Workers’ Compensation Billing

by Jackie Stack, AAB, CPC, CPC-I, CEMC, CFPC, CIMC, CPEDC, CCP-P

Workers compensation billing can be confusing at times. Knowing a few background guidelines and rules can help you along the way. 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. There are federal and state laws that require that employers maintain Workers’ compensation coverage to meet minimum standards.

Occasionally a patient will come into an office and see a provider for an illness or injury that is work-related; however, the patient fails to inform the provider that the illness or injury is work-related. If this happens, the patient’s primary payer then gets billed for the services or procedure. If the patient then requests that his/her workers’ compensation insurance be billed for the service and the primary payer has already paid the provider, the workers’ compensation insurance will need to be billed. If the workers’ compensation claim is denied, an appeal will need to be initiated. The reimbursement paid by the primary payer must be returned.

Sometimes a patient will present to the provider for a workers compensation injury and also wish to be seen for a reason unrelated to the employment injury. Providers must be cognizant of the need to keep both encounters separate, with separate encounter forms.

Keep in mind that HIPAA privacy rules must be followed, and illness or injuries unrelated to a workers’ compensation injury should never be billed to the employer.

Billing for workers’ compensation claims can differ from state to state, sometimes making it problematic. Knowing you state’s regulations, which are established by your state commission, will keep your practice in compliance. However, there is general nationwide billing information for workers’ compensation claims that does help keep billing somewhat uniform.

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.

CPB : Online Medical Billing Course

More information on workers compensation can be found at http://www.dol.gov/general/topic/workcomp

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20 Responses to “Workers’ Compensation Billing”

  1. DENISE says:

    I WORK FOR A COMPANY AND ABOUT 45% OF OUR BUSINESS IS WORKER COMP. WE ARE LOOKING FOR A CLASS OR SEMINAR ON WORKER COMPENSATION REGULATION IN THE STATE OF NEW JERSEY, OR THE REGULATIONS THEMSELVES IN WRITING. WE HAVE A REALLY HARD TIME COLLECTION FROM THE TPA’S AND NEED TO KNOW IF THERE IS ANYTHING THAT CAN BE DONE OR ARE WE DOING EVERYTHING WE CAN TO COLLECT OUR PAYMENTS..
    SO IF ANYONE KNOWS OF SOMETHING LET US KNOW….

  2. Peter says:

    Thanks Denise for posting this. I also work for a company that handles a large volume of workers comp surgical and PT business. We are looking for a similar program. If anyone can recommend a good program, it would be greatly appreciated. Thank you.

  3. Linda A says:

    I am working for a Labratory looking for classes how to bill work comp claim . Please advise

  4. Robin says:

    I would like to know about Work Comp billing course in San Jose, Ca. or closest location. Specified for Orthopedics would be even better. Thank you

  5. Steve Lowery says:

    I have been billing Workers Comp for over 15 years now and athough some laws varie from state to state the collections process and procedures are about the same. I can help!

  6. melody says:

    i am trying to bill work comp for psychological services 50 min sessions i have tried 5 diffrent cpt codes none of them are correct HELP!!!

    melody
    california

  7. La Quenta Gross says:

    Melody have you tried 90844 fo 45-50mins, hope that helps.

  8. La Quenta Gross says:

    Melody have you tried 90844 for 45-50mins, hope that helps.

  9. Rob says:

    There is a physician fee schedule (billing) class in Oakland on Nov. 15 and Dec. 13 in Los Angeles. The billing method for workers’ comp physician services changes on Jan. 1, 2014. A continuing education provider WorkCompCentral.com has medical billing and coding classes, live and online. The instructor Sue Honor is excellent; she worked for the California Division of Workers’ Compensation and knows the FAQs and most common mistakes medical billers make when submitting treatment bills for payment.

  10. Carolina says:

    Can I bill workers comp claims as incident to provider? We are in TX, the provider is credentialed by his physical therapist don’t. Can the physical therapist see the patients and bill under the provider npi ?

  11. LISA says:

    I would like to attend workers’ comp billing classes for the hospital facility side for the state of Ohio. Can you point me in the right direction of some traing classes for hospital workers comp billing?

  12. Julie says:

    Can our doctor bill workers comp for a meeting with the workers comp adjustor?

  13. Rochelle says:

    i am trying to bill work comp for psychological services 60 min intake session none of them are correct please HELP!!!

  14. Brad Ericson says:

    Hi Rochelle,

    Try the Member Forum. You should be able to find some help from your colleagues there. Also, please call your state workers’ comp bureau. Each state has a fee schedule, and they should be able to recommend a code.

  15. Kim T says:

    I have been reimbursed from a workers comp that is in New York where the injury occurred. Our practice is in North Carolina. The reimbursement rate that we received was based from New York rates. When I spoke with the workers comp carrier I was told that they reimbursed at the New York rate and I will not get reimbursed at the North Carolina rate. I just need some advice if this is correct.

  16. Debra Northrup says:

    I work for the State of Colorado, Division of Workers’ Compensation. If anyone needs assistance, with workers’ compensation, please feel free to contact me.

  17. stephanie encinas says:

    Can you bill a patient if the carrier denies for Out of Network – We are Internal medicine – These are ref’d to us by the surgeon for pre-op and some of the claims are being denied for OON – Please advise – Our billing service is billing the patients and I want to make sure this is correct

  18. Debra Northrup, RN, CPC, CPMA says:

    Stephanie,

    First make sure you know which workers compensation state or federal law is being applied. For instance, the Colorado Workers’ Compensation Act or the Office of Workers Compensation Program at the US Department of Interior (OWCP) . Look at how an injured worker gets authorized in that particular state or law. The answer will depend upon which law is being applied. Under a CO WC scenario, when the surgeon who I assume is an authorized treating provider in this case refers the injured worker to your office then the injured worker is authorized in that workers compensation claim. Who chooses the initial treating physician is normally a really big deal in state workers compensation claims because their is not a “policy limit”. Most if not all states work on the standard of what is “reasonable and necessary to cure and relieve the effects of the injury”, not a policy limit.
    I hope this helps.

  19. Danielle says:

    I work for a DME and a patient received a knee brace from us through work comp. My Customer Service has already dispensed the Item and Human resources is wanting us to send everything to them and they are going to file the claim but we can not get the Lady from Human resources to get back with us with a claim#. If we do not receive payment on this can we bill the patient/employee for the Item?

  20. Debra Northrup, RN, CPC, CPMA says:

    Danielle,

    These are tricky questions, because it depends upon which workers’ compensation law is being applied. It also could be a self-insured employer or an employer who does not have workers compensation insurance, or the workers compensation claim has not been established yet. Colorado requires employers to have workers’ compensation coverage and requires a first report of injury to be filed by the employer within 10 days of the injury (injured worker has to file within 4 days from injury).

    I would recommend that you send the bill without a claim # and follow-up by telephone shortly after you sent the bill to the employer (if self-insured) or the employer’s insurer. Whether you can bill the patient is dependent upon the status of the entire workers compensation claim (insurer/employer admitted or denied liability or liability is limbo – not established for any number of reasons?) . In Colorado if the claim is denied or in limbo I suggest the provider bill the injured worker; however, when the claim is admitted by the adjuster, or ordered by a judge as being workers compensation then never bill the injured worker. It is statutorily illegal to bill the injured worker for any type of reasonable and necessary care related to the injury; however, this is Colorado and other workers’ compensation states or the federal government could be different.

    I hope this helps.

    thanks & best

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