Primary Care Coding Alert

Family practice coders can make workers' compensation reporting easier by remembering the two D's: documentation and diagnosis coding. Unlike typical medical claims, workers' compensation (WC) claims follow a process that requires extraordinary attention to detail. Reporting is further complicated because each state has its own WC program with unique regulations and guidelines.
 
Procedural differences are observed even before the family physician sees the patient. Unless the family practice received preauthorization from the employer to evaluate and treat a patient, the WC claim may not be paid. "Family practices must realize that authorization from the employer is absolutely required," says Rudy Tacoronti, MD, director of occupational medicine for DeKalb Health Systems in Decatur, Ga. "In most WC programs, the employer has the right to select the treating physician or ask the patient to choose from a panel of physicians designated by the employer. If the patient doesn't comply, the employer may request that payment for the services be denied." Exceptions may be made on occasion, he adds, most often when injuries require immediate or emergency care.

An encounter with a worker to assess and treat the illness or injury is usually reported with CPT codes normally assigned for services provided. If a patient presents with a second-degree burn on his leg, for instance, 16020 (dressings and/or debridement, initial or subsequent; without anesthesia, office or hospital, small) is reported.
 
In other circumstances, an E/M code is used (99201-99215, office and other outpatient services), says Debra Wiggs, CMPE, chief executive officer of Community Physicians Administrative Support Services, LCC (ComPASS), a billing and collections firm that provides support to 45 primary care practices in Washington state. For example, a warehouse worker falls from a ladder and hits her head. She is seen because of an escalating headache and vomiting. The FP examines the worker and diagnoses a concussion. Depending on the level of service documented, the visit should be reported with the appropriate E/M code, e.g., 99203 or 99204. Since workers must be seen by a preapproved physician and not their regular FP, many of these visits are reported with new patient codes.
 
"Workers' comp claims require a lot of specificity about the circumstances surrounding the injury or illness," Wiggs says. "This information must be reported in order for the coder to submit a payable claim."
 
However, this type of detail doesn't determine the level of E/M code assigned. "All of the typical CPT documentation requirements must also be met. As with a more typical encounter, the level of E/M service will be determined by the physical exam, history and medical decision-making key elements," she notes.
 
In addition to the key elements, Wiggs says, "Practices seeing WC patients will be expected to provide great detail, including the date, time and place of the injury as well as precise information about the body part affected. This helps the insurer determine with certainty that the condition is work-related and a legitimate WC claim.
 
"For example, the FP must indicate if the injury appears on the front, back, left or right side of any area in order to meet the specificity requirements of many WC programs." Other details that might be required include:
 

patient's occupation

in-depth job description

last date worked

whether the condition caused lost days at work

where and how the accident occurred

if the injury is new or an exacerbation of an existing condition

treatment prescribed or undertaken

whether the patient can return to work at full or partial capacity.

This type of information is often collected and recorded on a detailed patient-history form customized for WC patients.
 
The documentation of the physician's assessment is one of three reports the WC claims processor will review. The other two are submitted by the employer and employee. Since the versions provided by the others may contradict one another, the physician's report often determines the validity of the WC claim. Tacoronti adds that for an illness or injury to be considered work-related, it must meet four conditions:
 
1. There was an incident or exposure
 
2. An injury or illness resulted
 
3. The two are temporally related
     
4. During that time, the patient was involved in activities that furthered the interests of the employer.

"The physician's documentation of these points often determines the patient's eligibility for a WC claim," he says.

Many family practice coders mistakenly report a workers' comp visit to treat an injury or illness with 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) or 99456 (work related or medical disability examination by other than 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).
 
"These codes are used for another purpose," Tacoronti says. "Workers' comp benefits provide for more than medical treatment. The program also includes facets like disability benefits and wage-loss compensation. Codes 99455 and 99456 are assigned when physicians assess a patient's condition in order to determine these types of benefits rather than to provide medical care."
 
Coders should note that the introductory language describing these codes specifically indicates that "when using these codes, no active management of the problem(s) is undertaken during the encounter."

A variety of injuries and illnesses may be covered by most WC programs, Wiggs says. "There are four major areas that are most common, including acute injuries like lacerations or fractured bones, orthopedic problems like back pain, repetitive-motion conditions like carpal tunnel syndrome, and occupational illnesses like allergic reactions to materials in the workplace."
 
The appropriate diagnosis code is reported for the injury or illness, she notes, in addition to an E code to explain circumstances surrounding the condition. For instance, a worker may have a headache, dizziness and blurred vision after falling from scaffolding at a  construction site. Family practice coders assign ICD-9 codes 784.0 (headache), 780.4 (dizziness and giddiness) and 368.8 (other specified visual disturbances), along with E881.1 (fall from scaffolding).
 
Coding professionals emphasize the importance of using the E code because it gives the insurer a better picture of how the employee was injured. This, in turn, affects payment of the claim. However, E codes are never the primary diagnosis code reported. They occupy the secondary position, supporting the patient's actual medical condition.
  
Note: Coders will generally be able to identify an E code explaining an injury. However, there are fewer E codes available to describe occupational illnesses.

At times, conditions other than a work-related injury or illness may be treated during the same encounter. For example, an FP is treating a patient for carpal tunnel syndrome (354.0) on an ongoing basis. During one appointment the patient complains of fever (780.6) and sore throat (462). The FP diagnoses strep throat and prescribes an antibiotic.
 
"This should be clearly delineated in the patient record," Wiggs says. "The physician makes notes related to the WC condition and links those to the work-related diagnosis. The strep is also documented separately and clearly mapped to that diagnosis." 
 
In most cases, the services are submitted to different insurers. Each claim reports only the applicable service and relevant ICD-9 code, i.e., the WC claim would be submitted, with documentation, to the WC insurer, while the illness would be reported to the patient's regular payer.
 
On rare occasions, one insurer may handle both claims, so modifier -25 (significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) is appended to the second service.

Due to workers' compensation programs differing from state to state, coding and billing professionals should expect some variations in reporting procedures, including the forms used to submit claims, says Rudy Tacoronti, MD, director of occupational medicine for DeKalb Health Systems in Decatur, Ga. "While the overall process is the same, family physicians will see differences in what cases WC programs will ultimately compensate."
 
For instance, some states will pay for mental-health claims only when there is a corresponding physical injury. Some cover supplies, e.g., casting materials, while others don't. Another primary difference is how various programs define "activities that furthered the interests of the employer," Tacoronti says. Some cover all injuries to employees that occur on company property, for example, while others would deny a claim concerning an employee who has left his work area to get a cup of coffee.
 
To ensure that they understand guidelines affecting claims in their state, family practice coders must know the  relevant policies. The United States Department of Labor's Employment Standards Administration oversees workers' compensation programs nationwide. Its Web site, www.dol.gov/dol/esa/public/owcp_org.htm, contains links to individual WC Web pages in every state and the District of Columbia. Coders may contact their state's department of labor or industry directly for specific information.