Orthopedic Coding Alert

Heads-up:  Not every state uses current-year CPT codes

You won't find any national standards to follow regarding workers- compensation claim coding, but that doesn't mean these claims should cause you additional effort. Here's how to nail down your diagnosis and evaluation coding without a hitch.

Avoid 99455-99456 for Standard E/M Visits

If your orthopedic surgeon sees a workers- compensation (WC) patient for an independent medical evaluation (IME) at the request of the patient's employer or insurer, you should familiarize yourself with the WC E/M codes, which CPT includes specifically to describe work-related or medical disability evaluations:

- 99455--Work-related or medical disability examination by the treating physician that includes: completion of a medical history commensurate with the patient's condition; performance of an examination commensurate with the patient's condition; formulation of a diagnosis, assessment of capabilities and stability, and calculation of impairment; development of future medical treatment plan; and completion of necessary documentation/certificates and report

- 99456--Work-related or medical disability examination by other than the treating physician -

-We use 99455 and 99456 only for special medical evaluations that include extensive tests for disability status evaluation,- says Mary Baierl, CCA, HIM coder at BayCare Health Systems LLC in Green Bay, Wis.

Be Cautious With WC Codes

Note: Don't automatically report the WC codes whenever a workers- compensation patient presents to your practice.

You should use these codes only if a patient's employer or insurance company requires a physical for employment or medical-disability purposes. If your surgeon subsequently takes over care of the patient's work-related condition, you should then revert to the standard E/M codes (99201-99215, Office or other outpatient visit for the evaluation and management of a patient ...).

The introductory language describing the workers- comp codes specifically indicates that -when using these codes, no active management of the problem(s) is undertaken during the encounter.-

Collect All Pertinent Data About the Accident

Coders can make their jobs easier if they ensure that the practice's intake form includes a box that asks, -Are you here for a work-related accident?- That way, the nurse will chart the pertinent work-related details, which you-ll need later when you file your claim.
 
Most insurers require the date of injury, workers- compensation claim number, employer at the time of injury, adjustor and case manager's name and phone number, and alternative private insurance information. Keep this information in the patient's file, and submit it to the carrier when necessary.

Preauthorize When Possible

If at all possible, you should obtain authorization from the workers- compensation carrier to treat the patient before you provide the initial visit.

Even if you collect the appropriate information and preauthorize the visit, you may still run into roadblocks when you submit your claim, because WC claims are not regulated by any one source.

Each state has its own WC regulations, and -not every state uses current-year CPT codes,- says Marvel Hammer, RN, CPC, CHCO, owner of MJH Consulting in Denver.

-Each state has its own little idiosyncrasies,- she says, so you should check your state workers- compensation carrier's Web site before you code.

Add Those E Codes

You should always use an E code from the ICD-9 manual to describe the mechanism of injury and place of occurrence (E800-E999, Supplementary classification of external causes of injury and poisoning). Although you cannot report the E code as your primary diagnosis, you can list it after the main diagnoses so the insurer gets an idea of how the accident happened.

In addition, some patients may have more than one WC claim open and in the system, so the E code can help the carrier differentiate between the claims and get them paid faster, Hammer says.

For example, suppose a patient fell from a ladder and complained of wrist pain. Your surgeon does not find a fracture, but he splints the wrist. You should report 842.xx (Sprains and strains of wrist and hand) followed by E881.0 (Fall from ladder).

File Your Claim With the State WC Carrier

Suppose a patient who lives in Arkansas falls off a ladder in Texas and comes to your practice in Arkansas for treatment. Should you file in Texas or Arkansas?
 
The answer depends on where the patient's employer filed the claim. If the employer is in Louisiana and filed the claim there, you should deal with the Louisiana WC carrier--not with Texas or Arkansas.
 
You can check out each state's workers- compensation agency pages by visiting the Web site www.comp.state.nc.us/ncic/pages/all50.htm.