Orthopedic Coding Alert

Question:  A 66-year-old Medicare patient came into our office after injuring an arm at the university where he does boiler maintenance. Our physician addressed the patient’s bruising and lacerations, and during the exam, the physician also discovered that the patient had severe wheezing in his chest, which the patient said he had never addressed. The physician performed a limited examination to ensure that the patient wasn’t in immediate danger, and then filled out a referral to a pulmonologist to address the wheezing. He wants to bill for the wheezing exam, as well as a separate one for the arm care. Can we bill these to workers’ compensation or do we send them to Medicare?

Washington Subscriber

Answer: You can potentially report both exams, but you can’t bill both to workers’ compensation.

If the physician documented separate exams — one for the wheezing and one for the bruising and lacerations — you can bill the bruising and laceration exam to the workers’ comp payer and report the wheezing exam service to Medicare.

“If [workers’ compensation] WC does not pay all of the charges because only a portion of the services is compensable, i.e., the patient received services for a condition which was not work related concurrently with services which were work-related, Medicare benefits may be paid to the extent that the services are not covered by any other source which is primary to Medicare,” the Centers for Medicare and Medicaid Services (CMS) says in Pub 100-05. “A physician/supplier is permitted under WC law to charge an individual or the individual’s insurer for services that are not work related.”

Tip: If your patient isn’t on Medicare, check his private insurer’s rules before you split the workers’ comp visit with the wheezing visit.

Make sure you link the fracture ICD-10 code to the workers’ compensation exam, and the wheezing diagnosis code to the Medicare claim.