Wiki Work Comp Office Visits


Abilene, TX
Best answers
I have just recently started billing out Workman Comp claims and I have a coding question. If a patient has been to our practice within the last three years and now comes in seeing the same specialty with an injury, would it be coded as an established visit or a new visit. I'm getting conflicted answers. The coder in me says not to use new visit, but the cust serv rep at TWCC says we can.
This is our state's definition...

New Patient

A new patient is one who is new to the physician or an established patient with a new industrial injury or condition. Only one new patient visit is reimbursable to a single physician or medical group per specialty for evaluation of the same patient relating to the same incident, injury, or illness.

Established Patient

An established patient is a patient who has been seen previously for the same industrial injury or illness by the physician.

In the instance where a physician is on call for or covering for another physician, the patient's encounter will be classified as it would have been by the physician who is not available.

No distinction is made between new and established patients in the emergency department. E/M services in the emergency department category may be reported for any new or established patient who presents for treatment in the emergency department.
We have an Urgent Care clinic and Occupational Medicine clinic in one. We use two different billing systems, but for us the same rule applies for our work comp patients as it does for our urgent care patients. Here, regardless of whether the patient is here for an injury or an illness, the 3 year rule applies. This is due to the fact that our providers see patients in both areas and we both bill using the same tax id. I hope this helps.
I would think you would use established...we have patients where i work that have been our patients and then they become workers comp...we are a specialists' group and we don't use new patient. This is interesting. Let me know which you ended up using...

Thank you

Does your W/C carrier have anything in writing? If so, that's what I would go with. WC guidelines sometimes supersede traditional coding guidelines. I do need to add one thing...If we see a patient from a different state (i.e. truck driver-we also have a Occ Health clinic), many times we have to follow that states guidelines.
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I agree. Our state Division of Workers' Comp has set this guideline and I'm sure each state has it's own set of rules.