Neurosurgery Coding Alert

Insurers often won't pay your WC claim without information about the accident or disease's cause

Suppose a patient suffers a vertebral fracture with nerve damage after falling off of scaffolding at his construction job. Your neurosurgeon sees the patient, and you report 806.24 for the fracture, but the patient's workers' comp insurer denies the charge. Why? 
 
Payers require E codes: When providing diagnoses for workers' compensation claims, you must add the appropriate E code to describe how the work-related diagnosis occurred.
 
E codes describe external causes of injuries or accidents, and range from the common (E880.9, Fall on or from other stairs or step) to the obscure (E847, Accidents involving cable cars not running on rails) and describe scores of accidents and injuries. In short, says Terry Fletcher, BS, CPC, CCS-P, CCS, CMSCS, CMC, a coding and reimbursement specialist in Laguna Niguel, Calif., E codes often help answer the question "How did it happen?"
 
In the case above, you should report 806.24 (Fracture of vertebral column with spinal cord injury; dorsal [thoracic], closed; T1-T6 level with other specified spinal cord injury), followed by E881.1 (Fall from scaffolding) and E849.3 (Place of occurrence; industrial place and premises).
 
Two E Codes Double Your Specificity

Some workers' compensation insurers require you to report two E codes together - one code to describe how the patient suffered the injury and a second to describe where the accident occurred. You'll find the "place of occurrence" codes in the E849.x series. For instance, if a patient falls off of a ladder while working on a farm, you should report E881.0 (Fall from ladder) and E849.1 (Place of occurrence; farm).
 
Remember: "E codes do not change your reimbursement amount because they are considered 'for informational purposes only' codes," says Laureen Jandroep, OTR, CPC, CCS-P, CPC-H, CCS, director and senior instructor for the CRN Institute, an online coding certification-training center. You should never report E codes in lieu of a diagnostic code to describe an injury, but E codes help the carrier understand how the patient was injured.

Because workers' compensation insurers' payment decisions hinge on whether the patient hurt himself at work, your E codes can help you collect. "The great importance of the E codes is that they confirm that, yes, the patient was hurt at work," Jandroep says.

Workers' Comp Covers Diseases, Too

Although most coders immediately think of accident-related injuries when they discuss workers' compensation claims, remember that occupational circumstances cause some diseases and illnesses as well. And, contrary to popular belief, workers' compensation insurance often covers occupational illnesses, says Mary J. Brown, CPC, CMA, coding specialist at OrthoWest PC, a seven-physician practice in Omaha, Neb.
 
Section 2370.1 of the Medicare Carriers Manual (MCM) states 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, the physician must chronicle any occupational environmental cause of the illness.
 
Example: A common occupational illness that may require a neurosurgeon's treatment is carpal tunnel syndrome (354.0). Carpal tunnel can develop as a result of repeated manual activities, such as typing and filing, machine work, or repetitive work with a knife in a meatpacking plant.
 
Symptoms for carpal tunnel syndrome often start slowly, and patients don't always present to the neurosurgeon for treatment until the symptoms are severe. Because physicians and insurers consider such conditions "repetitive strain injuries" and not "traumatic injuries," you may not be able to report an injury date to the insurer.
 
When dealing with occupational diseases, therefore, your physician should record the patients' job duties and when symptoms began. The clinical documentation must justify diagnoses, admissions and treatments that the physician has performed, Jandroep says.
 
Because you probably won't be able to write a first report of injury for occupational illnesses, you can help expedite insurance payment if you send the patient's medical records with the first workers' comp claim. The physician should document the progressive nature of the patient's injuries during the job's duration.

Check Insurers' Policies Before You Bill

Remember: "Workers' compensation laws differ from state to state," Brown says, "as does the reimbursement fee schedule." Therefore, you should ask the insurer for its guidelines and requirements before you bill.
 
Although Medicare always uses the most up-to-date CPT codes, workers' compensation insurers do not, and their code recommendations may vary widely. Some coders report that their workers' comp payers still require them to report codes that CPT deleted in 2002 (or even earlier in some instances) because the insurers haven't yet updated their systems.
 
Tip: "Make sure that Box 10a on the CMS-1500 is marked as 'YES' to state that 'patient's condition is related to employment,' " Brown says. "We use the patient's Social Security number for the insured's ID number (Box 1a) and the workers' comp claim number in the group ID box (Box 11). Check with the workers' comp carrier to see which numbers they want where."