Primary Care Coding Alert

Since coding for work-related injuries is dictated by each state, there are no national standards to follow. Thats why its important to obtain a copy of applicable state workers compensation agency billing manuals and guidelines to ensure payment.

Terry Fletcher, CPC, CCS-P, a healthcare coding consultant with McVey Associates, a national specialty coding seminar company in Novato, Calif., reminds coders that it is the state where the employee resides, not where the accident occurred, that determines coding.

CPT added codes 99455 (work related or medical disability examination by the treating physician that includes: completion of a medical history commensurate with the patients condition; performance of an examination commensurate with the patients 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) and 99456 (work related or medical disability examination by other than the treating physician). These may be used to report independent medical examinations to determine disability status but are only recognized in some states.

Despite the variations state-to-state, here are some suggestions to keep in mindno matter where the coding is done. Garnet R. Dunston, CPC, MPC, president/CEO of Dunston Enterprises, a coding consulting firm in Phoenix, Ariz., recommends using the appropriate ICD-9 injury code, as well as the external cause code(s), which show where and how an injury occurred. For instance, if a patients hand is cut by a mixing machine in a bakery, the location of the injury would be 959.4 (hand, except finger), while the cause would be coded E919.8 (other specified machinery, for the manufacture of clothing, foodstuffs and beverages, paper; printing, recreational machinery; and spinning, weaving and textile machines).

On the other hand, if an employee received a concussion when he was hit by a pulley block, the coding would be 850.1 (concussion with brief loss of consciousness, less than one hour) and E919.2 (lifting machines and appliances, including chain hoist, crane, derrick, elevator, forklift truck, lift, pulley block and winch). Remember that E codes should only be used as secondary diagnoses.

According to Fletcher, there are five key things to watch out for when coding for work-related injuries:

1. Appropriate history: Make sure you obtain an appropriate history for the patient, which she says can differ from the one taken during a regular E/M office visit. A form used to record a workers compensation history should capture:

the patients name, age, occupation and
address;
the name and address of the insurance carrier and of the employer;
type of business;
date and time of injury; last date worked;
whether the injury caused lost days at work;
where the accident occurred, how it happened,
which doctor treated it, what was the treatment and how long did it last;
what medications were required and did they help;
if physical therapy was necessary;
if the accident created new physical complaints
or were they caused by an earlier accident;
whether the patient has returned to work;
current medical complaints; and
an in-depth job description.

2. Authorization: Obtain an authorization from both the employer and insurance carrier to treat a patient injured on the job. The employers authorization supersedes that of the carrier.

3. New injury: Make sure that treatment is authorized for one of the following: a new injury, exacerbation of an existing injury or for the residual effects of an old injury, especially if quite a bit of time has passed since the last visit by the patient. Fletcher says that patients do not have carte blanche to come into see the doctor whenever they desire.

4. Insurance: Find out if the employee is covered under group insurance. If not, you may run the risk of providing ongoing treatment free of charge. Some patients claim workers compensation injuries to avoid paying
out-of-pocket co-insurance and deductibles, Fletcher says.

5. Re-injury: Determine how many other physicians have treated the patient for the same injury. The number of providers is often limited to two or three per injury by the state so you may not get paid if you are number four or five, Fletcher adds. She cautions physicians to watch out for patients who reinjure themselves or work the system. It is the physicians responsibility to return the patient to pre-injury status or maximum medical improvement, not to perfect health, she adds.