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Workers’ Compensation Billing and ICD-10 Coding

March 11, 2013

Workers’ Comp BillingSome medical practices deal with many workers’ comp cases. Other specialties see them rarely, maybe only once or twice a year. Workers’ comp billing is different from other medical billing specialties. While it still uses the same codes, workers’ comp payers have additional requirements for the CMS-1500 claim form. Under ICD-10, workers’ comp medical billing and coding will become even more of an exacting factor when submitting claims for payment.

Surgical practices, orthopedic practices, chiropractors, internists, and pulmonologists treat patients who have sustained injuries on the job. These treatments are not paid by the patient’s private health insurance. Instead, a company contracted by the patient’s employer will pay them.

A worker’s comp company is not going to pay for treatments that are not directly linked to the patient’s job-related condition. It is imperative the claim form contain precise information required by the payer to recognize what is being billed. For instance, the patient identification is not a social security number, but a case number assigned by the payer.

Unlike most other healthcare claims, worker’s comp claims require the date of initial injury to be included on the CMS-1500. The date must reflect when the payer initially added the case file. Likewise, the diagnosis code used to justify charges must be the code the payer has on file. Communicating with the worker’s comp payer, understanding its needs, and submitting bills to meet requirements is the key to timely worker’s comp reimbursement.

Many physicians are used to submitting healthcare claims, regardless of payer, using the codes found in ICD-9-CM. They are comfortable with ICD-9 and at ease documenting the patient’s record in a way that supports the assignment of ICD-9 diagnosis codes. On October 1, 2014, that reassurance will be removed.  ICD-10 codes will become the law of the land.

Diagnosis codes included in ICD-10-CM are more detailed, precise and specific versus what healthcare providers have come to expect. When an auditor reads an ICD-10 code, the patient’s diagnosis is more understandable as opposed to debatable ICD-9 codes.

Many worker’s comp carriers require a secondary or tertiary diagnosis to indicate the circumstances under which a work-related injury was sustained. Under ICD-9, the appropriate code would be V62.1, Adverse effects of work environment. ICD-10 takes greater pains to match the injury to the adverse effect. Crosswalking V62.1 to ICD-10 reveals the following choices:

V57.0 Occupational exposure to noise

V57.1 Occupational exposure to radiation

V57.2 Occupational exposure to dust

V57.31 Occupational exposure to environmental tobacco smoke

V57.39 Occupational exposure to other air contaminants

V57.4 Occupational exposure to toxic agents in agriculture

V57.5 Occupational exposure to toxic agents in other industries

V57.6 Occupational exposure to extreme temperature

V57.7 Occupational exposure to vibration

V57.8 Occupational exposure to risk factors

V57.9 Occupational exposure to unspecified risk factor

ICD-10 offers eleven qualifying supplementary diagnosis codes. Some of these read like E-codes under ICD-9. The difference between ICD-10 and ICD-9 is that the new coding system is designed to communicate maximum information within a limited space. Because of the greater specificity required under ICD-10, the medical record will need to contain the maximum amount of information needed to assign the most accurate code.

At M-Scribe Technologies, we deal with complex coding issues and payer requirements every day. We know the guidelines and requirements that affect your patient population. Instead of muddling through it after repeated denials, our professional medical billers will submit clean claims the first time, and get paid when payment is due.


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