Practice Management Alert

Knowing which state has jurisdiction over the claim is the key to success

If the thought of workers- compensation (WC) claims gives you a headache, you-ll want to incorporate these expert tips into your billing process to take some of the work out of WC encounters. You-re not the only one confused by WC billing complexities.

Take a look at these three common questions--with answers from the experts--to get the scoop on what you need to do to ensure proper WC claims processing.

Question 1: How do I know which state's rules to follow?

The biggest area of confusion is that workers- compensation is a state-run program. Each state has its own rules, fee schedule and setup for what providers the patient can see, which often leaves billers wondering where to go for billing information.

-There is no clear guideline, as it is different from state to state, contract to contract,- says Donna O-Hern, CPC, chief auditing officer at Parses Inc. in Tampa, Fla.

Bottom line: You need to follow the rules of the state in which the patient originally filed the WC claim.

Caution: Keep in mind that this may--or may not--be the same as the patient's current state of residence. You may encounter cases when a patient receives care in a state that doesn't have jurisdiction over the WC claim.

-Only one state will have jurisdiction over a workers- compensation claim,- says Marvel J. Hammer, RN, CPC, CCS-P, ACS-PM, CHCO, owner of MJH Consulting, a healthcare reimbursement consulting firm in Denver. -It is typically the state in which the claim was initially filed. So there shouldn't be situations when more than one jurisdiction is involved in a claim.-

Test yourself: A patient suffers an injury in Colorado and files a claim with Colorado. Then the patient moves to Florida and receives care in Florida for the Colorado WC claim. Which state's WC regulations apply to this patient's treatment?

Colorado rules apply to this WC claim rather than Flor-ida, Hammer says, because the claim originated in Colorado.

Exception: The only exception is WC for federal employees, which has nationwide rules. -Federal WC jurisdiction covers all federal employees regardless of where the injury occurred,- Hammer says. -For example, a postal worker in New Hampshire is injured on the job, and he files the initial claim with federal WC and not New Hampshire WC. Since this is a federal employee with a work-related injury, federal WC rules/regulations cover this injury regardless of where the patient is injured or receiving care.- On the other hand, WC for railroad workers is a mix--most states abide by nationwide rules, but some states have their own.

Where to look: Each state has a Web site for information on WC claims, so check your state's site for more information on individual state regulations and specific state policies about submitting your claims. For example, information on Florida's WC guidelines is on the myflorida.com Web site, O-Hern says. And there are some general WC information Web sites, such as www.workerscompensation.com, that have links to individual state Web sites, as well as some general information on each state's rules/regulations.

Question 2: What information do I need to ensure smooth WC claims processing?

To process WC claims, you-ll need the claim number for the specific injury, the injury date, the employer at the time of the injury, the adjustor name and phone number, the payer, and the address to which you should send claims, Hammer says. Because WC patients don't have a payer identification card as they would for private health insurance, you-ll need to dig a bit to get the information.

Be proactive: When a patient comes to your office with a presenting problem that might be from his job, the first question your office staff should ask should be, -Is there a chance this injury is job-related?-

-Front-office staff and/or providers need to capture the information ASAP that the services are associated with a work-related injury,- Hammer says. -The earlier a provider/practice finds out that the patient's services are covered by a work comp claim, the better. Then, authorizations, information release, billing and payment can all be handled appropriately.-

Tip: Make sure you create a separate case in your practice management software for each WC claim that includes the injury date so it goes on your claim forms. Experts also recommend that if your physician provides other services to the WC patient (for example, if he's the patient's primary-care physician), you should create a separate chart for the WC case.

Question 3: Are E codes essential on WC claims?

E codes are important on WC claims, but they will never be your primary diagnosis. E codes are informative and tell how the patient's injuries happened.

-E codes can be helpful in -linking- the cause of the injury to the services,- Hammer says. You may find this especially helpful when patients have more than one open WC injury claim and when payers use a patient's Social Security number as identification rather than specific claim numbers, she adds. An E code to indicate the injury's external cause, such as E849.3 (Place of occurrence; industrial place and premises), can help the carrier to differentiate between the claims and get them paid faster.

The sections you-ll use most for WC patients are:

- E880-E888--Accidental falls
- E919.x--Accidents caused by machinery
- E920.5--Accidental needle stick
- E927--Overexertion and strenuous movements.

Example: A drill-press operator lacerates two fingers while operating a power press. The injury does not result in tendon damage. Your primary diagnosis is 883.0 (Open wound of finger[s]; without mention of complication), along with E919.3 (Accidents caused by metalworking machines) to show how the injury occurred.

More information: To learn more about WC regulations and ensure that you-re up to speed on this complicater process, attend -8 Guaranteed Strategies for Workers- Comp Claim Success- by Marvel J. Hammer on Tuesday, Nov. 13. Visit www.audioeducator.com/industry_conference.php?id=527 for more details. Get 10 percent off by using this coupon code at checkout: 10%MOBWORKER.