Orthopedic Coding Alert

Workers' comp insurers may not pay your claim without accident details

Workers' compensation claims don't just apply to accidents - you may see patients who present with work-related diseases as well as injuries. Follow our expert tips to keep reimbursement coming for your workers' compensation claims.
 
A patient fractures his tibia after falling off of scaffolding at his construction job. Your orthopedist sees the patient, and you report 823.00 for the tibia fracture, but the patient's workers' comp insurer denies the charge. Why? Because you forgot to add the appropriate E code to describe how the work-related diagnosis occurred.
 
You should use E codes to describe external causes of injuries or accidents. E codes 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. E codes help answer the question, "How did it happen?"
 
In the example above, the coder should report codes 823.00 (Fracture of tibia and fibula; upper end, closed, tibia alone), 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 sustained 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 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 sustained the injury. 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. Contrary to popular belief, workers' compensation insurance often covers occupational illnesses such as arthritis.
   
Section 2370.1 of the Medicare Carriers Manual (MCM) notes 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 scenario in our practice is trigger finger," says Mary J. Brown, CPC, CMA, orthopedic coding specialist at OrthoWest PC, a seven-physician practice in Omaha, Neb. "We have many meat- packing plants in Nebraska, and the repetitive work with a knife can cause these. Another scenario would be carpal tunnel syndrome for the same reason."
 
Symptoms for carpal tunnel syndrome and trigger finger often start slowly, and patients don't always present to the orthopedist for treatment until the symptoms are severe. Because physicians and insurers consider such conditions "repetitive strain injuries," not "traumatic injuries," you may not be able to report an injury date to the insurer.

Document Disease History

When dealing with occupational diseases, therefore, your physician should record the patient's job duties and when symptoms began. The clinical documentation must justify diagnoses, admissions and treatments that you and other physicians have performed.
 
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."