00 (Burn [any degree] involving less than 10 percent of body surface; less than 10 percent or unspecified) for the burn damage, but the patient's workers' comp insurer denies the charge. Why? Because you forgot to add the appropriate E code to describe how the work-related diagnosis occurred.
 
You should use E codes to describe external causes of injuries or poisonings. E codes range from the common (E880.9, Fall on or from other stairs or steps) to the obscure (E847, Accidents involving cable cars not running on rails) and describe scores of accidents and injuries. In short, says Terry Fletcher, BS, CPC, CCS-P, CCS, CMSCS, CMC, a coding and reimbursement specialist in Laguna Niguel, Calif., E codes often help answer the question "How did it happen?"
 
In the example above, the coder should report 943.31 and 948.00, followed by E919.7 (Accidents caused by machinery; earth moving, scraping and other excavating machines) and E849.3 (Place of occurrence, industrial place and premises).
 
Two E Codes Double Your Specificity

Some workers' compensation insurers require you to report two E codes together - one code to describe how the patient was injured, and (as illustrated in the above example) a second to describe where the accident occurred. You'll find the "place of occurrence" codes in the E849.x series. For instance, if a patient falls off of a ladder while working on a farm, you should report E881.0 (Fall from ladder) and E849.1 (Place of occurrence, farm).
 
Remember: "E codes do not change your reimbursement amount because they are considered 'for informational purposes only' codes," says Laureen Jandroep, OTR, CPC, CCS-P, CPC-H, CCS, director and senior instructor for the CRN Institute, an online coding certification training center.
 
You should never report E codes in lieu of a diagnostic code to describe an injury, but E codes help the carrier understand how the patient was injured. Because workers' compensation insurers' payment decisions hinge on whether the patient hurt himself at work, your E codes can help you collect.
 
"The importance of the E codes is that they confirm that, yes, the patient was hurt at work," Jandroep says.

Check Insurers' Policies Before You Bill

Remember: "Workers' compensation laws differ from state to state, as does the reimbursement fee schedule," says Mary J. Brown, CPC, CMA, coding specialist at OrthoWest PC, a seven-physician practice in Omaha, Neb. Therefore, you should ask the insurer for its guidelines and requirements before you bill.
 
Although Medicare always uses the most up-to-date CPT codes, workers' compensation insurers do not, and their code recommendations may vary widely. Some coders report that their workers' comp payers still require them to report codes that CPT deleted in 2002 (or even earlier in some instances) because the insurers haven't yet updated their systems.
 
Tip: "Make sure that Box 10a on the CMS-1500 is marked as 'YES' to state that 'Patient's condition is related to employment,' " Brown says. "We use the patient's Social Security number for the insured's ID number (Box 1a) and the workers' comp claim number in the group ID box (Box 11). Check with the workers' comp carrier to see which numbers they want where."