How to Code and Process Workers’ Compensation Medical Claims

By Karen Smiley from Medical Billing and Coding For Dummies

With Workers’ Comp claims, not only are you billing and coding for the benefit of the medical provider or payer, but you are also coding something that will affect whether someone receives proper compensation for a possible at-work injury. A lot is at stake for everyone involved. For that reason, you’ve got to be on top of your coding game, even more so than usual.

The U.S. Department of Labor’s Office of Workers’ Compensation Programs (OWCP) administers disability compensation programs to injured federal workers or those who acquire an occupational disease. Workers’ Compensation claims can be a bit tricky. Here’s what you need to do when you work with these types of claims:

Follow the filing requirements established by the Department of Labor (DOL). First, providers must enroll, after which, they are assigned a DOL provider number. Second, DOL claims always require prior authorization for each procedure (even though pre-authorization doesn’t necessarily guarantee reimbursement), and each procedure must be supported by the approved condition being treated (medical necessity). Only the approved diagnosis for the patient’s treatable condition is accepted on these claims.
Prior to treating a patient who tells you he has been injured on the job, verify Workers’ Compensation claim information with the patient’s employer or the Workers’ Comp carrier if you have that information. Verify the claim number, date of injury, and the body part approved for treatment. Also get the adjuster’s name and contact information and verify the submission address for the claims.
Verify the approved diagnosis code. The Workers’ Compensation carrier has one or two approved diagnoses that must be used for all claims submissions. The treating physician must know what these approved diagnoses are so that the treatment administered is supported by medical necessity. If you vary from these diagnoses, your provider won’t be paid.
Make sure all reportable procedures have been pre-authorized. All OWCP claims need to be pre-authorized. Although pre-certification does not guarantee payment, failure to pre-certify guarantees no payment.
Include the medical records with the claims. Any treatment to be paid for must be a result of the injury. If the Workers’ Compensation patient with the injured shoulder also has bronchitis, for example, the bronchitis is probably not an approved diagnosis.
Provide regular follow up. As with any other government program, you must navigate through the maze associated with each individual claim.

Similar to other federal insurance programs, OWCP processes claims based on a fee schedule. The DOL fee schedule, in addition to CCI edits, are used to process DOL claims. To access the DOL portal, the provider must register and request a login.

Payments for DOL claims are made via electronic fund transfer (EFT). Prior to submitting any DOL claims, part of the enrollment process is to also enroll for the EFTs.

For specific information regarding OWCP claims, go to the Department of Labor’s website.

The DOL has the three divisions:

Federal Employees’ Compensation Act (FECA): This covers the majority of DOL claims.
Division of Coal Mine Workers’ Compensation (DCMWC): This division is dedicated to coal workers’ claims.
Division of Energy Employees Occupational Illness Compensation (DEEOIC): This division is dedicated to the claims involving federal employees of the Division of Energy.