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Eli's Rehab Report

Take the Work Out of Coding Workers' Compensation Claims

Published on Sun Sep 04, 2005 Print Friendly and PDF PDF

Hint:  Report the most severe injury as the primary diagnosis

Although you don't have any national standards to follow, that doesn't mean you've got to put more effort into your workers' compensation claims. Here's how to get your diagnosis and evaluation codes done in no time.

Face Off Diagnosis Coding Challenges

You've got two major challenges when reporting  ICD-9 codes for workers' comp (WC) patients: the order of the injuries and using E codes.
 
Note: When a patient presents to your provider's office, you should remember to use the reason for the visit or why the patient sought care for your ICD-9 basis. Until you have a definitive diagnosis, you should report codes from Chapter 16: Symptoms, Signs, and Ill-defined Conditions in your ICD-9 manual.

If you're coding multiple injuries, you should list the most severe as the primary diagnosis. For instance, an employee stacking heavy boxes slips and falls on a wet floor, landing on his left knee and right palm. The physician diagnoses a left knee contusion, Colles' fracture of the right wrist, and a lumbar sprain. The ICD-9 order would be 813.41 (Colles' fracture), 847.2 (Sprains and strains of other and unspecified parts of back; lumbar), and 924.11 (Contusion, knee).

Complete the WC Picture With E Codes

You'll never use E codes as a primary diagnosis. E codes are informative and merely support the picture of the patient's injuries, says Minaxi M. Patel, coding specialist for Marianjoy Rehabilitation Hospital in Wheaton, Ill.

The sections you'll most frequently use for workers' comp patients are:
 

  • E880-E888 - Accidental falls
     
  • E919.x - Accidents caused by machinery
     
  • E920.5 - Accidental needle stick
     
  • E927 - Overexertion and strenuous movements.

    Example 1: A drill-press operator lacerates two fingers while operating a power press. The injury does not result in tendon damage. Your primary diagnosis is 883.0 (Open wound of finger[s]; without mention of complication) and E919.3 (Accidents caused by metalworking machines).

    Example 2: A painter fell from a ladder and complains of wrist pain, normal range of motion; R/O fracture. Your primary diagnosis is 719.43 (Pain in joint; forearm) and E881.0 (Fall from ladder).

    Narrow Down Your E/M Codes

    If your provider is seeing WC patients, you should familiarize yourself with the WC E/M codes. CPT includes the following codes specifically to report work-related or medical disability evaluations: 

  • 99455 - Work-related or medical disability examination by the treating physician that includes:
       
  • completion of a medical history commensurate with the patient's condition;
       
  • performance of an examination commensurate with the patient's condition;
       
  • formulation of a diagnosis, assessment of capabilities and stability, and calculation of impairment;
      
  • development of future medical treatment plan; and
     
  • completion of necessary documentation/certificates and report
     
  • 99456 - Work-related or medical disability examination by other than the treating physician.

    "We use 99455 and 99456 only for special medical evaluations that include extensive tests for disability status evaluation," says Mary Baierl, CCA, HIM coder at BayCare Health Systems LLC at Green Bay, Wis.

    You shouldn't report a standard E/M code on the same day you report a work-related visit unless your provider sees the patient for a separate condition. If possible, you may try to schedule the patient for a separate visit for the non-work-related condition because you'll report these visits, in most cases, to different insurance payers.

    If that isn't possible, most compliance personnel recommend having your provider document the services into two separate notes clearly indicating the services performed for the work-related condition and the non-work-related condition.

    For example, your physiatrist sees a patient in follow-up for delayed recovery of whiplash in a work-related truck accident. During the course of this visit, the patient also complains of urinary frequency and burning. Your provider orders a urinalysis and reviews the results. Because the patient is often "on the road" and has limited access to medical care, the physiatrist agrees to go ahead and initiate treatment for the diagnosed urinary tract infection. 

    For this visit, you would report the appropriate E/M code (99211-99215) for the work-related visit linked with diagnosis codes 847.0 (Sprain/strain neck) and E929.0 (Late effects of motor vehicle accident). On a separate claim to the patient's private health insurance, you would report the appropriate-level established patient E/M code (9921x) for the non-work-related service and link it to diagnosis code 599.0 (Urinary tract infection, site not specified).

    Caution: You shouldn't always revert to the WC codes 99455-9456 when a WC patient presents at your office. These codes are used only if a patient's employer or insurance company requires a physical for employment or medical-disability purposes.

    Read Up on Your State's Regulations

    Because each state determines the regulations for reporting work-related injuries, you'll find no national standards to follow when processing workers' compensation claims. Therefore, you must know these regulations before taking on any patients with work-related injuries or illnesses. Be sure to look for: 

  • Mandated "local" (state-specific) codes that aren't standard HIPAA-compliant CPT or HCPCS codes
     
  • Rejection of valid CPT or HCPCS codes because their rules or regulations use prior-year codes
     
  • Local coding modifiers
     
  • Special medical documentation requirements.

    Note: What state or entity the workers' comp claim was originally filed with - not the patient's residence, your provider's location, or the employer's location - determines the jurisdiction for the workers' compensation claim.

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