Orthopedic Coding Alert

If your workers'compensation examination (99201-99215) turns up a separate problem, maintain separate notes for each problem injury versus noninjury if you plan to bill the patient's health insurer separately for the nonwork-related E/M service.

For instance, a workers'compensation patient suffers a vertebral fracture (805.x) while lifting a box of copier paper during her work as a secretary. During the workers' compensation examination, the patient also complains of persistent knee pain (729.5), and the orthopedist performs a separate thorough examination for that condition.

"The orthopedist should maintain separate chart notes for the workers'compensation visit and the knee pain visit," says Laureen Jandroep, OTR, CPC, CCS-P, CPC-H, CCS, director and senior instructor for the CRN Institute, an online coding certification training center based in Absecon, N.J.

You would bill the appropriate E/M code to the workers'compensation carrier with 805.x and the other E/M code to the patient's insurer with 729.5. "Your documentation must reflect what was related to the injury and what wasn't," Jandroep says. "In addition, the codes you select for each problem must reflect the work the physician did and cannot appear to be double-billing. This is why you need separate documentation for each service."

Submitting your codes to separate insurers can become even more troublesome when the Correct Coding Initiative (CCI) bundles the codes you intend to split-bill. Kim Walker, RHIA, coder at Willamette Surgery Center in Salem, Ore., offers the following example:

"The surgeon performs a rotator cuff repair (23410, Repair of ruptured musculotendinous cuff [e.g., rotator cuff] open; acute) and acromioplasty (23130, Acromio-plasty or acromionectomy, partial, with or without coracoacromial ligament release). Workers'compensation only authorized the rotator cuff repair because it reasons that the acromioplasty was required for the patient's arthritis, a chronic problem unrelated to the work injury. However, the CCI bundles 23130 into 23410, so it may appear to be unbundling if we bill the patient's insurer for the acromioplasty and the workers'compensation insurer for the rotator cuff."

If either the workers'compensation insurer or the patient's health insurer uses CCI edits, any attempt to split the bill would be considered unbundling, Jandroep says. If these insurers do not follow CCI edits, however, send the workers'compensation insurer the rotator cuff repair claim for your full fee, then send the acromioplasty claim to the patient's health insurer with a letter explaining the reason you are split-billing.

"Append modifier -52 (Reduced services) to 23130 because you can't recoup the cost of pre- and postoperative care, and opening and closing the patient, in your charges, and bill a lower amount accordingly."

Although workers'compensation insurers'rules vary, most prefer practices to bill evaluations using the standard E/M codes (99201-99215). CPT dictates that 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 you should not use these codes to report evaluating work-related injuries.