Two Problems, Two Payers, Two Bills

If you discover another problem during a workers’ comp visit, you don’t have to make the patient return for a second visit — if you document properly.

By Douglas J. Jorgensen, DO, CPC

Mrs. Johnston arrives at the office complaining of her usual right hip pain, the result of a work-related injury covered under workers’ compensation for the state. While in the office, she notes that she recently suffered a motor vehicle accident (MVA) and is wondering if her physician could please take a look at her neck and shoulder, which were injured in the MVA. Moreover, she wants to make certain that the car insurance provider of the person that hit her gets today’s bill because that person has admitted fault.

Evaluation and Management – CEMC

Sound all right? The answer is not as clear as one might hope. Confusing matters more is that the answer can vary from region to region, payer to payer, and even state to state. In looking at this matter, the coding professional must approach it judiciously and clearly because the key lies in the encounter and subsequent documentation.

The neck and shoulder can and should be appropriately billed to the MVA insurer. How to do it is the question at hand. Some insurers will argue that you need to bring the patient back on a separate date of service to evaluate each problem separately, but that is not pragmatic in today’s society.

In many instances, no real policy on this conundrum exists. Additionally, if you look at and address each issue separately, it makes sense to get paid for both — legitimately. Thus, this case requires at least two notes, and each note must stand on its own in order to properly represent the services rendered. The history, examination and medical decision making (MDM) need to be clearly outlined in each note. The hip — a chronic problem — may warrant a detailed history, an expanded problem-focused to detailed examination, and MDM of low to moderate complexity, depending on how the hip is doing and what interventions are warranted.

Let’s say she needs a greater trochanteric bursa injection, so you bill 20610 and 99214-25. Is this related to the MVA? Of course not. Therefore, don’t bill it to that payer. Instead, bill it to the primary insurer (and secondary/tertiary where applicable), as that is where the care for the hip should be billed. However, if that same visit addresses the MVA, this, too, needs to be managed, as it is acute and she needs the doctor’s care. The history and examination are the two most likely E/M components where similar areas could be evaluated, making these areas of critical concern. If the MVA evaluation requires a detailed to comprehensive history, the elements of the history of present illness (HPI), the past, family and social history (PFSH) components and the review of systems (ROS) cannot be even remotely redundant or duplicative.

The examination cannot include a “well-developed white female in no apparent distress” constitutional examination for both notes, as this, although part of virtually every examination, should not be used twice. Vitals could be used instead, if germane. Elements of the examination could be similar, but regionally distinct. For example, strength and weakness or deep tendon reflexes (DTR) could be used specifically for the upper extremity for the MVA with C5-7 and not L4/S1; however, you’d address the latter under the hip and lower extremity neurologic examination.

Skin exam for the hip would likely include “no signs of erythema or infection at injection sites,” while the MVA portion would likely comment on the extent of ecchymotic changes. If the physician looked for edema about the shoulder and right arm and also edema in the lower extremities for the shoulder/neck and hip portions, respectively, then the cardiovascular examination should specify examination of these sites specifically. ‘Peripheral pulses symmetric’ is also not adequate, for it is too general. The note should specify that on the shoulder/neck documentation, the radial pulses were checked; the lower extremity pulses evaluated were the dorsal pedal, posterior tibial and/or femoral pulses along with edema. Despite edema often being placed under the extremity (or skin) examination, it speaks to the extravasation of blood into the third space — the space that is neither intravascular nor intracellular (the first two spaces) — therefore, it is a cardiovascular and not an extremity or skin finding.

The evaluation for the hip required a history, exam and MDM for the hip and the hip alone. Thus, the neck and shoulder need to be addressed using a history, examination and MDM that are entirely and unambiguously unrelated to the hip issues and hip note. In doing the extremity examination, the lower extremity should not be there, as the shoulder/ neck relate more specifically to the upper extremity. Moreover, there should be nothing in the history that is redundant from the hip note.

One could argue that neither payer will ever see the other note, so why worry about it? But that is truly not the point. What needs to be overtly avoided is any impropriety — perceived or real — that suggests the two services are in any way commingled or unbundled. The ability to create two notes — one for the hip and one for the neck/shoulder — will allow two payers to be billed for the services rendered. Neither payer should pay for services covered and reimbursed by another insurer/payer, as that is redundant billing and is clearly fraudulent. Therefore, if these guidelines are followed and no local guidelines or rules exist to prevent it, one could potentially bill two E/M encounters and any related procedures to the two different insurers, while happily satisfying a patient with the service of one stop shopping for two unrelated problems.

As with any nuance in the billing and coding world, if a question exists, seek clarification from a local, experienced and qualified health care attorney, along with following your payer guidelines.


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