Orthopedic Coding Alert

Each of the 50 states and the District of Columbia has its own Workers Compensation program. This means that when it comes to coding and reimbursement, there is no one set of rules upon which providers can rely.

With orthopedics comprising such a big part of work-related injuries, its no surprise that orthopedic practices have their share of Workers Compensation claim denials. Though the only consistency from state to state seems to be the lack of consistency, the variety of problems ortho coders face is indicative of the variety of rules for Workers Compensation.

Billie Jo McCrary, CPC, CCS-P, CMPC, is practice manager of Wellington Orthopaedic and Sports Medicine in Cincinnati, a six-office practice with 18 physicians. Her practice sees enough Workers Compensation patients to warrant a staff position devoted entirely to handling those claims. While I oversee all of the billing and reimbursement for our offices, we have one person whose sole responsibility is to process Workers Compensation, says McCrary. She keeps me informed as to what gets denied and what gets paid and where we are in the appeals process on certain claims, so I am familiar with some of our challenges.

For Some, Unusual Procedural Services Usually Dont Get Paid

Our (Ohio) policy manual has a list of modifiers they consider acceptable, but they dont pay any additional for them, says McCrary. Modifier -22 (unusual procedural services) is one that we use frequently. Quite often, our physicians want to use -22 on patients requiring a 27134 (revision of total hip arthroplasty; both components, with or without autograft or allograft.) We use this modifier a lot for a variety of orthopedic scenarios, including massive bone grafting and the extra preparation and surgery time that goes with that, placement of a custom device requiring extensive surgical deliberation, osteotomies on either side of the joint to correct a preoperative deformity, revision of a revision surgery and morbidly obese patients, etc.

Regardless of the procedure, the Ohio Bureau (of Workers Compensation) says we get the fee scheduled for that procedure, and not any more regardless of the -22 modifier, says McCrary.

Casting Supplies Are Not Always Covered

We bill for casting supplies using 99070 (supplies and materials provided by the physician over and above those usually included with the office visit or other services rendered [list drugs, trays, supplies, or materials provided]), says Kim Davis, McCrarys Workers Compensation Specialist at Wellington Orthopaedic. The Bureau just says supplies are not covered and we have to write off the cost, which we do quite often, since we cannot balance-bill the patient with Workers Compensation. This is either a $35 or $90 write-off for us, depending on the amount of supplies used for casting. The only possible alternative to a write-off, adds Davis, is if the patient has secondary insurance. In that case, we will bill the secondary insurance company for the balance and hope for the best. Regardless, we cannot transfer any of the costs to the worker.

McGregor adds that they have recently had some Workers Compensation insurers deny claims for casting supplies. Ive had to send some back for an appeal, says McGregor. We bill using 99070, and we list all our supplies and describe what they are. We also include a copy of the invoice showing how much we had to pay for the supplies. This seems to bolster our case for reimbursement, when the carrier can see that we incurred out-of-pocket expense for casting supplies.

Be Prepared to Fight for SynVisc Injection Pay Up

Before administering SynVisc (code J7320), says Davis, we always ask for pre-authorization. The typical scenario has been that the claim is denied, we appeal it, and the appeal gets denied. Then we reappeal, and the reappeal is rejected. Then we wind up in alternative dispute resolution with a representative from the bureau serving as the intermediary between the MCO (Managed Care Organization) and us. Then we finally get paid.

In Ohio, as I imagine it is in most states, says Davis, the MCOs serve as middlemen between bureau and providers, and inevitably, we have a long, drawn-out fight to get paid for SynVisc. A lot of corporations, like Anthem Blue Cross Blue Shield, do not cover SynVisc, but these companies also have an MCO division that has to adhere to the rules of state Workers Comp. Anthem was applying their own rule rather than the bureaus regarding SynVisc, which says that SynVisc is a covered benefit. We had to go to dispute resolution to win that one. I believe that with a lot of MCOs being run by these larger companies, they merely apply their rules and assume no one will try to fight them for reimbursement.

Editors note: For more information on SynVisc reimbursement, please see page 6 of the January 1999 and page 22 of the March 1999 issues of Orthopedic Coding Alert.

Problems Billing E/M Care With Injections

When we do an injection, we bill using 20610 (arthrocentesis, aspiration and/or injection; major joint or bursa [e.g., shoulder, hip, knee joint, subacromial bursa]), says Davis. But in Ohio, the office visit is considered mutually exclusive to the injection and therefore non-billable. We are now billing the office visit component with a modifier -25 (significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service), to show that it was separate E/M care. Otherwise, we have to write off the office visit. Now that we are using the -25 modifier with the E/M office visit code, we are getting paid for some rather than none.

Davis also says that when submitting their claim for 992XX-25, 20610, they attach the office notes to show that the doctor examined the patient and discussed treatment options before deciding to administer the injection. Coders should keep in mind that most carriers, not just Workers Compensation, consider the office visit to be part of the injection of the joint, unless it is the first time the patient has been evaluated for the problem.

When asked what amount of -25s are getting paid, Davis replied, I honestly think that depends on the conscientiousness of the person who is keying in the Health Care Financing Administration (HCFA) form. The -25 modifier is acceptable in Ohio and if the person entering the information makes the effort to look over the office notes, he or she will see that our claim is valid.

Problems Are as Varied as the U.S.

Curt Udell, CPAR, CPC, president of EMphysys, a Georgia-based physician reimbursement, compliance and practice management consulting firm, has clients nationwide and is familiar with the frustrations of various Workers Compensation policies.

Each state has its own plan and policies, says Udell. Its especially important for those practices that straddle one or more state lines to make sure they have all the current manuals and plans for those state Workers Comp programs. Some of my clients tell me that the Workers Compensation bureaus are not sending out updated manuals unless requested. Some issue new manuals in January, some in April, so practices need to stay on top of their state agencies. On the plus side, the manuals are usually very complete guides to each states system.

I try to stress to my clients to go by not just the fee schedule, says Udell, but the policy and procedural manual as well. I also tell them not to adjust their coding based on what theyll get paid for. Go by the American Medical Association guidelines, not the Workers Comp guidelines for your state. If there is a procedure or service that is prevalent to your practice for which you feel you should be reimbursed, write a letter to the Workers Comp commissioner, your state insurance commissioner, even the Department of Labors Employment Standards Administration. Show them that you are doing these medically necessary procedures and not getting reimbursed. It may take some time, but you may make some headway, too.

Where To Find the Rules

For coders and practice managers who want to make sure they are working with the most current set of Workers Compensation rules, help is just a few mouse clicks away. The United States Department of Labors Employment Standards Administration is the division that administers Workers Compensation nationwide. They have a link to every state and the District of Columbias individual Web pages for Workers Compensation. The sites are administered by the states, so information varies. Sites include everything from the most minimal of information, like addresses and phone numbers of the state office, to Ohios site, which enables medical professionals to enter a CPT code with or without a modifier and find out whether it is a covered code in the state. The address for this Web site clearinghouse is www.dol.gov/dol/esa/public/owcp_org.htm. At the minimum, each states Web site will provide you with the contact information you need to obtain the most up-to-date information about your states Workers Compensation regulations and fee schedules.