Primary Care Coding Alert

Presented by Marvel J. Hammer, RN, BS, CPC, CCS-P, CHCO

The following supplement to Family Practice Coding Alert is the transcript of a teleconference presented by The Coding Institute. To obtain the slides for the conference, please log on to our Online Subscription System at http://codinginstitute.com/login and open the PDF version of the current issue, and the slides will be contained therein. If you-re not sure how to use the Online Subscription System or need help opening the issue, please contact our customer service department at 1-800-508-2582 or service@medville.com, and one of our representatives will be able to assist you.

The speaker for the teleconference, Marvel J. Hammer, RN, BS, CPC, CCS-P, CHCO, is an accomplished professional with many years of experience in both business and healthcare. She is a coding and compliance consultant and principal of MJH Consulting in Denver, Colorado. She provides documentation auditing, healthcare compliance evaluations and coding/account receivables assistance for her clients. In addition, she teaches providers and their staff correct coding and billing strategies. She is currently the president of the Rocky Mountain chapter of AAPC. Marvel is a registered nurse with over 25 years of experience in numerous specialties.

Good morning everyone.  I should say good morning and good afternoon depending on where you are in the country.  I would like to start off today's session with a little anecdote that I ran across.  It is called an EMT true tale.  We got a call to respond to a work site related injury and when we arrived, we found one of the employees clutching his hand.  Not paying attention, he had run his hand through an electric plane.  After stabilizing the guy and whisking him off to the hospital, my partner and I returned to the base.  However, a short time later, we received another call to another emergency at the same work site.  When we arrived, low and behold, the same guy returned to the work site to explain or possibly brag about the incident to his co-workers.  Upon demonstrating the accident, his bandages were caught in the revolving plane and again he ran the same hand through for a second time. 

As many of you have probably seen in your practices, Workers- Compensation injuries do not always make sense.  We are going to talk today about some guaranteed strategies for Workers- Compensation claim success and how to take the work out of Coding & billing Work Comp claims.

Let us go ahead and get started.  I would like to briefly talk just a little bit about the history of Workers- Compensation and that will give you some insight as to what the mechanics of what we have current day.  Workers- compensation is basically the oldest social insurance program known.  It first started in Europe in the 1800s and it became quite common in the United States in the early 1900s.  Wisconsin had the first Workers- Compensation regulations in 1911 and by 1949 all states had a Workers- Compensation system.  And basically, prior to having any system in place, an employee that became injured would need to take the employer to court and show that the employer was at fault for their injuries, so frequently employees would have a catastrophic injury and not have the mechanism to obtain a lawyer and sue the employer, so there were employees that were becoming injured and not being compensated.  So this legal compromise between workers and businesses, basically what it is, is that it encourages businesses to accept full responsibility for the insurance premium costs and the workers give up the right to sue the employer for damages resulting from a job-related injury.  So in return for compensating employees who require the medical treatment or who miss work due to a workplace injury or disease, employers avoid potentially costly lawsuits.  So injured workers receive medical care and disability income irrespective of fault, so in essence it is basically a no fault system.  There are a few exceptions of course.  Employees who hurt themselves due to reckless behavior, hurt themselves due to drug or alcohol abuse, they hurt themselves while off duty or of course engaged in a criminal act.  Unfortunately, litigation is not totally eliminated.  Now, there are other issues, such as was the injury sustained on the job and how much benefits is an injured worker entitled to receive? 

In 2003, and that is the most recent information that we have available, there were almost 4.4 million recordable cases, that is separately reportable cases, of non-fatal injuries and illnesses related to work, 1.3 million of those had days away from work.  The vast majority of those for occupations were truck drivers, not surprisingly, then nursing aides, orderlies and attendants and so on.

I would now like to look at is the coverage of where we are at.  Workers- Compensation laws and regulations are created by each state, as I said historically, and they are regulated and administered by state officials.  There are certain state options that each state determines.  States can decide whether they are going to allow private Workers- Compensation to write policies in their state, such as Liberty Mutual and Kemper, State Farm has a Work Comp program.  So private insurances, some states allow it to be written in there; other states have state exclusive insurance agency, in that there is no private insurance, such as Ohio, West Virginia, Wyoming have exclusive state insurance.  Other states also allow for the employer to be self-insured and that now accounts for more than one-third of the traditional market premium.  Most states have policies in place that require, if the employer is going to self-insure, they will frequently use some type of a third party administrator, whether it would be a private insurance or a TPA that administers that.  But they are self-insured against the loss and they will need to satisfy the certain dollar amount in bond so if that employer were to go bankrupt, then the injured employees would not be at a loss.  Also, there are combinations, there are certain states that have a state fund and they also compete with private insurance, such as Arizona, Kentucky, Montana and Oregon.  These states also have a state fund, but they also allow private insurance to be written.

Some other differences are federal employees, federal employees are covered by the Federal Employees Compensation Act and they are covered under this act irrespective of geographic location of injury, so it supersedes the state jurisdiction.  Whereas, if you were injured and you are not a federal employee and you are injured in a particular state and the claim gets filed with that state, those state laws govern.  Whereas a federal employee, they are covered by the Federal Employees Compensation Act and their Work Comp claim is administered by OWCP.  Maritime employees are covered by the Longshore and Harbor Workers- Compensation Act.  It is also administered by OWCP, again that is irrespective of the geographic location of the injury.  The only one that is slightly different is railroad employees.  They are covered under the Federal Employees Liability Act of 1908 and it is still basically a fault type of coverage.  Often, the medical expenses are processed by the railroad medical coverage policy, so you will just be needing to watch that when it gets processed and an EOB comes back, many times there is a co pay processed with that.  But if that is submitted back to the railroad adjuster, they will go ahead and take care of that co pay.

I would like to move on to the bottom of page 2, Webster's definition of -jurisdiction- is the power, the right, or the authority to interpret & apply the law; the limits or territory with which authority may be exercised.  So the basic question is which of the multitude of Workers- Compensation laws apply to this patients particular claim?  I have come up with a series of questions and I am going to pose them to you and you jot down the answers as I lead them and I will give you the answers.  First of all we have a coding clerk in Florida that trips over a stack of coding reference books and injures his ankle.  The first report of injury is filed with the State of Florida, which regulations apply?  Okay, I can hear many of you out there, you are saying Florida and in fact it is indeed Florida.  The first report of injury is filed with the State of Florida and this is pretty straightforward.  The injury occurred in Florida, the report of injury was filed with the State of Florida, so Florida's regulations apply.  The next one we are going to get a little more complicated, a billing data entry employee in Ohio has a computer monitor fall on her head.  The first report of injury is filed with the state of Ohio.  However, the recovery is prolonged.  The injured employee moved to California with her spouse and now is receiving medical treatment in California.  What state regulations now apply?  I hear a few of you saying California, I hear a few of you saying Ohio.  Actually, in fact, it would be Ohio.  Just because the patient moves and is now receiving medical treatment in another state or another entity, it does not mean that the regulations transfer.  It does not have anything to do with the location of where the services are provided, but moreso where that injury was filed with, what jurisdiction, and in this case that was filed with the jurisdiction of the State of Ohio.  This frequently causes problems with billers and coders as they are thinking that everything should follow with the state where the services are being provided.

Now, our third example, we have a postal employee in Oklahoma, who is being treated for carpal tunnel syndrome and it is considered a repetitive motion injury; where is the first report filed with and which regulations have jurisdiction?  I hear a couple of you saying Oklahoma, but the vast majority of you are saying the Federal Workers- Comp and so it will have OWCP, that is correct.  Remember I said for postal employees or any federal employees, it is irrespective of where the injury occurred.  Federal Workers- Comp takes right over the jurisdiction and their regulations will apply. 

Our fourth example is a nationwide coding consultant injures his back unloading coding manuals from his car in Georgia.  He was first seen in Occupational Medicine Clinic in Georgia, but the consultant lives and is based in Pennsylvania and will return there for treatment, they employer follows the first report with Pennsylvania, which regulations apply?  Oh, I think you guys are getting this-.that is right-..Pennsylvania.  Just because the employee was injured in Georgia and first seen in Georgia does not necessarily mean that it is going to be filed with the State of Georgia or where the injury occurred.  In many instances, employers will file it where their employee has domicile or where they live at because the vast majority of their treating providers will be very familiar with the Workers- Compensation rules of that state.  This is particularly true when you see truck drivers that are possibly injured in a work related injury, they can be traveling nationwide, but often times it would be filed with the state that they are going to be receiving the vast majority of their care in, often their home state.

The last one is a regional nurse case manager who was involved in a motor vehicle accident in Wyoming while working.  She lives in Colorado, but the employer is based in Illinois.  First of all, could this injury be a Workers- Compensation claim?  I am hearing a resounding- yes it is probably a Work Comp claim- that is because she was in the process of working while involved in that motor vehicle accident.  So just because the patient, such as traveling salesman, delivery man, comes in and was in a motor vehicle accident does not mean that it is necessarily an automobile injury claim, but it could potentially be a Work Comp.  What state would have jurisdiction for this?  Probably Colorado, because again she lives in Colorado.  However, there are some employers that will file the claim based on where they are set at, so it could potentially be Illinois.  Well, now that we have that straightened out, I would like to move onto some Workers- Compensation jargon.

On page 3, starting on pages 3, 4, 5, and 6, I have compiled a dictionary for you.  We are not going to go over all of those, but I would like to pull out a few of them.  The first one is called the first report of injury and that is about halfway down on page 4.  Basically, the first report of injury, or the abbreviation ROI, and there are many acronyms in Workers- Compensation, often is required to be filed by an employer in cases of an employee's occupational injury or disease that results in incapacity from work of one day or more.  The next, I would like to look at is DOI or date of injury, that is on the bottom of page 3, it is an important date that the work-related injury occurs, or for occupational disease the date of total or partial incapacity to work due to disease.  This becomes very important.  It is easy to determine our date of injury when someone has a fall or someone has a twisting bending sprain mechanism, but what about the diseases, such as repetitive trauma, carpal tunnel?  There is not an individual date.  It is an important to obtain from the adjuster, so that it can be related on your billing.

Maximum medical improvement, that is actually on page 5 about halfway through.  This is an important concept.  It is the time at which a claimant's attending physician determines that the claimant has healed from a compensable injury or occupational disease to the fullest extent he is expected to heal.  We have to realize that in some situations, physicians have that inability to make whole.  They may have followed all the treating Work Comp guidelines and they cannot bring this injured employee back to the state of health or condition prior to the injury.  In a catastrophic crush of a foot where they have had to do a below knee amputation, of course, we cannot make that patient whole again and bring them back to two functioning legs.  They may reach MMI.  Where it gets more gray and more difficult for patients to understand is when they have a back sprain or strain, they maybe have had surgery and they are left with long-term pain, it may be determined that they are at MMI, but they still have pain.

Impairment, that definition is found on the bottom of page 4, it is what is anatomically or physically wrong with an individual.  It is often confused with disability.  It means to assign a numerical rating for whatever type of bodily function has been lost.  It is often specified as a percentage of either whole person or of a limb. 

Disability, that is at the top of page 4, it represents how an impairment combined with the patient's age, educational background, vocational background, and other factors affect an injured worker's ability to return to work.  Again, often it is used synonymously with impairment, but that is not correct.  Impairment is a part of the overall disability.  Chronic disability to a work injury is really relatively rare, only approximately 10% of the cases are termed -chronic disabled-.  However, this 10% of injuries account for approximately 80% of the cost in Workers- Compensation. 

I would like to now move on and you can review these other terms at your own leisure and use them in your day-to-day practice.

I would now like to move onto the top of page 7, the best place to start is can your provider see this patient?  Each jurisdiction has decisions as to who dictates, who has the choice for the medical provider.  In some states, the employee has the choice, such as Alaska, New Hampshire, Federal Work Comp, the employee has the initial choice.  Other states have an employer choice, such as Florida, Iowa and South Carolina, those jurisdictions say the employer has the initial choice for who the patient is going to be seeing.  Other states have panels or lists of approved providers.  The New York and the District of Colombia have a state agency list, where Georgia and Virginia have an employee choice from an employer list, so the employee gets to choose, but it is from a list that the employer determines.  And there are some states that have a mixture or a combination, such as Colorado which  has an initial employer selection, but the employee, the injured party, can petition to the state agency for a change.  In California, the employee has the free choice following a specified period, so the employer has an initial selection, but the employee has free choice after a certain period of time, likewise for Pennsylvania.  So it is important to know first of all the jurisdiction that your typical Work Comp patients are seen and who has the say, can your provider see this patient? Are you on the list?  Also you need to be careful of how your front desk asks questions.  You will get an answer, but possibly not the correct answer to the question intended.  For example, if I present to my doctor and the front desk says, -what's your insurance?- I am going to say -United Healthcare;- but potentially if this is a Workers- Compensation claim, you do not want to hear that it is United Healthcare particularly as the primary insurance for this.  Second of all, -who is your employer?- Well you may get the response of -I-m unemployed- and many patients do unfortunately go on to become unemployed with the Work Comp injury because of the catastrophic nature or they are unable to perform their job duties.  But if they have a Workers- Compensation injury, they have had to be employed at sometime.  So your front desk needs to be trained to ask the appropriate questions.

We are now looking at the bottom of page 7, important information to get is date of injury, the type of injury, Workers- Compensation carrier, the claim number, the employer at the time of the injury, the adjuster's name and telephone number, and/or the case manager's name and telephone numbers.  Many times, if is a delayed recovery, your provider is a physical medicine rehab or a surgeon.  They may have both an adjuster and a nurse case manager.  Alternate private insurance information--this is important, I think, to get upfront, so that if it is an initial injury and it is deemed not to be work-related, you already know the patient's private health insurance and it can already be turned over because the injury is being deemed not work related.  As I mentioned in the beginning, there are still many times an attorney is related and attorneys can help you in these delayed recovery cases, so if the patient has an attorney and is being represented, it is good to get that information.  I have provided you with an example of an intake sheet that has that information and that is in the back of the packet.

I would now like to move onto documentation, the top of page 8 has a great illustration for documentation viewed from the four points.  In this instance, a nurse sprains her back while lifting her patient, so it describes the four portions of what we like to see in documentation, the nature of the disabling condition (it is a sprain), the event or exposure (lifting), the source directing the disability (the patient), and the part of the body affected.  So from the initial history, the bottom of page 8, I would like to see in the documentation, how the how the injury happened, what parts of the body were involved, when the injury took place, was the injury observed by another person?  When its manifestations occurred--what I mean by that is it may initially started as low back pain, but now the patient is having a manifestation of radiculopathy or numbness and tingling going down the back of the legs, it may have a different time period.  Statement of causality of condition--these are all the important things that we would like to see in the initial history.

Now for follow-ups, probably one of my pet peeves is to include more history than -patient here for a follow-up---that to me is a red flag for any provider.  I would like to see as, in the bullet point 2, a link in the HPI back to the injury.  -Mr. X returns for a visit for low back pain due to slip and fall accident at work on June 1, 2004.-  This gives us that this visit is due to a Work Comp injury, it is the Work Comp injury that was a slip and fall, and it is low back pain.  It clearly separates out.  Unfortunately, in this world, we see patients that have multiple Work Comp claims, they may have a slip and fall that has a low back pain, they also may have a carpal tunnel going on that is a totally separate Workers- Comp claim.  So when we have this type of a link in a follow-up, it makes it very clear to the adjuster, to the nurse case manager, to the attorney, anyone that is reading it that this note has to do with the low back pain that is slip and fall.  You want to clearly have indicated any work restrictions, the patient's progress, and more importantly, the treatment plan.  These are all things that nurse case managers and adjusters are looking for to communicate to the employer any work restrictions that are necessary.  How this patient is progressing along.  The key emphasis for all parties for Workers- Compensation claims is to try and get that patient back to work as soon as possible.  The longer the patient is out from work, the more difficult it often becomes to get them back into the work situation.

I can't emphasize the timeliness of documentation.  Unfortunately, we all know that we have providers out there that tend to a little lackadaisical about doing their documentation, whether it would be handwritten or dictated.  This is what nurse case managers and adjusters use this documentation to follow the treatment plan.  So if you are needing to get authorizations or approval for certain procedures, either diagnostic or therapeutic, if your provider is not very timely on their documentation, you may have great difficulty getting that.  Expedites the authorization process, as I mentioned, for diagnostic testing, maybe your doctor thinks that they need to have an MRI or CT, but the nurse case manager or the adjuster has not seen, for the last three visits any notes, it is difficult for them to do an approval for an MRI if they do not know what is going on with the claim.

I would like to briefly just mention using time is the key component.  It is important that providers do a lot counseling with these patients, it is a different kind of visit than maybe what they have had before, this may be their first Work Comp injury.  And often times the guidelines allow for documentation of mechanism of the injury, return-to-work issues, work restrictions, compliance with treatment plan, tools, exercise, positions to prevent worsening of the current injury or re-injury.  Again, as documented in our CPT guidelines, we need to have a clear documentation if we are going to use the time to determine the level of an E/M and it needs to be greater than 50% of the time spent on counseling the patient, so we need to see the total amount of time, the amount of the time spent counseling, and a brief inclusion of the area spent.  So I want to see things like, -I spent 45 minutes of the 60-minute visit discussing with the patient on the mechanism of their back injury,- or -I spent greater than 50% of the 25-minute visit counseling the patient on return-to-work issues, their work restrictions.-

I would now like to look at the issues on the top of page 10, jurisdictions.  Some regulate the usage of regulated forms or required forms.  Some jurisdictions or entities have up to 10 different forms that are used for reporting different patient occurrences.  Providers may or may not be reimbursed for completion of the required forms.  Each jurisdiction is different.  Another entity that you need to be aware of or an occurrence is apportionment.  There are some patients that have pre-existing conditions or they may have two Work Comp injuries, these Work Comp injuries may not be covered by the same payer, so be watchful of the wording.  Some payers will process the reimbursement of the services at a stated percentage of the apportionment, so if a claim has been apportioned 10% due to the current Work Comp and 90% due to pre-existing, there may be some payers that will process the services at 10%.  Also, the reimbursement for services may be split between multiple payers depending upon the apportionment.  They may have an open Work Comp claim for the low back and they may have an open automobile injury for a totally different injury that is open with their neck, and it will be a process of adjudication just as if we have a primary and a secondary insurance in our private health system.  Likewise, we would send the bill to the Work Comp and they pay portion and you would send an explanation of benefit onto the other payer.

We need to be aware of multiple patient complaints, where Work Comp is the chief complaint along with non-Work Comp complaints.  I see this more frequently with primary care that is managing the Work Comp claim, they will have a patient come in and they are being seen for the low back pain, but they are also have a complaint of earache and ear infection.  Remember that the documentation is frequently required by the jurisdiction to be sent for Workers- Compensation claims, and the release of more PHI than is minimally necessary.  Options for this is to separate documentation, have your provider do documentation for the Work Comp claim on a separate note and the non-Work Comp complaint on a totally separate documentation.  Some practices have even gone to the step of separate charts.  They have a chart for Workers- Compensation for that patient and they have a chart for non-Workers- Compensation complaints.  Other options are to reschedule the patient to be seen for the non-Work Comp complaint.  I really want to emphasize that it is very important that providers do not get caught with treating non-Work Comp complaints and submitting the bill to the Work Comp carrier.  Remember that documentation is not only read by people in the medical field, but it also may be read by non-medical people, including the injured worker, their attorneys, the payer's attorneys, and insurance adjustors.  We certainly don't want to have a patient having discussions of, let us say for example, sexually transmitted diseases that has nothing to do with a Workers- Compensation claim--having that dictation being mixed in with the Work Comp claim of a sprained ankle.  So I very much want to caution providers on choosing a mechanism, when they do see patients for Workers- Compensation and non-Work Comp, to establish a policy.  They are either going to have separate documentation or reschedule the patient or see the patient for what the emergent need is and reschedule them for the non-emergent need.

I would now like to look at Workers- Compensation and HIPAA.  Do you sometimes feel like you are being swallowed up by HIPAA?  We just recently passed the compliance date for HIPAA security and we are still working on HIPAA privacy.  Well, specifically, I have provided you on page 11 some of the specific regulations that have to do with Workers- Compensation and HIPAA.  Specifically, 45 CFR 160.103 excludes Workers- Compensation from the definition of a health plan.  Basically, what that entitles is that HIPAA Privacy Rule does not apply to entities that are either Workers- Compensation insurers or payers, Workers- Compensation administrative agencies, or employers.  So when the claim is a Workers- Compensation claim, the privacy rule is excluded and not applicable.  Now, if you are in a private practice and you are to be seen for both the Work Comp and for non-Work Comp issues, the privacy rules still applies to those non-Work Comp visits and the conditions that the patients are seen, but the privacy rule does not apply to the Workers- Compensation.  So how this rule basically works:  It permits the covered entities, which are your providers, to disclose protected health information as authorized by and to the extent necessary to comply with Workers- Compensation or other similar programs established by law that provide benefits for work-related injuries or illnesses without regard to fault.  The HHS also notes where a state or other law requires a use or disclosure of PHI under Workers- Compensation or similar scheme, the disclosure would be permitted.

So basically we can have disclosures without individual authorization, so covered entities are allowed to disclose PHI to Workers- Compensation insurers, state administrators, employers, and other persons or entities involved in Workers- Compensation systems without the individual's authorization.  What we need to be aware of, and this is why I really stress the point of when you are having next visits, we need to carve out any of the PHI because again, as in the bottom of page 11, we only want to provide the minimum necessary.  We are required to reasonably limit the amount of PHI disclosed, so again we do not want to disclose PHI regarding a sexually transmitted disease when it has no applicability to the Workers- Compensation information.  Does this mean that that we can provide information to the employer?  If it is a Workers- Compensation claim and the documentation has to do with Workers- Compensation claim, yes we can, we can disclose without an individual patient's authorization.  Again, we need to caution and look at that documentation to make sure that it is the minimum necessary.  This occurs potentially and more frequently when the employer is self-insured, they are the ones that are going to be getting the HCFAs and the notes and so we need to be particularly careful about what documentation goes.

At the bottom of page 11, I have given you a Web site address and this provides great information.  Basically, you link that up, you click on -answers to your frequently asked questions,- and there are two different strings that you can type in search text.  One is -Workers- Compensation,- there are currently right now seven different answers found, such as will the privacy rule impede the disclosures needed to pay Workers- Compensation claim?  May I disclose the information that is needed to adjudicate a Workers- Compensation claim?  And what types of insurance are not covered by HIPAA?  Another string that you can put in that search text is -employer- and there are six answers currently listed there; if my state law permits a disclosure with a workers- written release, would the Privacy Rule require more?  This is a great source of information and I strongly encourage you to look that up and using different search texts, but as I said using -employer- or -Workers- Compensation- gives you great information as to the privacy rule and information that can be disclosed without authorization.

I would now like to shift onto looking at coding and billing.  We are going to look at ICD-9, CPT and the HCFA-1500 form.  We are going to look at now in 2002, the back involved almost one-fourth of all occupational injuries and illnesses, almost 25% of all injuries and illnesses that had days away from work involved the back.  We had 617,000 involved sprains, strains and tears in 2002.  What does this mean to us?  Well this means what of types of diagnosis are we going to use.  Typically, the chapters that include diagnosis codes or chapter 16-symptoms, signs, and ill-defined conditions, particularly at the beginning where there is no specific diagnosis at time of visit, the reason for the visit or why patient sought care.  Chapter 17 includes injury and poisoning, you need to remember the guideline rule when you are coding multiple injuries.  We always want to code most severe injury as the primary diagnosis.  So if a patient has an injury, let us say they have a stack of boxes fall on them and they have a fracture to their forearm and they also sprained their ankle, our primary diagnosis is going to be the fracture to the forearm and our secondary diagnosis is going to be the sprain/strain to the ankle.  What about coding chronic disease in association with an injury?  We want to make sure that we are only going to code the comorbidity if it has an effect to the patient's injury or treatment.  If the patient has had chronic disease, let us say they have chronic urinary tract infections, that in most cases will not have an effect to the patient's injury or treatment.  But let us say the patient has carpal tunnel and they also have cardiomyopathy, they have diabetes, they have other issues going on that do have an effect as to what type of physical therapy, what kind of medications can be prescribed to this patient and that our provider has to consider as comorbidities and take them into consideration.  Then it would be appropriate for coding the chronic disease along with it.  I want you to be suspicious of routine provider use of -same as;- where they progress, there is a normal progression from an injury or a disease with symptoms and signs that it needs to go from a suspected or ruled out to a confirmed diagnosis.  So if your provider has been seeing this patient for 10 months and we still have -rule out herniated lumbar disk,- you need to probably go back and talk with that provider that they need to improve their documentation, so that you can code correctly for the diagnosis.

I want to stress that the Federal Workers- Compensation jurisdiction has changed that came into effect approximately a year ago.  They did this for the primary reason that there are many instances that payers pay for services that do not have anything to do associated with the Work Comp injury and so Federal Workers- Compensation put into their ruling that they are going to establish a diagnosis for that injury and at the time of that injury that is going to be the diagnosis on record.  And providers need to code and submit billing with that diagnosis, the reported diagnosis, or petition to have it changed.  So if a patient comes in with a sprain/strain of a shoulder and it gets listed as the diagnosis on record and now we have come to find that the patient actually has a rotator cuff tear or a more specific diagnosis, if you use the torn rotator cuff diagnosis, that claim will be denied.  Now certainly as a provider, there are forms from Federal Work Comp to append or change that diagnosis code and that is the correct procedure to do, but you need to be aware of that.

I want to briefly look at the E codes that are on the bottom of page 12.  Effective April 1, 2005, we got new ICD-9 guidelines that apply to the E codes and it specifically says, -assign the appropriate E code for all initial treatments, but not for subsequent treatments- and that is the Web link address for the PDF file for those guidelines.  Of course, we never are going to report an E code as primary or first listed diagnosis, it can never be the primary, but it frequently completes the picture and assists the payer in determining if the accident or injury was caused by something that would render a third party responsible for the payer.  It allows for separation of multiple Work Compensation claims.  If the patient has a fall and they also have a carpal tunnel, the fall would have an E code assigned to it.  Also, it is very important:  there are many coders that do not use E codes, however, that is how we get the statistical tracking, so I strongly encourage coders to all compliantly use E codes.  The sections that are frequently used are E880-E888, E919, E920, E927, and E849.  These are all various sections that are typically used, accidental falls, accidents caused by machinery, accidental needlestick, overexertion and strenuous movements.  E849 is the place of occurrence.

Now at the top of 13, we are going to look at the late effects of accidental injury--E929.X.  The new guidelines state use late effect E code for subsequent visits when a late effect of the initial injury is being treated.  However, do not use a late effect E code for subsequent visits for follow-up care of the injury when no late effect of the injury has been documented.  So when we have got a fracture and your provider is seeing that patient for the current treatment of that fracture, we would not use a late effect code.  However, if the patient is coming back in and they have a nonunion or a mal union of that fracture, then it would be appropriate to use the late effect of an accidental injury, the E929 with appropriate fourth digit code. 

A couple of examples, #1, a drill press operator lacerates two fingers while operating a power press.  The injury does not result in the tendon damage.  Well, our primary diagnosis of course, as we indicated, would not be the E code, but would be 883.0, while our secondary diagnosis would be E919.3 accident caused by metalworking machine.  I-ll let you look at the second scenario at the bottom of page 13, where we have got a rule out sprain/strain fracture, can we code rule out sprain/strain fractures?  No, we cannot.  The primary diagnosis for this visit needs to be the pain in the joint which is the pain in the wrist, 719.43.  We will include secondary diagnosis E881.0, which is a fall from the ladder.  Again, after your doctor has maybe done some diagnostic studies, ruled out the fractures and determined that it is a sprain/strain, as I mentioned before, we do not want to necessarily stay with the symptoms or signs, we want to progress onto the diagnosis of sprain/strain.

Moving onto CPT codes.  What year CPT code do we use?  And this is what is often frustrating for coders and billers.  Many states- regulations mandate past year codes and again, remember Workers- Compensation insurance and the state regulations are not covered entities by HIPAA regulations, so they are not mandated to use 2005 codes.  What you want to do is check each state that you send claims to.  Typically, let us say, your practice is in the middle of the state, we will say the middle of Minnesota, and you very rarely, if ever, get Work Comp claims for outside jurisdictions, you want to be very familiar with the what Minnesota will allow.  Whereas, let us say, if your are close to state lines, we will say Missouri and Iowa and Kansas and Nebraska, your practice is up in that corner, you want to be very familiar with all four of those jurisdictions because they may vary;  I would recommend creating a coder's reference sheet, so that you know exactly what CPT code to use for the procedures that your providers do for the correct code to be reported.

The bottom of page 14, I just showed you an example of what codes to use for these common Work Comp procedures and services.  Remember that we said that back sprains/strains are one of the more typical and possibly leading to herniated disks.  Interlaminar epidural steroid injections, code 62310 and 62311, are frequently performed for Workers- Compensation injuries.  This new code came into effect on January 1, 2000.  However, the State of Louisiana currently still uses 1994 codes.  So if you reported 62311 for a lumbar epidural injection to Louisiana as a jurisdiction, your claim will in most likelihood be denied as not a valid CPT code.  Trigger point injections; we know that they came about on January 1, 2003, however, California is currently using 1999 CPT codes.  So you would need to default back for a California claim to the 20550 codes.  Starred procedures in the CPT code 99025.  In Occupational Medicine, starred procedures got performed many times--the lacerations and the 99025. However, that was deleted effective January 1, 2004.  Maine uses 2002 CPT codes, so for Maine the starred procedure and the use of 99025 would be compliant.  Acupuncture codes became effective this year in 2005.  The 97810-97814, however, Colorado is a year in arrears and they are using 2004 claim.  So if your provider performs acupuncture in the State of Colorado for non-Work Comp claims, non-Colorado-based jurisdiction, they are going to be using the new codes.  However, in Colorado Workers- Comp jurisdiction, they are going to be using old codes that are not time based.

At the tope of page 15, what does the jurisdiction allow for non-compliant codes?  Again, remember there is no need to be HIPAA compliant, so they can have own codes.  Example: Arizona has multitudes of noncompliant codes, likewise Michigan, these are just examples.  Does the jurisdiction have other descriptions or interpretations for valid CPT codes? An example is that Colorado currently uses the relative value physician's guide for their CPT codes and the basis for reimbursement.  The description on motor nerve conduction studies and sensory nerve conduction studies varies from the AMA CPT book slightly and that has an effect on the quantity of units billed, coded, and processed.  Does the jurisdiction have other rules for coding of valid CPT codes, such as a new injury?  Some jurisdictions allow that if the patient is being seen for a new injury, you can bill a new patient E&M code, the 99201-99205 versus an established patient.  That is something to be aware of and the basis behind this is that they are thinking that these patients are typically seen by Occupational Medicine doctors who do not have the benefit of seeing these patients on a long-term basis and so when they see them for a new injury it is basically like seeing them as a new patient again.  Also, how do you handle multiple valid open work comp claims?  If they have one visit for multiple claims, how many E&M codes do you get to bill for?  Different jurisdictions have different policies.  Some make them be seen on separate days.  Some allow them to bill multiple E&M codes.  Let us say, they have got two open work comp claims: one for a carpal tunnel and one for an ankle.  The patient was seen at one visit, but one the provider documents two separate documentations, they can bill two E&M codes.  You just need to be aware of the jurisdiction rules.

As I mentioned before, some jurisdictions allow for the coding, billing and reimbursement of some required workers- compensation forms.  You just need to be aware.  Impairment rating:  The typical codes used are 99455, 99456.  When the evaluation is for the treating physician, which is slightly less than other than the treating physician, which is typically a consultant.  It makes sense because the consultant does not have the benefit of knowing the patient and has to do additional record reviews. 

I want to talk briefly about independent medical evaluations or examinations.  Look at the definition in the dictionary that I provided for you.  It is not uncommon for patients to be sent for an IME.  There are various codes that can be used.  What I like to see used is 99499 because typically IMEs are pre-agreed upon dollar amount rather than based on RBRVS evaluation or RVU, so you may have already established that for this IME that  you are getting a box full of old records.  It is going to be valued at X dollar account so if you submit with 99499 then that is going to be adjudicated by hand rather than if you submit a 99245--that is going to go into your payer's computer system and be processed as that.  So just be aware of how it is determined.

At the top of #16, I would like to look at different medical legal issues.  We have record reviews, depositions and testimonies.  Your jurisdiction may have special codes.  Typically, they are established and may be per hour.  You want to have that very clear ahead of time before you do any record review, deposition or testimony.  I strongly recommend having a written and signed agreement.  It can be as simple as a faxed page that you fax over.  Prior to the services, the adjuster or the claims manager signs off on it and it covers the provider time required, the fees, the cancellation and refund policy.  This is very important because it is very, very common that your provider might be called to go and testify in a legal proceeding to try and get this work comp claim settled.  They set this up.  They need him for 4 hours that you carve out of your schedule.  This is set up two months in advance and two days before the trial occurs the case gets settled.  The two attorneys for the payer and for the patient come to an agreement and get settled, and no longer is your provider necessary to testify.  Well, now you have a 4-hour block of time that has been carved out of the schedule.  How is that going to be handled?  My recommendation is that these be handled as prepaid.  That way it is clearly up front rather than having something canceled and then you need to be trying to getting money from something that has already been settled.

Now we were going to look quickly at the bottom of page #16.  This is a HCFA form.  I have pointed out certain areas where information may either be mandatory or helpful.  In box 1A and in box 11, I strongly recommend including both the patient's social security number and/or their claim number so if you put social security number in 1A then put their claim number in 11 or vice-versa.  Work comp claim numbers can be a long string of alphanumerics and if you are off by 1 digit or one alphabetic character, frequently they can find the patient by their social security number.  You need to indicate in box 10A the work comp relationship.  It is helpful to have an 11B, the employer at the time of the injury of course; and in box 14, we want to have the actual date of injury.  This is where it becomes important for the disease related, such as black lung or carpal tunnel, that we have a date of injury even though it is not a specific date.  Frequently, claim adjusters will establish a date for the benefit of that patient.  Also, it may be helpful--it is not mandatory--to have the dates in box 16.  Some states require the provider's medical license number down in 33.

I would like to briefly look at some claims processing issues.  Authorizations:  You want to look at your regulations regarding prior authorization.  Fee schedule basis:  Remember that jurisdictions may vary.  Some may be based on RBRVS.  Some may be based on RVU.  Some may be based on usual and customary.  You want to make sure that you are sending the claim to the correct payer and now we are starting to see some electronic claim submissions coming about.  Many payers are trained to be more efficient and having mechanisms that you can send work comp claims electronically and possibly sending the documentation either by fax or electronic submission. 

Balanced billing:  I would like to quickly say that per most state regulations this is not allowed, so that if you are billing a jurisdiction, say you bill $100 and the jurisdiction allows for $75, in most states the regulations do not allow you to bill the patient for the balance of the $25.  You need to be aware of the down coding.  There are some state regulations or jurisdictions that strictly forbid payer ability to change the submitted codes.  Many of the jurisdictions have timely filing, timely payment, timely appeals and refund requests.  Those are all important things to be aware of.  One thing that I want to emphasize is that be watchful on your explanation of benefits for PPO discounts taken, particularly when the provider is not participating with that PPO.  You want to be watchful of those. 

On page #18 and #19, I have prepared a Web site address list for the 50 states, plus the districts of Columbia, plus federal and railroad and some general information sites for your use.  These will at least get you to the workers- compensation Web site for that state or that jurisdiction and frequently you can find most medical provider information there.  If not, it will provide you with telephone numbers for whom to contact.  At this time, operator we are ready to open up the lines for questions.

Thank you Ms. Hammer.  Ladies and gentlemen, I would like to remind you that this portion of the teleconference is also being recorded.  If you have a question at this time, please press star (*) one (1) on your touchtone telephone.  If your question has been answered or you wish to remove yourself from the queue, please press pound (#).  Please limit yourself to one question at a time so that everyone may have a chance to participate.  If you have another question, you may reenter the queue by pressing star (*) one (1).

Q & A Session:

Our first question comes from Debi Melillo of The Coding Institute.  Please state your question.

Question: Hi Marvel I have a couple of questions that were sent in by e-mail.  The first one asks can we bill the patient if we do not get a claim number and carrier name and address at the time of service?

Answer:  Basically this is addressing it to your front office information and my understanding is that you are not getting the information at the time of front office so I would first recommend that if that patient is scheduling an appointment, you are going to treat this patient just as you would any other patient that has private health insurance.  You may want to get that information up front and if he/she states that it is for workers- compensation, you want to let that patient know that we are going to need the claim number, the carrier name and address and the adjuster, as the items pointed out earlier in the presentation.  Of course, the patient is always ultimately responsible, particularly if the determination is that it is not work related--if the visit is not work related or the injury is not work related--but I strongly recommend that you try and obtain that information up front.  Frequently, unfortunately for workers- compensation, there is not a scan card like we have for our private health insurances.  But frequently the patient will know the name and telephone number of their adjustor and you can get that information from the adjustor usually very quickly.  Also, you want to make sure that you are authorized to see this patient for workers- compensation so it is an additional incentive to know ahead of time or verify before your provider sees that patient.

Question: Okay she also asks if there is a way online to get this information from the Industrial Commission without having to bill the patient or request the info from the patient?

Answer:  To my knowledge, basically due to HIPAA, even though workers- compensation is not mandated by the rules to comply with HIPAA--they are not a specific entity--on a specific individual patient claim there is not, but certainly by calling the jurisdiction, most jurisdictions have a customer service line that will allow the provider to call the jurisdiction.  For instance, if in the State of Tennessee, if it is a Tennessee claim, but the patient does not know, you can typically call the division of workers- compensation in Tennessee and say, -this is the patient's social security number.  Is there a worker compensation claim on file and who is the responsible party on file?  The payer or the employer?-  Additionally that is why I like to get the employer's information on file because frequently they will know who is their insurance for that injury.

Question: Okay and then I have one last question that was just sent in.  It says, you discussed HIPAA and how workers- comp is exempted from the privacy portion.  Due you have any information on the portability section, for example, e-claims submission?

Answer:  Again, because workers- compensation is not a covered entity, that basically excludes them from any of the portions of HIPAA.  So as to security, privacy, portability and all mechanisms of HIPAA, workers- compensation, adjustors and all such entities are exempted.  Now I know that many of the jurisdictions are putting into place privacy-type rules that they are encouraging both their providers and the jurisdictions to follow, but that covers all things.  So they are not mandated to accept electronic claims, but many of the payers are moving in that direction because they are realizing the cost savings and also they are getting information quicker.  It allows them to manage these claims much better if it can come in as an electronic method.

Comment: Okay, thank you.

Our next question comes from Diana of FHN.  Please state your question.

Question: Excuse me.  My question is in regards to the claims form--the UB-92.  Where should you be putting the information that you have laid out for the HCFA, like the date of injury, the employer and social security number?  Where would you like that on the UB-92?

Answer:  Well, typically on the UB-92, I do not have one in front of me and my expertise is certainly provider-based rather than facility-based, but what I would like you to do is if you can fax that question in--I will give you a toll-free fax number--and I can give you back the exact areas.  I just do not have a UB in front of me to give you all of the fields.  The fax number is 800-508-2592 and then I will get that information to you.  But typically these are not new information as to, you know, social security number, claim number, date of injury or that type of thing on a UB-92.  I just cannot give you the specific fields off the top of my head.

Comment: Thank you.

Our next question comes from Leslie Lockman of Path Radiology Group.  Please state your question.

Question:  If we receive a payment from a payer that is not participating but  they take a discount and we are not accepting that, are we able to balance bill the employer and if not, what course of action do we have to collect the charge amount?

Answer:  So basically what I am understanding is that you are billing for a fee and at the time of processing the payer is bringing it down to the jurisdiction allowable and then taking a discount off of that jurisdiction allowable.  Is that correct?

Question:  Yes.

Answer:  And you are non-participating with the PPO basically

Question:  Yes.

Answer:  What you need to do is to go back to that payer and inform them that you are non-participating with that PPO.  So it is going back to the payer because in some mechanisms, they have it set up with a tax ID or with a particular provider name that it is linked in.

Question: But if they are not willing to change their payment amount, can we pursue the employer for the balance?

Answer:  Again what I go back to is that if the payment amount is coming down to the maximum allowed by the jurisdiction then that is basically an above usual and customary type amount and those have to be accepted.  Let me give you an example where your fee is $250.  Okay, and the maximum allowable by the jurisdiction is $200.  That $50 you have to accept and adjust off.  But if there is another 10% taken off for a preferred provider organization affiliation with another $20 taken so you are really only getting check for $180 and you do not participate with that PPO, then you go back to the payer and process.  You can also contact that PPO and say, -we are not participating with you.  You need to correct the files.-  But the $50 difference--the difference between your fee and what the jurisdiction allows--is not typically billable to anybody.  There are one or two states that do allow balance billing, but it is very rare.  Does that answer your question?

Comment: It does.

Answer:  Okay.

Our next question comes from Tina Emery of Seacoast Orthopedics.  Please state your question.

Question:  We are a New Hampshire provider on the border of Maine.  Our patient filed his claim in Maine.  He ended up having an attorney who requested a deposition from us.  We sent our fee schedule to the attorney stating our fees and the attorney wrote back and said, -we are in Maine, he filed his claim in Maine and, therefore, you need to abide by Maine's worker comp fee schedule-, which by the way is lower than us in New Hampshire.  So we wrote back and said, - we are not willing to accept your lower fee, otherwise, we would not do your deposition.-  No, we were not that mean actually!  Anyway, we got our corporate attorney and he did end up saying that we are not bound by Maine workers- comp law, but according to what you explained about jurisdiction on page #2, it sounds like we are bound by Maine workers- comp law--their fee schedule and that kind of thing.

Answer:  Many of the jurisdictions have ranges for medical legal services rather than explicit amounts.  Unlike, let us say, for a 99214, many of the jurisdictions have explicit amounts.  We are going to pay 130% of X year RBRVS, or our conversion factor is going to be $53.  There will be a set amount allowed, but many of the jurisdictions allow a range for depositions and testimony or they will use something that is called--typically in many states, there is a bar--a legal medical bar agreement to become what is considered reasonable fees.  So depending on what Maine set-.you are NOT bound by that in New Hampshire for a New Hampshire claim, but because the claim is filed in Maine it does fall under there. 

Question:  So we are bound by Maine law even though we are treating him in New Hampshire?

Answer:  That is correct because the claim falls under and is handled by Maine.  No different if the claim is filed in Hawaii and the person gets transferred to New Hampshire because of spouse or whatever and now you are seeing them.  The claim is going to be still continued to be adjudicated according to the entity that the rules are set.  Same as if it is a Federal work comp claim, but for medical legal, there is more flexibility.

Question: Now if our attorney wanted to question you on this.  May he contact you?

Answer:  Sure.  I have no problem having anyone contact me.  The best mechanism to contact me is through e-mail, but it is for him to talk with the Maine Division of Workers- Comp.  That is my best direction.  No one is mandating that your provider perform the deposition -

Question: That is true and we understand that except, you know, it is our patient.  Of course, in the patient's best interest we have agreed to treat this patient and have been all along.  It just would not be ethical not to-

Answer:  Right and the other person to get potentially involved is the patient's attorney.  Frequently the patient's attorney can come and have discussion with the payer's attorney so that it can become mutually agreeable.

Question: All right and we have another question, but we have to do star (*) one (1) so we will.

Comment: Yes indeed.  Okay, thank you.  Bye.

Our next question comes from Diana of FHN.  Please state your question.

Question:  This is in regards to privacy issues.  What kind of documentation can a worker comp carrier request on postexposure or preop?

Answer:  Diana, I am not quite sure I understand about the postexposure or preop

Question:  Actually this is Chris, and postexposures are like needlesticks and then they actually have like labs for sexually transmitted diseases that might have been incurred because of the needlestick and the preops are just before surgeries that are done.

Answer:  Well, the key point is that if the employer or if the work comp provider is paying for those then we will go with the preoperative labs first if they are paying for them.  Let us say they are going to have an open reduction internal fixation of a fracture and the patient has preop labs drawn and the work comp carrier or the employer is paying for those.  Yes, that is covered.

Question:  And all the past history that is actually dictated?

Answer:  You know, if it is an applicable past history.  As for a needlestick, I am a nurse by training and I worked in the operating rooms and many times - not many times, but I had the unfortunate occurrence a couple of times to have needlesticks and you only want to have documentation that is appropriate and applicable.  You cannot withhold information within that documentation.  If I had a past history of hepatitis or if I had a past history of a communicable disease that would have an affect on this workers- compensation claim, that certainly needs to be included in, but if the past history has no applicability or has no bearing on the potential workers- comp claim then that should not be included in the documentation.

Question:  A lot of the time, like a preop, you know, they go back to childhood diseases and everything that has happened to them from birth till present and I guess I have a problem with sending that to a workers- comp carrier when it basically is just supposed to be preop history.

Answer:  Right, but the preop history is not going to be sent because you are not billing for it.  That is not included in the global fee for the surgery--unlike the labs for accidents.

Question:  We bill for them here.  Preops are billed out separately.

Answer:  That may be for another issue to discuss, but if you are submitting a bill for a service to the work comp carrier or to the employer, it is their right to have that information, so whether it is an office visit or whether it is labs, just like a drug screen.  If your patient is on long-term narcotics and they have a urine drug screen performed and that drug screen shows illegal drugs that drug screen is being paid for by the entity and they have a right, by usually the jurisdiction, to get that information.

Question: Hi this is Diana.  Can I tag on to that?   Do you recommend sending records with all the claim forms?

Answer:  It varies with jurisdictions.  Many of the jurisdictions require it in some mechanism--either faxed to the adjustor or attached by paper.  Currently in the states that I have clients in, they all send them in with the claims--one way or another--either through electronic and then they fax them in or they scan them in and send them if they are sending electronic.  In the vast majority that is the mechanism--as I mentioned in the presentation--for the adjustor to be able to keep track of where this claim is going. 

Question: Okay.

Answer:  It is kind of like you have got a third party.  You have got the patient, you have got the employer and then you have got this adjustor that is trying to manage.  It is very similar to say, in private health when a patient has many comorbidities, and private health insurance states getting nurse case managers in to try and ensure that we have got good timely care going on.  That is very common with workers- compensation that the adjustor has a very active role because again their whole goal is to get this patient well and get this patient back to work as soon as possible.

Question:  Okay, thank you.

Answer:  Sure.

Our next question comes from Tina Emery of Seacoast Orthopedics.  Please state your question.

Question:  And Ellen who is in the room is going to ask the question.

Answer:  Okay.

Question:  Hi, I just wanted to know what our obligation is once the patient has received settlement from work comp.  Do the claims still have to be submitted?

Answer:  Well basically the process is that the patient will reach MMI--maximum medical improvement.  There will be determination for impairment and then accordingly any disability.  Workers- compensation then is determined at that time.  What kind of post-case closure services medically are they going to be provided?  In some cases, as in a simple laceration with a few stitches, there is not going to be any medical services provided, but possibly in the case of, say an amputation or a severe crush injury, it may be that the case is closed so that the patient is no longer receiving a wage benefit because there are two parts of workers- compensation.  But they may have an addendum or an addition written to their case closure that certain medical benefits continue to be processed.  In some cases, it may be full medical benefits.  In some cases, it may be that they are allowed 10 PT visits over the next year and then it ends.  So it really varies case by case, but after the patient has received money and the case is settled and closed and there have been no medical benefits decided upon when that case was closed, then it converts to whatever the patient has for private health insurance.

Comment: Thank you.

Our next question comes from Susan Reiss of Metaphase.  Please state your question.

Answer:  Hi Susan.

Question:  Actually it is Liz as Susan is not here right now.

Answer:  Okay.

Question:  I have two questions.  One of them has to do with the modalities.  How many are actually allowed at one time and does it matter that it is towards different body sites?

Answer:  Well again that is going to depend upon your jurisdiction.  You know each state and each jurisdiction may have their own rules as to how many modalities are allowed in a 24-hour period or in one calendar day visit.  So for specific states, it may vary.  What is allowed in Wyoming may be very different than Texas as to how many modalities are allowed.  What state are you in?

Question:  Texas.

Answer:  Texas.  Again, it will vary as to the total quantity allowed and the rules.  Texas--the last year and the next year coming are a major transition for the Texas workers- comp rules.  As you know, they converted up to current year.  It is based off of Medicare RBRVS now and there are changes and reforms coming in this year to probably implement them in 2006.  So it is really going to vary.

Question: Okay the other question that I have is that they are continuously bundling these two codes--the 97014 and 97032--into the office visit.  Can you tell me why?

Answer:  Are they bundled by CCI edits?

Question:  I do not think so.

Answer:  If you will fax that in--I do not have my CCI edit software up--but I will be glad to look that up and get back to you. 

Question: Okay.

Answer:  And that way it will expedite and allow other people to ask their other questions.  That fax number is 800-508-2592 and actually if you will delete any PHI you could jut fax in with that fax face sheet an example of a HCFA.

Question: Okay.

Answer:  Okay.  But make sure you delete any patient information.

Question: Okay.

Our next question comes from Leslie Lockman of Path Radiology Group.  Please state your question.

Answer:  Hi Leslie.

Question: Hi.  We had a particular incident where the place of employment only has two employees.  They do not carry workers- compensation coverage and we are having difficulty collecting from them and again I am wondering, as an employer, can we pursue collections on them with an outside agency?

Answer:  In this situation since it is truly does not fall under workers- compensation jurisdiction since they are one of the few instances that they are exempt from carrying the coverage, most certainly it will be no different than you having a claim with anybody responsible.  But I would certainly get the employee--the injured party--involved and they may actually - it sounds like there are some difficulties going on - your patient may have an attorney and that is a great person to get involved in the case also.

Question:  What if we have an employee who was injured and the employer is not willing to provide any type of workers- comp coverage so we are not sure if they are not carrying it when they should.  Do we have any course of action there?

Answer:  Well first I would recommend contacting the state jurisdiction that you are in and see if there has been a claim filed and put them on notice.  But you are providing services to the patient and that is when you actively get the patient involved: having them come into your office manager's office and explaining the situation that you have got difficulties.  At that time, because there is a questionable worker comp claim--and this comes up not that frequently, not necessarily that the employer does not want to give you information--but when there is a question as to if this claim is work related I actively get the patient involved and they may prefer to have it submitted to their private health insurance while it is being sorted out so that they do not have a delay of treatment.

Question:  Often that is not an option for us.  We are a radiology practice.  We practice in multiple states so some of our patients do not even live close to us.

Answer:  Right, I understand.  Again, it is contacting that patient and dealing with them.  Also, if you are a radiology practice, that means that you got a referral from a provider to do the diagnostic testing and I would work with that provider who sent the patient over because they either have the information, number one, or, number two, they are having the same difficulties, and if a collective group of providers can work together that tends to be more effective.

Comment:  Okay.  Thank you.

Our next question comes from Lisa Rennin of Christi Clinic.  Please state your question.

Question:  Okay the question that I have is that often times we have a patient that actually gets hurt and then just within minutes comes into the clinic to be seen, so hence there is no adjustor set up.  Most of the time, the patient does not have a clue who the insurance company is so there would be no claim numbers at that point; or the employer so deems to accept the bills up to a certain amount and pay them for themselves and they do not turn it in until it is over that.  How would you suggest handling that kind of a situation and what should we do to help expedite that?

Answer:  You know that is a very typical scene for any occupational medicine clinic.  You know, if the patient comes in as a first visit or certainly in a lot of family practices where it is not a large metro area that has occupational medicine specialized clinics, in that situation, I work hand in hand with the employer.  And the billing gets set up to the employer if they specifically state, -I want all bills to be sent to me.-  In many cases, the jurisdiction mandates though that the employer provide the first report of injury within an X amount of time, so that they are talking about no matter what the limited amount.  Why they do this?  Why employers elect to do this is because their premiums are based on several factors.  Some of which is what type of business they are in and how many employees they have, but also the historical number of claims submitted against them, and that will stay with them for a period of time, sometimes 3-5 years.  So if it is relatively minor, let us say a laceration that is maybe going to be a couple of hundred bucks out of pocket for an employer, some employers say look, -we will just pay and we are not going to turn it into work comp because they are not going to have any lost wages and take the risk that they are not going to have any problems and not turn it into workers- compensation.- Because they do not want their premiums to go up.  That is the employer's decision and then the employer is then the responsible party.  Does that help explain it?  But frequently, there will not be, until the claim has been accepted as a work compensable injury, a claim number issued and so at that very initial visit you will frequently know that Joe's Caf- uses XYZ insurance and you can contact them.  But your first people who you want to talk to is that employer, because as you are saying, in many instances the employee does not know who their work comp carrier is, who to contact or anything particularly at that first visit.

Question: Thank you.

There are no further questions.  I would like to turn the program back to Ms. Hammer.

What I would like to do just finishing up is to thank you all for attending for this work comp session.  There are many workers- compensation changes that are coming in.  Just to let you know, from 1997-2002, the medical cost per claim increased by 125% for workers- compensation.  It rose from $13,000 to $31,000 per claim, while employers have reduced the frequency of workplace injuries by almost 40% since 1990 and that is in part due to the OSHA directive.  The National Insurance Crime Bureau estimates workers- compensation fraud alone costs insurers $5 billion each year so there are many jurisdictions that are proposing recent changes that you want to keep abreast of.  Just because of the way it was done two years ago does not necessarily mean that it will continue on.  Some of the ones that are having the biggest changes are California, Texas and Missouri.  West Virginia is looking into privatizing its workers- compensation system.  Tennessee has a new law that goes into affect from July 2005.  Hopefully, we have met your goals of taking some of the work out of the billing and coding workers- compensation.  I appreciate you listening and hope you have a great day.

This is the conclusion of -Guaranteed Strategies for Workers- Comp Claim Success - national teleconference.  We hope that you enjoyed this session.  Please complete your teleconference evaluation form and return it to The Coding Institute at the address listed on the form.  Ms. Hammer, The Coding Institute and I would like to thank you for attendance.  To end this call, simply hang up your phone.  Good-bye.