Optometry Coding & Billing Alert

An established patient may not actually always be a new patient

When you-re billing a workers- compensation claim, you should always check your state regulations about how to bill for the physician's service.

A reader question, "Don't Ignore Patient Status for WC Claims" (Optometry Coding & Billing Alert Vol. 6, No. 8), asked, "An optometrist in our practice said that if an established patient comes in for workers- comp, we code it as a new patient visit for the first workers- comp visit. That doesn't make sense to me. Who is right?"

The answer advised, "You need to explain to your provider that the type of insurance coverage for a visit, including workers- compensation, does not affect whether you should bill a patient as new or established." The answer went on to say that the reader should bill the service using the correct level of E/M service (99212-99215, Office or other outpatient visit for the evaluation and management of an established patient ...) under the workers- compensation insurance. Although this advice is correct in some situations, it is incorrect in some states.

Why? "Each workers- compensation jurisdiction may set their own rules/regulations as they are not considered to be a covered entity under HIPAA," explains Marvel J. Hammer, RN, CPC, CCS-P, ACS-PM, CHCO, owner of MJH Consulting, a healthcare reimbursement consulting firm in Denver, who brought the error to our attention. "Some workers compensation jurisdictions do base their fee schedule similar to Medicare/AMA rules and would not allow a more frequent new visit E/M code to be reported -- but not all."

Example: Hammer cites Colorado's Medical Fee Schedule Rule 18 - 5 (I) (2), which states: "An E/M visit shall be billed as a -new- patient service for each -new injury- even though the provider has seen the patient within the last three years. Any subsequent E/M visits are to be billed as an -established patient- and reflect the level of service indicated by the documentation when addressing all of the current injuries."

Best bet: Check your state's WC regulations before billing any WC claim.