Wiki No fault/Workers Comp guidelines

[mnuhfer04]

Hi all, I’m a coder/biller in NY, recently due to unforeseen circumstances, I have taken on our No Fault and Workers Comp billing. I’m wondering if these specialties follow CMS E/M guidelines or if they have their own.

I’ve only billed for our primary care patients and am comfortable leveling the visits. But with our no fault and comp patients, I’m having difficulty. When medications aren’t managed or testing aren’t ordered or reviewed, I’m having a hard time leveling the visit. The verbiage isn’t being used like I’m used to. For example, for primary, our providers use stable, unstable, chronic, ect. But our no fault and comp providers don’t. I was told that the patients conditions are all unstable that’s why they come every month.

I’ve been doing some research into and not really finding anything online. I was hoping someone might have experience in this and can help point me in the right direction. Thanks!

 

[amyjph]

You have to check the carrier to find out what the rules are along with your state WC rule. As far as the E/M, some may use parts and pieces of CMS while others may want straight CPT. Additionally, other carriers may make up their own guidelines. If you are talking about WC/Auto, in general you will be looking at injuries. So, in your example, when talking about the Number and Complexity of Problems, you would be looking at acute, uncomplicated injury, acute complicated, etc. However, some of those folks may have moved into a realm of chronic such as with spinal injuries, etc. It all depends on the presenting problems and documentation. If you are used to more of a PCP, preventive and family type visit it will be different. Either that, or they would be done by time if the provider documents it that way.
The carriers have provider portals or sites and also manuals, so you would have to see what they follow.

https://www.wcb.ny.gov/content/main/hcpp/hcpp.jsp

Example of a carrier site: https://www.pinnacol.com/workers-compensation/providers/medical-providers

 

[mnuhfer04]

I just purchased the New York Workers Comp medical fee schedule and billing guideline book from Optum. Thank you for your response. I’ll be doing some research.