Neurosurgery Coding Alert

Neurosurgeons should not dread billing for work-related diseases just because the coding can be challenging. The Medicare Carriers Manual (MCM) explicitly notes that workers' compensation insurance covers occupational diseases in addition to work-related injuries. Comprehensive documentation of the disease will help obtain compensation in these cases, as will education about your particular state or carrier requirements for reimbursement.

Section 2370.1 of the MCM notes that Medicare policy requires compensation for injury or disease suffered in connection with employment, "whether or not the injury was the fault of the employer." Therefore, chronicling any occupational environmental cause of the illness is crucial. Codes 99455 (work-related or medical-disability examination by the treating physician that includes: completion of a medical history commensurate with the patient's condition; performance of an examination commensurate with the patient's 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) and 99456 (work-related or medical-disability examination by other than the treating physician) are designed specifically to report work-related or medical-disability evaluations.

Billers must know when a condition can be considered work-related for reimbursement purposes. Carpal tunnel syndrome (354.0) is a fairly common occupational injury treated by neurosurgeons, but less common neurologic conditions should also be billed when they are related to the patient's work. For instance, toxic encephalopathy (349.82) due to exposure to organic solvents and organophosphate pesticides can occur in workers performing automobile body repair or applying pesticides. Those patients whose work entails considerable travel should also be considered for workers' compensation claims for chronic conditions.

"Truck drivers have back injuries a lot because of the constant bouncing of the truck," says Sharon Tucker, CPC, president of Seminars Plus, a healthcare consulting firm in Fountain Valley, Calif. "A back injury can hide itself for a long time, and many are progressive for someone doing a lot of lifting. Lower-back injuries are probably one of the hardest to prove, however, and the employer has to accept this as a work injury."

When dealing with occupational diseases, practices should be especially careful to record documentation of the patients' job duties and when symptoms began. That clinical documentation must justify diagnoses, admissions, treatments performed and continued care. The information in the operative report must be comprehensive and readable.

Because occupational illnesses do not have a first report of injury -- which the insurance companies typically like to see -- sending the patient's medical records with the first billing can expedite payment. These records likewise should document the progressive nature of the patient's injuries during the duration of the job.

For patients with multiple conditions, only one of which is related to a work injury, the neurosurgeon should keep parallel medical records -- one specific to the injury and the other detailing unrelated health issues.

"The neurosurgeon should bill separately and according to the services provided," says Eric Sandham, CPC, 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. "The patient can be billed for the non-work-related visit, and the workers' comp insurance for the work-related visits. Separate records will also help maintain compliance with HIPAA's privacy requirements that only the minimal necessary information be released in response to any request for medical records."

Coders cannot bill for a standard E/M service on the same day as a work-related evaluation unless a separate condition is evaluated. When charging separate E/M evaluations during workers' compensation visits be especially careful to save all documentation, including authorization forms, chart notes, accident reports, dictation and superbills.

Billing for any work-related claims requires a check of all state requirements because workers' compensation insurance differs from group insurance. Services unrelated to the workers' compensation evaluation should not be included, and may instead be billed to the patient.

Section 2370.2 of the MCM states, "If workers' compensation does not pay all of the charges because only a portion of the service 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. A physician/supplier is permitted, under workers' compensation law, to charge an individual or their insurer for services which are not work-related."

The rules for processing workers' compensation claims are determined on a state-by-state basis, and some states have limitations on the amount of medical and hospital care covered, so you must know these requirements for proper billing.

In general, however, prior authorization from the patient's insurance carrier may help avoid claim denials and delays in reimbursement. A letter to the workers' compensation company outlining what is being sent helps avoid confusion for the reviewer attending the claim. In addition, although Medicare always uses the most up-to-date codes, workers' compensation carriers are under no such requirements and may vary widely in the CPT codes they use. Copies of the appropriate pages from the current CPT may be sent during an appeal or during initial claim filing.

E codes, or circumstance codes, can usually speed up reimbursement by eliminating questions the insurer might have about the claim. E codes clarify how the injury occurred to a high degree of specificity. These codes are used with injury codes to explain how the injury occurred, the intent (whether accidental or intentional), and the location where the injury took place. For example, E823 describes other motor vehicle nontraffic accident involving collision with stationary object. An E code should be the last designation of the diagnosis in all workers' compensation claims.

E codes should never be used as the principal diagnosis and "are always secondary to the patient's actual condition," Sandham says. He cites a patient who suffers from a herniated disk (722.2). "The herniated disk would be the primary code. The cause of the herniated disk, the E code, would be secondary.  For example, if the herniated disk was caused by a fall from a ladder, E code E881.0 (fall from ladder) would be used."

E codes are required in some states and for certain payers. Therefore, billers should always check whether their particular carrier requires the E code during claim filing. The ICD-9 Tabular List includes a description of guidelines and a list of E diagnoses. Submission of E codes may prevent delays in payment of injury-related claims because they provide the information necessary to determine if another payer is responsible for the services rendered.