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Family Practice Coding Alert

2-D Approach Simplifies Workers Comp Claims

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.
Details, Details, Details
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 [...]