Neurology & Pain Management Coding Alert

There are no national standards for coders to follow when processing workers compensation claims; the rules are determined on a state-by-state basis. This creates a challenge for billers, but handling such claims does not have to be a chore. First and foremost, the neurologist who wishes to treat a patient with a work-related illness or injury should acquire prior authorization from the patients insurance carrier, as this may avoid claim denials and delays in receiving appropriate reimbursement.

Neurologists who bill for workers compensation claims also can avoid delays in reimbursement by using caution when billing for evaluation and management (E/M) services that do not relate to the workers compensation evaluation, and by determining how the patients job affected his health, says Sylvia Albert, CPC, president of the Tidewater AAPC Chapter and a customer support manager at the AcSel Corp., a healthcare reimbursement consulting firm in Virginia Beach, Va.

Work-related Injuries and Diseases Are Covered

Some neurology billers are under the misconception that workers compensation insurance only covers patients suffering from work-related injuries, but the Medicare Carriers Manual notes, All states now provide compensation for at least some occupational diseases as well.

Carpal tunnel syndrome (354.0) is a very common occupational injury treated by neurologists, says Eric Sandham, CPC, a coder who specializes in neurological procedures and is compliance educator for Central California Faculty Medical Group, a group practice and training facility associated with the University of California at San Francisco in Fresno. Head or spine trauma as a result of automobile accidents also may fall under this category. Many people work on the road in sales, repair, transportation and delivery. Sandham says, If part of their job is on the road and theyre injured on the road, not at a work site, they should be eligible for workers compensation benefits.

Documentation Is Key for Workers Compensation

When dealing with occupational injuries, practices should be especially careful to record documentation of the patients job duties and when he began experiencing symptoms, says Sharon Tucker, CPC, president of Seminars Plus, a healthcare consulting firm in Fountain Valley, Calif. Since youre talking about an occupational illness, you wouldnt have the first report of injury that the insurance companies like to see from a patient with an occupational injury. Therefore, the doctor should always send all of the patients records to the insurance company to prove that the patients condition progressively worsened during the job. The workers compensation company usually asks for all of the records anyway, so its a good idea to just send them along with the first claim.

Another point to remember when dealing with workers compensation claims is to always add an E code whenever possible. The E codes are the Supplemental Classification of External Causes of Injury and Poisoning (E800-E999) codes listed in the final section of the ICD-9 manual. E codes are to be used to indicate the external cause of injury, says Albert, and are used with diagnosis codes to provide information about how the injury occurred, the intent (whether accidental or intentional), and the place where the injury took place.

Sandham says that with automobile accidents, E codes are considered the circumstance codes, giving insurance companies a better idea of how the person was injured. The highest level of specificity possible is preferred. If the neurologist is coding for a car accident, the E codes allow the neurologist to indicate if the injury was sustained in a car vs. car situation, or if it was car vs. train, and if the patient was a driver, a passenger or even a pedestrian.

The E codes are never primary, they are always secondary to the patients actual condition, Sandham says. If a patient suffers from severe headaches (784.0) and dizziness (780.4), the headaches and dizziness would be the primary codes, and the cause of the headaches and dizziness, the E code, would be the secondary. For example, if the patient with the headaches and dizziness had the condition brought on as a result of a fall from a ladder, E code E881.0 (fall from ladder) would be used.

Anytime you have a workers compensation claim, its best if you can use an E code as the last designation of the diagnosis, agrees Tucker. In the case of occupational illness, there may not be an E code available, but if you have one, always add it. It usually helps you get paid faster because it takes away some of the questions the insurance company might have.

Albert reminds billers that although E codes should never be used as the principal diagnosis, reporting these codes provides additional data for the injury research. Using the E codes is optional unless required by particular carriers or is mandated by your state. She urges practices to follow the guidelines for reporting E codes to establish consistency in claims filing and refers coders to the ICD-9-CM tabular list for a description of the guidelines and a complete list of E diagnoses.

E/M Services During Workers Comp Evaluations

Coders should be aware that they cannot bill for a standard E/M service on the same day they bill for a work-related evaluation code, unless a separate condition is being evaluated other than the work-related injury. CPT 2000 states, If other evaluation and management service and/or procedures are performed on the same date, the appropriate E/M or procedure code(s) should be reported in addition to codes 99455 and 99456, which are designed specifically to report work-related or medical disability evaluations:

99455 work-related or medical disability examination by the treating physician that includes:
completion of a medical history commensurate with the patients condition;
performance of an examination commensurate with the patients condition;
formulation of a diagnosis, assessment of capabilities and stability, and calculation of impairment;
development of future medical treatment plan; and
completion of necessary documentation/certificates and report
99456 work-related or medical disability examination by other than the treating physician

Note: 99456 requires all of the same components as 99455. Code 99455 is for the initial evaluation of the patients disability to establish a baseline for treatment. If the neurologist continues to treat the condition, then he or she would use the established patient office or other outpatient visit codes (99211-99215) for subsequent evaluations.

Sandham further recommends that if a patient has multiple conditions, only one of which is related to a work injury, the neurologist should keep two parallel medical records. One record centers on the condition that is workers comp related, and a separate record focuses on the non-work-related problems. Sandham says, Separate documentation allows the neurologist to accurately bill separately and according to the services provided. The patient or their personal insurance can be billed for the non-work-related services and the workers comp insurance for the work-related visit.

Billers who charge for separate E/M evaluations during workers compensation visits should be careful to save all documentation, including authorization forms, chart notes, accident reports, dictation and superbills. When billing for any work-related claims, coders should take special care to check all state requirements, as workers compensation insurance differs from group insurance.

In addition, if the patient is being seen on an ongoing basis for a workers comp and a non-workers comp-related injury, that is one of the few instances in which two established patient office or other outpatient visit codes (99211-99215) can be submitted on the same day. The neurologist may report 99212 for the non-work-related condition and another 99212 for the work-related condition. The second established patient office visit or other outpatient office visit should be billed with the -25 modifier.

Reimbursement problems can come up with workers compensation when the claim is contested or if liability issues are involved. A patients attorney may ask the neurologist to sign a document delaying charges until a settlement has been received. Sandham says that neurologists need not accept this. In these cases, Sandham advises, Attempt to get the money from the patient or the patients attorney up front. If you do not, you could experience a very long delay of payment.

Of course, documentation for each charge must appropriately support the levels of service billed. A common review of systems and past medical family and social history can be referenced, but the history and present illness must be specific for each condition.