Workers Comp BIlling Question please help I'm a little lost and new to this

cmanion

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I work for a family practice and we had a patient that was seen for an er follow up visit due to a work related injury, apparently the patient did not inform us that the injury was work related at the time of service. So the provider treated him for the injury and ordered an X-ray, but the provider also restarted the patient on some previous meds not related to the work injury, the patient was referred to cardiology and had some medications refilled. The DX codes that were used are: S60.450A9This is the work related injury, I10, I70.0 and E78.2. My question is, can I still submit this claim to workers comp with all of these DX codes? and if there is no workers comp claim do I then bill the Patient?
 

CHROMEa8

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This probably won't get paid as is, the S60.450A9 is invalid, so once you get the denial
the patient will get an eob and will call you or insurance company....start all over.
Also the insurance company will need notes, notes should indicate this was a work
related injury! The cardiologist/billers/coders will hopefully catch this as well.
 
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My doc used to try to see someone for a work comp visit and a regular visit on the same day until I put a stop to it. He tended to blend it all together in one note and then bill it as two separate visits, and I showed him that neither one of the insurances would pay with one note all jumbled together. After that, we made the patient come in on two different days, and kept the work comp and non-work comp issues separate.

Now I know you didn't know in advance, but if the regular portion was minimal and the work comp portion was most of the visit, I would bill the visit to work comp and forget the rest. If the patient does not or refuses to give you the work comp info, then make him cash pay for work comp issues.
 

cmanion

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Thank you so much for the information, I have contacted the patient and he informed me that he is self employed and does not have any employees, which according to the patient, makes him exempt from workers comp coverage. the Patient is on his wife's health insurance, so I'm not sure if I should bill the Patient or bill his wife's health insurance?, I feel like his wife's insurance will reject it because it is a work injury. Also I do apologize for my typing error in the first post, the DX code is S60.450A not S60.450A9
 
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The Basics of Michigan Workers’ Compensation
Who Is Covered?

Any private employer who has three or more employees at any one time, or who employs one or more workers for 35 or more hours per week for 13 or more weeks, is subject to Michigan’s workers’ compensation law. Agricultural employers must provide workmans’ comp coverage if they have three or more employees who work 35 hours or more per week for over 13 weeks a year. Domestic employees who work more than 35 hours per week for 13 weeks or longer during the preceding 52 weeks are entitled to workers’ compensation benefits in Michigan.

Named partners and officers who are shareholders of small, closely-held corporations may exempt themselves from Michigan workers’ compensation coverage. The Worker's Disability Compensation Act covers the employees of a sole proprietorship, but the self-employed sole proprietor does not have to be covered. Independent contractors may be covered by Michigan workmans’ comp, under certain circumstances.

They are considered to be employees and qualify for coverage if they do not maintain a separate business, do not render services to the public, and do not employ other workers. A few classes of workers who are covered under federal laws are not covered under the Michigan Worker's Disability Compensation Act:
  • Federal employees (postal workers, Veterans Administration workers, etc.)
  • People who work on interstate railroads
  • Seamen on navigable waters
  • People who load and unload vessels
********************************************************************

Okay, so he can choose to get the coverage or not. Bill the wife's insurance. Expect they will deny the first claim. Tell the patient to have his wife call the insurance and tell them that the spouse has a work comp injury, and as a self-employed person, he doesn't carry coverage (and does not have to carry coverage), and ask them to pay the claims.
 

cvanemon

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I agree with Sharon. You don't want to submit the workers' comp charges together with any other charges. The patient should check with his insurance company to confirm, but typically bills (it's not a claim in WC) would be paid separately under a different part of the policy so they may not want to have the charges submitted together. You might want to create two separate CMS-1500 bills.

If this patient had WC coverage, you would definitely NOT want to submit either Dx codes or CPTs for the non-work-related services. This would potentially cause those services to be denied, or the bill to be rejected for additional information. This would have a big impact on the E&M level of service, so they might just reduce it to a 99202. if they review it.
 
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