Medical Billing & Coding For Dummies
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Medical coders and billers have another set of guidelines which impact their work, Workers Compensation. Workers’ Compensation carriers underwrite policies that employers carry to cover treatment for injuries or illness that occur as a result of employment.

Processing Workers’ Comp claims adds yet another layer to the already teetering tower of things you need to know as a coder.

When you’re dealing with Worker’s Comp services, keep in mind the following points:

  • Workers’ Comp claims are normally specific regarding which diagnosis code and body part are authorized for treatment. In fact, workers may have multiple claims, with a different claim number for each body part.

    When verifying a Workers’ Compensation claim prior to an encounter, always check the approved diagnosis and body part connected to the claim number.

  • Follow-up treatments may be part of the claim. For this reason, ask for documentation of the history of a particular illness or injury.

    Here’s an example: A patient who broke her arm had pins put in to reinforce a fracture repair. Now she comes back in complaining of pain because of the hardware. If the fracture was part of a Workers’ Comp claim, then removing the hardware is part of the original claim.

    Similarly, if a patient returns for a hardware removal, and it’s scheduled as a Workers’ Compensation claim but you see that the original treatment was billed and paid by private insurance, you can contact the Workers’ Comp carrier to verify that the claim should have been billed to them. Then you can voluntarily refund the dollars paid to the commercial carrier.

  • Sometimes, a Workers’ Compensation carrier subrogates a claim with the patient’s commercial insurance and simply reimburses the commercial insurance for a claim paid in error. This action is unfair to the provider because the Workers’ Comp carrier benefits from a contracted discount that shouldn’t have been used to price the claim. Make sure you catch errors of this nature before any outside negotiation occurs between the carriers.

    Subrogation is the process where one insurance company determines that another payer was responsible for claim payment. In this case, the insurance company that paid the claim can demand restitution from the company that was actually responsible.

  • Some Workers’ Comp carriers are part of a PPO network (or several networks). For your sanity, make sure that your PPO network contracts do not allow silent PPO access. Figuring out how to handle Workers’ Comp claims is challenging enough; a silent PPO situation only slows the process.

    Some states have Workers’ Compensation laws that serve as contracts for any provider who offers services under claims filed in that state. This is another factor to consider when negotiating a PPO network contract. Verbiage that states a discount is applied to the fee schedule rather than to the billed charges prevents double discounting.

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