Neurosurgery Coding Alert

Question: The surgeon saw a patient as a follow-up for a workers' compensation claim. He identified a malignant mass on the spine, unrelated to the workers' comp case. If the majority of the visit relates to the WC claim, should we bill the whole visit to WC? Or should we bill the patient's private carrier?

Alabama Subscriber

Answer: Don't submit two workers' compensation  claims for the same visit. If the visit primarily concerned the WC claim, report the appropriate work-related evaluation code (99455-99456) as well as the condition that represents the patient's original illness.

"[A] physician/supplier is permitted under [workers' compensation] law to charge an individual or the individual's insurer for services which are not work-related," states the Medicare Carriers Manual, section 2370.2D. Therefore, in the scenario above, the physician could report both the workers' comp service (99455-99456) and the E/M service concerning the mass (99211-99215).

The physician should submit a separate bill for the E/M service. To ensure payment, make sure you fill in the appropriate check box in block 10 of the CMS-1500 form that indicates that the surgeon performed a nonwork-related service. Some physicians find it useful to document two separate notes to show the level of service attributable to each condition, but this is not necessary.