Optometry Coding & Billing Alert

Question: We have a patient who comes in for one diagnosis for his workers- comp coverage. He also seeks treatment for several other diagnoses that are not covered by his workers- comp. Can I bill both the private insurance and office visit? 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, and 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. Also state that you billed workers- compensation separately for all services related to the work injury.

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 the optometrist write two notes -- one for the services related to the workers- compensation case and one for the patient's other diagnoses. Make sure you carve out the work for each service so you can determine the level to bill at for each one.