Internal Medicine Coding Alert

Published on Wed Jan 11, 2012 PDF

Make you filing hassle-free by checking schedules.

Worker's compensation (WC) cases raise ongoing questions when it's time to code your physician's services. Begin your journey toward reimbursement by collecting pertinent information before the patient arrives for his appointment, and by focusing on the state where the claim originated, even if it's different from the state where your physician practices. (See "Make Your Workers' Compensation Billing Smooth with These Tips" in Internal Medicine Coding Alert, Vol. 15, N. 1 for details.)

Once you've started on the right path, check multiple fee schedule and steer clear of other filing traps to successfully reach your goal.

Compare Multiple Fee Schedules

You don't need the WC payer's fee schedule to bill claims, but you might want to reference it, because following their fee schedule might actually increase your revenue. For example, you might normally bill $200 for a procedure but discover that the workers' comp fee schedule will reimburse you $300.

Alternative: You can also submit claims based on your practice's normal fees. "We bill our usual charge and then make any adjustments when payment is received," says Linda Huckaby, CMA (AAMA), with Carolina Medical Rehabilitation in Greenville, S.C. "Our office bills according to our fee schedule, and the carrier applies the contractual adjustments when they send payment with their EOB."

Caution: Not all workers' compensation payers use the Medicare physician fee schedule as their basis, warns Marvel Hammer, RN, CPC, CCS-P, PCS, ASC-PM, CHCO, owner of MJH Consulting in Denver, Co. "So understand very clearly how much you're going to expect for payment."

If your practice sees a fair percentage of workers' comp patients, know the fee schedule for your state and any nearby states with whose claims you sometimes deal. Big carriers sometimes process your claims in another state, and reimbursement can be incorrect because their computers are dealing with several state fee schedules. Knowing your state's fee schedule allows you to verify that you get paid what you deserve.

Use Caution Treating -- and Billing -- Other Problems

Your internal medicine physician can technically and legally see a patient for a workers' comp visit and other unrelated problems on the same day, but you may find it easier in the long run to keep the visits separate. Otherwise, you'll be sending claims to two different payers if your physician treats the WC condition and an unrelated problem in the same visit; one claim will go to the WC carrier and the other to the patient's normal insurance.

"This is not a situation that we deal with since we are a specialty group. But, visits like this can be billed," Huckaby says."Great care must be taken to be sure all the information is filed to the appropriate payer."

Your physician might also treat WC patients who "have multiple injuries that have happened on different dates and are for other body parts," says Kristine Newton, CPC, billing coordinator for a physician group in Fla. "Those have to be scheduled in separate time slots, with separate encounter forms and separate dictations."

Best bet: If a patient wants to discuss other issues, try to have him schedule a new appointment so you'll have a clearly separate record for the workers' comp claim. Although medical necessity or good patient relations may require the physician to treat unrelated problems during a workers' comp visit, the best scenario is to have the patient return for a separate appointment to address other nonrelated problems.

If the physician chooses to see the patient for both problems in one visit, tell the doctor to dictate separate notes for the workers' comp claim and the unrelated problem. Having a clear and separate record for your workers' comp claim will help reduce payer confusion and expedite payment.

Watch Special DME Regulations

If your physician provides durable medical equipment (DME), you may need to jump through a few extra hoops to ensure you get paid for that equipment as well as the office visit and treatment services or procedures.

"Some carriers -- especially the Department of Labor -- require prior authorization for durable medical equipment," Newton says. "Be sure to have the DME pre-authorized prior to dispensing. Having the patient sign an ABN (advance beneficiary notice) is often worthless."

Plus: "When filing DME, injectables, [and] medications, most WC carriers want a hard copy of the invoice for that particular item," Newton adds. "Be prepared to send that along with your initial filing, so the claim is clean when you send it the first time."