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New versus established for an WC patient

  1. Question New versus established for an WC patient
    Medical Coding Books
    We see many patients for WC injuries. When an established patient comes in with a new injury and it has been less than 3 years since the patient has been seen either on his private insurance or a possible closed WC injury, can we bill a new visit for the new injury? We are in AZ and I cannot find anything that can help me answer this question for one of our coders. Does anyone know where I can get the answer or does anyone have the answer for me?

    Any help is appreciated.

    Thank you.

  2. #2
    North Carolina
    I wish I could answer for AZ but NC does allow a new E/M for each new injury...

    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.

    Have you contacted the Industrial Commission for AZ?

  3. Exclamation Coding/Billing Manager
    New or Establisihed guidelines are the same regardless to who you are billing. With work comp, you should check with the state work comp guidelines. Also you need a new claim number (sometimes refererred to as reference number.. obtain this # from the work comp carrier) for each new work related injury.
    Last edited by vlwinfrey; 05-17-2010 at 09:58 AM. Reason: update

  4. #4
    North Carolina
    Quote: "New or Establisihed guidelines are the same regardless to who you are billing."...

    Who are you referring to? Workers Comp or commercial claims? Workers Comp is unique in nature and doesn't, always, follow conventional coding guidelines.

  5. Smile
    in the state of ohio - a new patient visit cannot be billed for a new claim...our guidelines state that if the patient has been seen by the same provider or provider group/same specialty within the past 3 years - they are an established patient...

    look for your states billing guidelines for bwc - a pain to look through but when you take the time - it really does give you a useful resource to back yourself up in times like these and/or ammunition for your appeals.

    bwc is more frequently beginning to mimic CMS guidelines on many things...

  6. #6
    Sioux Falls South Dakota

    As you can tell by the responses, work comp varies from state to state. The best place to find the information is on your own state's website. They should have a link of some kind to their Department of Labor, or even directly to workman's compensation. That will have their fee schedule (check carefully, they don't always use the latest edition of the coding books, so new codes may not be there) and all of their regulations. Once you find the site, bookmark it or save in your favorites; it will become your best friend when billing for work comp.

    And just an FYI, here in SD it's a new patient visit when it's a new injury. But we have to send records with every single claim - even when the visit has been pre-approved!!

    Good luck,
    Lucinda (Cindy) McGarry, CPC-P
    Applications Specialist
    Avera Health Plans
    Education Office Sioux Falls SD Local Chapter
    Past President Sioux Falls SD Local Chapter

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