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Eli's Rehab Report

Workers' Comp:

Get Your Workers' Comp Claims Paid With These Expert Tips

BONUS: 5 Handy Checklists Make Workers’ Comp a Breeze!

Handling workers’ compensation billing doesn’t have to be a pain, says Trish Bukauskas, a coding and billing expert who recently presented a session on the topic for AudioEducator.

And workers’ comp claims don’t have to saddle your RCM cycle with extra A/R days either. You can get them reimbursed within one week of filing — if you know the ropes.

Sweat the Details

Workers’ comp claims typically require a high level of precision, and even small mistakes can result in denials. To start out right, research ahead of time what the requirements and guidelines are, and go from there. You’ll typically need:

  • claimant name,
  • claimant case number,
  • CPT® or HCPCS code(s),
  • ICD-10 code,
  • the requested date of service,
  • appropriate supporting documentation,
  • the provider name, and
  • provider number/ID

Prior Authorization Checklist

Wondering about prior authorization? You’ll need it if you are billing for:

  • Durable medical equipment and medical supplies. Send a copy of the original order, but providers are not required to furnish a product invoice and providers must use proper HCPCS of A9999 if the item is unlisted.
  • Biofeedback.
  • EMG/NCS services.
  • Physical medicine (PT and OT).
  • Manipulative treatment.
  • Chiropractic treatment.
  • Pain management.

Factors that will sink a prior authorization request include:

  • The case is closed.
  • Claimant can’t be found.
  • Injury date is missing for a claimant with multiple cases.
  • The service requested is unclear.
  • Any of the following are missing: prescription (if required), rental or purchase price (if required), and frequency and duration.

Caution: “They want the authorization form to be exact,” Bukaukas says. “If we put ‘four weeks’ and [the patient’s] verbiage says ‘one month,’ the federal Department of Labor says [the claim] can be denied for that.”

Steer Clear of These 14 Denial Triggers

Some reasons for workers’ comp denials are similar to what causes other payers to deny non-workers’ comp claims. They include:

  1. Claimant is ineligible.
  2. Disagreements with accepted condition.
  3. No authorization.
  4. Improper CPT code(s).
  5. Improper ICD-10 code(s).
  6. Claimant ID or tax ID are missing.
  7. Incorrect provider number.
  8. No physician signature on file.
  9. The provider is not enrolled.
  10. The patient reached maximum medical improvement.
  11. Service is not considered “medically necessary.”
  12. Service is not related to the condition.
  13. There is no active, open claim on file.
  14. The claim wasn’t filed on time.

CPT® Reference Tool for Workers’ Comp Claims

There are several services unique to workers comp that are worth keeping in mind, Bukaukas says.