Medicare Compliance & Reimbursement

Question: A 66-year-old patient presented to the emergency department (ED) after falling off a loading dock at a home improvement store where he works. The physician addressed the patient’s fractured femur, and during the exam, the physician also discovered that the patient had severe wheezing in his chest, which the patient said he had never addressed. The physician performed a limited examination to ensure that the patient wasn’t in immediate danger and then filled out a referral to a pulmonologist to address that. He wants to bill for the wheezing exam as well as a separate one for the fracture. Can we bill these to workers’ compensation or do we send them to Medicare?

Codify Subscriber

Answer:  You can potentially report both exams, but you can’t bill both to workers’ compensation.

If the ED physician documented separate exams — one for the wheezing and one for the fracture — you can bill the fracture exam to the workers’ comp payer and report the wheezing visit to Medicare.

 “If [worker’ compensation] WC does not pay all of the charges because only a portion of the services is compensable, i.e., the patient received services for a condition which was not work related concurrently with services which were work-related, Medicare benefits may be paid to the extent that the services are not covered by any other source which is primary to Medicare,” CMS says in Pub 100-05. “A physician/supplier is permitted under WC law to charge an individual or the individual’s insurer for services that are not work related.”

Tip: If your patient isn’t on Medicare, check his private insurer’s rules before you split the workers’ comp visit with the aneurysm visit.

Make sure you link the fracture ICD-10 code to the workers’ compensation exam, and the wheezing diagnosis code to the Medicare claim.