Neurosurgery Coding Alert

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

Defining Work-related Conditions

Some neurosurgery billers are under the misconception that workers compensation insurance only covers patients suffering from work-related injuries, but the Medicare Carriers Manual (MCM) 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 neurosurgeons, 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, a coder who specializes in surgical and neurosurgical procedures.

Head or spine trauma, however, as a result of automobile accidents also may fall under this category. Many people work on the road in sales, repair, transportation, delivery and more. 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, Sandham says.

Using E/M Codes for Workers Comp Evaluations

Coders should be aware that they cannot bill for a standard evaluation and management (E/M) service on the same day they bill for a work-related evaluation code unless a separate condition is being evaluated. 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

Section 2370.2 of the MCM outlines Medicares policy on paying for separate E/M services during workers compensation services. It states, If workers compensation 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. A physician/supplier is permitted, under workers compensation law, to charge an individual or their insurer for services which are not work-related.

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 in case of an audit. And, when billing for any work-related claims, coders should check all state requirements because workers compensation insurance differs from group insurance.

Documentation Is Key For Workers Comp

When dealing with occupational diseases, practices should be careful to record documentation of the patients job duties and when they 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 send all of the patients records to the insurance company to prove that the patients condition progressively worsened during the duration of the job. Workers compensation companies usually ask for all of the records anyway, so its a good idea just to send them along with the first claim.

A letter to the workers compensation company outlining what is being sent will help avoid confusion when a reviewer attends to your claim.

Use E Codes to Define Circumstance

Another point to remember when dealing with workers compensation claims is to always add an E code whenever possible. E codes are the diagnosis codes listed in the final section of the ICD-9 that indicate the external cause of injury, says Albert, and are used with injury 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. In coding for a car accident, E codes allow the neurosurgeon to indicate whether the injury was sustained in a car vs. car situation, car vs. train, ect., 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 a herniated disk (722.2), it would be the primary code and the cause of the herniated disk, the E code, would be the secondary. For example, if the patient with the herniated disk 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, 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 E codes is optional unless required by particular carriers or 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 Tabular List for a description of the guidelines and a complete list of E diagnoses.

Know the Rules and Regulations

Because the rules for billing work-related injuries are determined on a state-by-state basis, there are no national standards for coders to follow when processing workers compensation claims. Therefore, its especially important for billers to know their states workers compensation regulations before taking on any patients with work-related illnesses.

Sandham further recommends that if a patient has multiple conditions, only one of which is related to a work injury, the neurosurgeon actually can keep two parallel medical records. One record centers on the condition that is workers compensation related, while a separate record focuses on the non-work related problems. He adds, The neurosurgeon should bill separately and according to the services provided. The patient can be billed for the non-work related visit and the workers comp insurance for the work related visits.