Wiki J1 Status Indicator

[saraandrews]

My question is if I bill Workers Compensation CPT codes that fall under the J1 Status Indicator but are on separate body parts like different fingers and a modifier of 59 is used along with the specific digit are they separately payable. Also, if they are using a network contract does the contract stating codes paid at 100% 50% 25% supersede the 1 code payment? Basically we are getting paid for 1 code at the very low contracted rate when billing Workers Compensation even when its separate body parts.

 

[thomas7331]

I'm assuming you're coding for facility and not professional here, is that correct? If so, and if the Work Comp payer is following the Medicare OPPS payment rules, then if there is any single code on the claim having the J1 indicator, the entire claim will pay at the highest comprehensive rate among the codes that have that indicator - there will be no separate payment for individual codes, and no separate multiple procedure reductions for additional surgical codes. In other words, when any surgical code is reported that has a J1 indicator, all other surgical codes become packaged into that rate.

Again, this is assuming that the payer is using Medicare rules to determine payment. But you've said that they are using a 'network contract', so that suggests they the are not following Medicare payment rules (unless the contract states that they will use Medicare rules, of course). Any contract that is in place should govern how payment is determined, but without knowing the exact language of the contract, it's impossible to answer that second question.