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Family Practice Coding Alert

Reader Question:

Workers' Compensation Claims

Question: We had a patient come in for a job-related injury, but also had a cold. Can this exam be billed to both the patients health insurance and to the workers compensation insurance?

Marla Martinez
Burlington, Wash.

Answer: These types of scenarios present themselves frequently and usually both can be billed.

Heres another example: An injured worker presents with back pain. In the course of the physical exam, the physician notes that the patient has an upper respiratory illness (URI). The physician meets the key components for both the back injury and the URI. Can you bill both the workers compensation insurance for the office visit for back pain and the patients health insurance for the URI? Yes, it is essential that two separate office visit notes be created one that documents the key components as they relate to the back pain and one that documents the key components of the URI.

The biggest problem lies with reimbursement. Usually a company contracts with a physician group to provide service for their workers compensation injuries. If the injured worker has an HMO for their health insurance, the physician that provided the treatment for the injury may not be their primary care physician (PCP) for health problems. Thus, an authorization must be obtained from their PCP for treatment of a health problem. Often the PCP denies authorization. So it is wise to find out what kind of health insurance the patient has before your physician evaluates and treats a health problem.