Ophthalmology and Optometry Coding Alert

Question: We have a patient who comes in for one diagnosis for his workers' comp coverage. He also sees the physician for several other diagnoses that are not covered by his workers' comp. Can I bill the private insurance and office visit also? If so, can the documentation be combined all in one progress note?

Indiana Subscriber

Answer: You can bill both carriers. Because you are not dealing with just one insurer, you should send the workers' compensation insurer the first claim, then send the other claim to the patient's health insurer with a letter explaining why you are split-billing. Tell the insurer that you diagnosed the other problems while performing a workers' compensation examination for a separate condition, but that the condition is not work-related and that you billed workers' compensation separately for all services related to the work injury.

For your evaluation, although workers' compensation insurers' rules vary, most prefer practices to bill evaluations using the standard E/M codes (99201-99215). CPT dictates that codes 99455 (Work-related or medical disability examination by the treating physician ...) and 99456 (Work-related or medical disability examination by other than the treating physician ...) "are used to report evaluations performed to establish baseline information prior to life or disability insurance certificates being issued." So avoid these codes when evaluating work-related injuries.

Documentation tip: While you can have all of the information in one progress note, experts recommend that physicians write two notes -- one for the services related to the workers' compensation case and one for all of the patient's other diagnoses. Make sure you carve out the work for each service so that you can determine the level to bill at for each one.