Wiki Workers Comp Consult

[mdm58]

We had a consult(IP Consult) that was billed to workers comp and they are denying because of our DX we saw the pt for 427.31 and the WC pays for DX 202.2 pt has expired pt's daughter calls and wants the 202.2 DX added to our claim. I get a call for our A/R person asking if it can be added to the claim. The only mention of the WC DX is that the afib is "likely " due to the pt's systemic illness. Can the 202.2 dx be added to the claims?

 

[MarcusM]

IF Dx 202.2 is part of the compensable WC injury, and your provider appeals the denial with a causal relationship of the afib to the S?zary's disease (dx 202.2) as supported in the medical records documentation with a statement that in all medical probability (51% or greater), the WC compensable injury was the primary factor in causing the afib, then the work comp carrier should go ahead and pay the claim on appeal.

Per the Supreme Court of Texas, “producing cause” in a workers’ compensation case is defined as “a substantial factor in bringing about an injury or death, and without which the injury or death would not have occurred.” Transcontinental Ins. Co. v. Crump, 330 S.W.3d 211 (Tex. 2010).

 

[mdm58]

WC Consult

Thank you so very much Marcus.