Internal Medicine Coding Alert

Published on Sun Jan 16, 2011 PDF

Gather information before seeing the patient to avoid trouble during billing process.

Just the thought of processing a workers' compensation claim can bring on a headache, thanks to factors such as workers' compensation being authorized with federal guidance, but is a state-run program. Add individual state rules, fee schedules, and processes to the mix -- and the fact that federal and railroad employees have their own WC programs -- and you could be tempted to leave that WC claim for another day.

Solution: Follow our experts' two tips for getting your WC claim rolling, and you won't feel the need to file your own claim for pain and suffering.

1. Capture All Pertinent Claim Info Before the Patient Comes In

Your practice's work on a WC claim should begin before the patient even sets foot into your office. When a patient calls to schedule his first appointment for an injury that could have been on the job, such as a sprained back, the first question your staff should ask is: "Is there a chance that this injury is work-related?"

If the answer is yes, collect as much pertinent information as possible over the phone. Details should include the date of injury, workers' compensation carrier, claim number, employer at the time of injury, adjuster and/or case manager name and phone number, and alternative private insurance information.

Watch out: The patient often won't tell you the reason she needs to see the doctor is related to a WC claim if you don't come right out and ask. So take your cue from the reason for the patient's visit. If it sounds like it could be a work-related injury, go ahead and ask.

Pointer: "We have to be very careful how we ask the questions, because you'll get an answer and it may be a correct answer but it's a correct answer to a different question," cautions Marvel Hammer, RN, CPC, CCS-P, PCS, ASC-PM, CHCO, owner of MJH Consulting in Denver, Co. For example, the front desk staff might ask the patient "What's your insurance?" and the patient will give his normal health insurance information rather than the workers' compensation insurance data.

After getting the information from the patient, you need to get in touch with the WC insurance company to obtain authorization to treat the patient before the initial visit.

"A phone call to the WC carrier is a good idea, before the patient is seen," explains Linda Huckaby, CMA (AAMA), with Carolina Medical Rehabilitation in Greenville, S.C. Ask: "Is this really a WC case? Is our office authorized to see the patient? Is a pre-authorization required for each office visit? Who is the adjuster or case manager?" she adds.

Good practice: "We have the adjuster call, not the patient -- that way we can ask particulars about the claim," says Kristine Newton, CPC, billing coordinator for a physician group in Fla. "Many times the newly injured person has not a clue and cannot answer some of the questions we pose."

2. Focus on the State Where the Claim Originated

Many times a patient will sustain an injury in one state, but seek treatment in another. In these cases, you should follow the rules for the state in which the injury occurred. Focus on where the claim was first filed because that state will have jurisdiction over the claim.

Problem: "Jurisdiction is probably one of the most confusing things for workers' comp for physician billing and office staff," Hammer says.

"When we have had this situation come up, we are bound by the rules of the state where the accident occurred," Huckaby confirms.

Example: A billing data-entry employee in Ohio has a computer monitor fall on her head. This first report of injury is filed with the state of Ohio. The patient's recovery is prolonged. During the recovery and treatments, the injured employee moves to California with her spouse and now receives medical treatment at your practice in California.

"The California provider needs to understand which state regulations now apply -- is it going to be California because they're now being treated in California or is it going to be Ohio," Hammer explains. "In most cases, it's going to be Ohio."

Good news: Federal employees fall under federal rules, which are standardized nationwide, so you avoid the "which state" dilemma.

Next month: Move your WC claims closer to success with three more tips on handling fee schedules and tricky billing issues.