Ophthalmology and Optometry Coding Alert

Each state has its own rules, fee schedule, and set up for what providers the patient can see and is required to see, says Marvel Hammer, RN, BS, CPC, CCS-P, ACS-PM, CPCO, owner of MJH Consulting in Denver. And federal employees and railroad employees have their own workers’ comp programs, Hammer adds.

Check out these five frequently asked questions — with answers from the experts — to strengthen your understanding of workers’ compensation and refine your billing skills.

FAQ 1: Do I have to bill according to the workers’ comp fee schedule?

Answer: “We follow the fee schedule to a T,” says Christine Pereira, CPC, CPMA, coding manager for Brown Surgical Associates in Rumford, Rhode Island. You don’t need the workers’ comp fee schedule to bill claims, but it’s advisable “if you want to set your fees optimally for all payers,” Udell explains. Workers’ comp programs often pay fairly well, so you may actually increase your revenue by following their fee schedule, he notes.

If your practice sees a fair number of workers’ comp patients, you should know the fee schedule for your state and any nearby states whose claims you sometimes deal with, Hammer says. Big carriers sometimes process your claims in another state, and reimbursement can be incorrect because their computers are dealing with several state fee schedules. Knowing your state’s fee schedule allows you to make sure you get paid what you deserve, Hammer adds.

FAQ 2: If more than one state is involved in a workers’ comp case, which state’s billing rules should I follow?

Answer: You need to follow the rules and fee schedule of the state in which the workers’ comp claim was originally filed, according to Hammer. This may or may not be the same as the patient’s current state of residence, she adds. Billing can get complicated when you’re dealing with truck drivers and other mobile professionals because a patient may initiate care for an injury in a state other than where they live.

Remember: Focus on where the claim was first filed. That state will have jurisdiction over the claim. The only exception is workers’ comp for federal employees, which has nationwide rules. Workers’ comp for railroad workers is a mix — most states abide by nationwide rules, but some states have their own.

FAQ 3: Should I code any differently for workers’ comp claims?

Answer: Generally, no. However, you should be aware that “not every state uses current-year CPT® codes,” Hammer says. You may get denials or experience delays if you’re using new codes and your workers’ comp carrier isn’t up to date. “Each state has its own little idiosyncrasies,” so it’s best to ask your state carrier or check the website for the appropriate CPT® codes to use, Hammer adds.

Make sure to use additional diagnosis codes to reflect the external cause of the injury. Of course, these codes will never be the primary diagnosis, but they’re important because they complete the picture of the patient’s injury, treatment, and claim. If a patient has more than one workers’ comp claim open and in the system, an external cause of injury code (V00-Y99) code, such as Y92.63 (Factory as the place of occurrence of the external cause), can help the payer differentiate between the claims and get them paid faster, Hammer says.

FAQ 4: What can front desk and scheduling staff do to help workers’ comp initial visits and claims go smoothly?

Answer: The front desk provides a great stopping point to collect vital information about a workers’ comp case, Hammer says. When a patient schedules their first appointment for an injury that could have been on the job, such as a foreign-body sensation or eye pain, the first question the front desk or appointment scheduling staff ask should be, “Is there a chance that this injury is work-related?”

If the answer is yes, Hammer advises that you collect pertinent information such as date of injury, workers’ compensation carrier, claim number, employer at the time of injury, adjuster and/or case manager name and phone number, and alternative private insurance information.

Important: Obtain authorization from the workers’ comp carrier to treat the patient before the initial visit.

Also, you should shy away from seeing a patient for a workers’ comp visit and other unrelated problems on the same day. “It’s truly better to have separate visits,” Hammer says. If a patient wants to discuss other issues, try to have him schedule a new appointment so you’ll have a clearly separate record for your workers’ comp claim.

FAQ 5: Where can I get a copy of the workers’ comp fee schedule for my state?

Answer: Every state has a workers’ comp webpage that outlines the rules and provisions of the program to some extent, Hammer says. “Some states have their fee schedules posted,” and the vast majority at least provide some indication of what their fee schedule is, she says. If the fee schedule is not available online, you can usually call your state’s program to obtain a copy.

Hint: Workers’ comp programs are usually run by your state’s Department of Labor, which may be able to help you locate a website or phone number. To search for state websites, go to www.workerscompensation.com.

For federal program information, go to www.dol.gov/agencies/ owcp. For railroad program information, go to www.brs.org.