Pulmonology Coding Alert

Question: Our pulmonologist is seeing a patient as a follow-up for a workers' compensation claim. During an office visit, the physician informed the patient of a mass, unrelated to the workers' comp case, that turned out to be malignant. If the majority of the visit was related to the workers' compensation claim, should we bill the whole visit to the workers' compensation carrier? Or should we bill the patient's private carrier?

Alabama Subscriber

Answer: You should not submit two claims for the same visit. If the visit is primarily related to the workers' compensation claim, report the appropriate work-related evaluation code (99455-99456) to that carrier along with the diagnosis representing the patient's sustained illness or injury.

If the pulmonologist discovers a condition that is unrelated to the work-related illness or injury, such as a lung mass (786.6) that is suspected or confirmed as malignant (162.9), concurrent care for the unrelated condition may be reported to the patient's medical insurance. Concurrent care is provided during the same time frame in which separate conditions are being treated simultaneously. It should be reported with the appropriate E/M code (99211-99215) and the diagnosis code representing the unrelated condition as long as it is not reported on the same day as the workers' compensation claim.

A designation in box 10 of the CMS 1500 claim form can distinguish the claim as "unrelated to employment" (i.e., not associated with the workers' compensation illness or injury). In the above scenario, the patient will most likely be referred to an oncologist for treatment and care of the malignancy. Any follow-up care by the oncologist related to the mass should be reported to the patient's medical insurance.