August 2000 Bulletin

Treating 2 problems needs 2 reports

Workers’ comp, private insurer must get separate documentation

By Margie Scalley Vaught

Has this ever occurred in your office? A patient is being treated under Workers’ Compensation Insurance. The key components for a 99213 are performed on the patient’s knee injury. Just at the close of the treatment plan, the patient states "By the way, I think I did something to my shoulder while playing with the kids. It hurts to raise my arm up. What do you think?" Since most physicians are trained to treat patients, the physician proceeds to take a problem focus history, perform a problem focus exam and establish a treatment program for the shoulder problem.

Now the physician has met the criteria for a second E/M visit for the shoulder problem. The physician takes the patient to the front office and explains to the billing people that Mr. Jones was seen for two separate problems today and also two separate insurance companies are involved.

Mr. Jones gives the office his private insurance information and is told that the bill will be submitted. Now the hard part begins. How is this bill to be submitted? How are both insurance companies notified of what was done and concerns of double dipping removed? The key to this problem is proper documentation. The physician must be the one to substantiate this documentation.

Per CPT guidelines and from a CPT perspective, all codes billed for must meet or exceed the key components in the E/M level selected. The physician should provide a dictated note pertaining to the Workers’ Compensation knee injury, since that was the initially scheduled exam, making sure to document all components of that visit. Then a note should be added similar to: "at the end of the treatment given on this patient’s knee injury, he stated that his shoulder was giving him problems. This shoulder problem is unrelated to the Workers’ Compensation injury and documentation, bills and treatment plans will be submitted to the patient’s private insurance carrier in regard to this shoulder problem." The physician then needs to dictate and document all aspects of the shoulder exam and treatment plan, drawing special attention to show the key components of the second E/M visit were met or exceeded.

In many cases, the orthopaedic surgeon needs to ascertain prior to examining the patient, if referral or precertification is required for this different problem by the private insurance company. The physician also must be sure to document that he or she used the review systems and the past, family and social history in the decision-making for the shoulder problem.

If the above recommendations are followed, from a billing/auditing/compliance standpoint, the physician has explained and documented his billing for the encounters. Some offices go one step further and provide a cover letter explaining what took place, codes selected, dollar amounts billed per carrier, and the physicians rationale for billing. This cover letter is sent to both insurance carriers and the patient.

You may wonder "why the patient?" The patient needs to be reminded that a portion of that visit was unrelated to his Workers’ Compensation claim and that his private insurance carrier has been billed. This also notifies the patient of the amount that was billed to his private carrier and the amounts that he and/or his private carrier are liable for.

Most insurance carriers appreciate knowing in detail what took place, the physician’s rationale and the office’s billing protocol. Where the physician may run into problems is in the lack of documentation for each separate problem. If the physician just "runs" it all together in one long note, not separating out the two different problems and the fact that two different carriers are involved, the bill is likely to be denied. Most Workers’ Compensation carriers require documentation to be submitted to justify the bill. If they see unrelated body parts and/or unrelated diagnoses in the note there is a possibility that the claim may be denied based on the edit code "not work related injury."

Physicians should not combine all components of the visit and up the E/M level and bill only one carrier. This could be considered a false claim as per the scenario provided earlier that the physician knew ahead of time that part of the exam and treatment rendered was unrelated to the scheduled encounter.

Remember, the key to coding multiple problems, multiple carriers on the same date of service is documentation. Insurance carriers are responsible only for that part of the visit that affects them.

Margie Scalley Vaught, CPC, is an independent coding specialist in Ellensburg, Wash. She also is a member of the American Academy of Professional Coders National Advisory Board.

Answers to common coding questions may be addressed in future editions of the Bulletin.

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