Wiki Billing 99204 for Work Comp Visits

[01051184]

I've been coding and billing for a Work Comp organization in Indiana for years. Since last year, we have a new system that also has an audit tool. The providers feel that all of their initial visits now should be a 99204. They've been told from outside sources that 85% of their initial visits should be 99204. Of course they are having many down codes. Does anyone that codes WC in Indiana have any resources I could reach out to. I don't feel the same way they do.

 

[daedolos]

Part of that drive is that the Doctor's First Report is never paid and is usually written off for $250. You can see from a provider standpoint that they feel their first visit is extensive work including a usually very thorough report that is never getting paid.

Peace
@_*
I'm in California and regularly deal with Department of Labor, EMPLOYERS, Travelers, Sedgwick, Coventry, Zurich, and Gallagher Bassett. However, I usually do end up coding first visits as 99203 as they usually are complicated injuries. I would imagine certain jobs would have worse injuries than carpal tunnel or shoulder or knee issues though. Documentation would drive the service level.

 

[01051184]

Thank you for responding. I work with all of those carriers also.
Do you have any tips on best way to document family history for WC? Normally that has no bearing on the presenting problem and we have been told that is confidential and shouldn't be noted in the medical record going to the payer. We've tried a couple different ways to document that it has been reviewed but is negative or non contributory. Some carriers don't accept that, so I wondered how your group documents that?

Thank you

 

[daedolos]

Thank you for responding. I work with all of those carriers also.
Do you have any tips on best way to document family history for WC? Normally that has no bearing on the presenting problem and we have been told that is confidential and shouldn't be noted in the medical record going to the payer. We've tried a couple different ways to document that it has been reviewed but is negative or non contributory. Some carriers don't accept that, so I wondered how your group documents that?

Thank you

It's not relevant for WC claims on the provider's side. Medical necessity should have been established by Utilization Review prior to the WC claim even being approved. I'm not sure if you are working on the provider's end or the legal end or both?

Peace
@_*
I would imagine that most auditors at the WC insurances would only regard matters in the Dx that applies to the body part affected by the injury sustained at/during work. In our office, we try to only code relevant ICD-10 codes pertaining to the injury although I don't see how having a family history status code negatively impacting your claims. I personally wouldn't add on extra codes unnecessary to WC processing.

 

[01051184]

I bill for WC providers. We use the "95" guidelines.

In Indiana, all new injuries are billed as a new patient visit. To have a comprehensive hx, we have to meet 1 of each of the 3 from the PFSH, which means proving to the carrier that family hx was reviewed. Even when we have a moderate mdm, comprehensive ex, some carriers automatically down code our 99204 to 99203 stating detailed history. The audit program in our new system states a comprehensive hx.
I was just wondering if other WC biller's have the same problem or if it's something we can change.

I appreciate your help. The forum must not have many Indiana WC billers.

 

[daedolos]

I bill for WC providers. We use the "95" guidelines.

In Indiana, all new injuries are billed as a new patient visit. To have a comprehensive hx, we have to meet 1 of each of the 3 from the PFSH, which means proving to the carrier that family hx was reviewed. Even when we have a moderate mdm, comprehensive ex, some carriers automatically down code our 99204 to 99203 stating detailed history. The audit program in our new system states a comprehensive hx.
I was just wondering if other WC biller's have the same problem or if it's something we can change.

I appreciate your help. The forum must not have many Indiana WC billers.

I see your dilemma. I assumed that you meant coding for family conditions. If your provider has been documenting PFSH as well as all the other necessary elements, then I would definitely submit an appeal for the appropriate E/M level. I have noticed that EMPLOYERS has downcoded our office's follow-ups especially since some of our doctors do an extensive exam and note issues not relevant to the body parts not authorized under the claim. Since I have to code for WC, I omit these from the PR2 report although they are stated as I have been told not to avoid claim denials.

Peace
@_*

 

[01051184]

Thank you. I have those issues with follow ups also. I normally won't appeal those. I will continue to appeal new injury visits having history down coded.