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WC case worker

Caralee Posted Wed 10th of May, 2017 13:04:26 PM
Please provide cpt coding guidelines for treating physician face to face visit with case worker for worker's comp pt to discuss the case details. Pt. was not seen on that day. Thanks you.
SuperCoder Answered Thu 11th of May, 2017 03:33:29 AM

Worker’s compensation is a specialized type of medical insurance that covers treatment for injuries incurred on the job. Workers’ compensation provides coverage for wage replacement benefits, medical treatment, vocational rehabilitation and other benefits to workers who are injured at work or acquire an occupational disease. Unlike most other health insurance policies, workers’ compensation medical claims are processed manually. Because of the specific nature of workers’ comp, greater oversight is administered by the plans to ensure that the treatment received is work-related and injury-specific.

Coding guidelines:

Provider should bill the appropriate CPT code from the code range (99201-99215) as per the documentation submitted.

Work Comp is allowed to state which year of the CPT book they use for their fee schedule and that is the year codes you need to use for the work comp claims. Usually this can be found by going into your state work comp website and looking at the physician fee schedule, most will then tell you what year version this is based on. The best bet is to contact your state workers comp department.


When a paper CMS-1500 is received with the appropriate progress notes, the adjuster reviews the charges and supplied documentation to ensure that the services were related to the injury in question, and to ensure that the services were previously authorized as conforming to the agreed-up treatment plan. When the charges are found to be appropriate, the adjuster reprices the charges in accordance with the carrier’s fee schedule. Like other insurance coverage, healthcare providers are not allowed to bill patients for the balance between the fee schedule and the full amount of charges submitted. Workers‘ comp insurance does not normally include co-insurance or co-payments. Instead, providers agree to accept the fee schedule rates as payment in full for services rendered.

It’s important to utilize the correct forms when billing for workers compensation; these forms include the First Report of Injury Form and the CMS-1500 claim form. The First Report of Injury Form should be completed when the patient first seeks treatment for a work-related illness or injury, and the physician is responsible for completing this form. The physician’s billing department will also need to submit a CMS-1500 claim form along with the physician’s documentation to the workers’ compensation insurance for reimbursement. The date of injury always needs to be completed on the CMS-1500 and can often be overlooked by billing.

Workers’ compensation insurance will have no deductible or copayment, and all providers must accept the compensation payment as payment in full. Balance billing of patient is prohibited. The state compensation board or commission establishes a schedule of approved fees and can be found on individual state websites.

Like other healthcare claims that are submitted on paper via the mail, claim turnaround time from submission to payment is typically forty-five days. Workers‘ comp healthcare claims require greater attention to detail than commercial claims submitted electronically. The CMS-1500 must be completely legible and all fields must be completed with the claim form aligned with the printer. Misaligned claims may prevent claims from being legibly scanned upon receipt, and correct information in the wrong fields may delay processing. Additionally, since copies of a provider’s progress notes must accompany each claim form, the copies must be legible, they must be complete, and they must pertain to the codes included on the form. Submitting claims without appropriate documentation will delay prompt payment.


Caralee Posted Thu 11th of May, 2017 18:07:28 PM
Thank you.
SuperCoder Answered Fri 12th of May, 2017 00:00:30 AM

Happy to help!

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