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Workers Comp vs. Regular Insurance visit

domaha28

Contributor
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22
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I have a question and hope someone can help me. We have a patient that was seen for the request of surgical clearance by the surgeon due to a work related injury. During the exam, the provider noted cellulitis of his leg that was not related to the work injury. The surgery was cancelled due to the leg problem. Treatment was done and now the surgeon is requesting the primary to see the patient again to evaluate the leg and clear him for surgery. Do we bill the comp carrier because it is due to the surgeon requesting clearance again or do we bill the personal insurance because it is to check the leg which is not work related. Anyone??? :confused:
 

Chelle-Lynn

True Blue
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626
Location
Modesto, CA
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If the surgeon is requesting clearance for the work related surgery, then I would bill the Work Comp Insurance. The purpose of the visit is not to treat the patient for the cellulitis, but to provide the surgeon clearance to proceed with the work related care.
 

domaha28

Contributor
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Thanks so much. I thought that was the case but always best to ask for another opinion. A person in the office checked with their wife who works for an insurance company and she said to "split" the claim. Half to comp and half to personal insurance. Have you ever heard of this? I have not but that doesn't mean it can't be done but didn't sound ethical to me. Your thoughts? Thanks again.
 

Chelle-Lynn

True Blue
Messages
626
Location
Modesto, CA
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I have heard of the "split" option and am aware of the use of this practice. Basically the coder would pull out the documentation related to the work comp injury and level that code and bill that carrier for the services related to that part of the visit. Then using the remaining non-work related documentation (in this case the cellulitis care) level a second code. The question would be...did your provide "treat" the cellulitis or just provide the medical determination that the patient should wait on surgery?

It is not a practice I would recommend...but like with other things in the coding world it is subjective.
 
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