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Medicare E/M visit with and injury diag??

  1. #1
    Exclamation Medicare E/M visit with and injury diag??
    Medical Coding Books
    Hi everyone: I hv a question I was told once upon a time that for Medicare pts if they are seen for an injury to never place that code first or Medicare will not pay the visit. Is there any truth to that? I hv a pt here for a 99214 and diag of 959.11 and 796.4. Any help would be appreciated! Txs!

  2. #2
    North Carolina
    That's not exactly true. If Medicare finds out that another carrier/party is responsible for the claim, they may recoupe the money and require you to file with the responsible carrier/party. Injuries/Fx that are a result of fall (ex.) would not necessarily have a 3rd party involved.

    30.2 - Provider Billing Where Services Are Accident Related and No-Fault Insurance May Be Available

    "If a provider learns that no-fault insurance may pay for covered services, it must bill the insurance company as the primary insurer during the promptly period."

  3. #3
    But if its not subject to a third party carrier, then it would be acceptable to submit the 959.11 first??? Because that is the primary reason they came in... Txs for your help!

  4. #4
    North Carolina
    Yes. There are some fields on the electronic fields (HCFA 1500) that you complete to also denote that this was unrelated/related to 1-employment 2-auto accident 3-other accident. Other accident could be falling out of the bed and fracturing a hip. Is it an accident? Yes...another party involved? No...payable to Medicare with a hip fracture diagnosis? absolutley.

    I would be as specific as possible with your Dx's, possibly including an "E" code to further define the accident.

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