Coding, Classification and Reimbursement

Medicare and Workers Comp

  • 1.  Medicare and Workers Comp

    Posted 01-04-2019 08:17
    I received an email from my corporate billing office asking me to remove 2 codes (neck pain, back pain M54.2, M54.9).
    I was told that a Medicare billing rep said they match a workers comp claim exactly. But we are chemical dependency and psych facility. The neck and back pain are coded as secondary diagnosis not primary.
    Does anyone have any experience with this?

    Theresa Guerra, RHIT
    HIM Coder

  • 2.  RE: Medicare and Workers Comp

    Posted 01-07-2019 12:31
    I don't believe our facility has ever received a request like that. At least not since I have started working here. We report various pain codes as well when the patient receives medication for the pain. Perhaps the primary diagnosis wasn't reported to billing properly? As long as it meets the requirements for reporting additional diagnoses there shouldn't be an issue.

    Have you heard back from billing?

    Megan Del Rio
    His Discharge Coder

  • 3.  RE: Medicare and Workers Comp

    Posted 01-08-2019 02:59
    Hi Theresa,

    Try to see if you have a diagnosis for the cause of the pain such as spinal stenosis or lumbar spondylosis.  I worked for a Pain Management Clinic and that is usually what they need, to be preceded by a code for acute or chronic pain if the physician diagnosis it. If it is an Inpatient encounter and not for Pain Management, sequence the code for the specific site of the pain first, then the code for acute or chronic pain.

    Mary Headley, CCS
    Remote Inpatient Coder
    Tallahassee Memorial Healthcare
    Universal Coding Solutions

  • 4.  RE: Medicare and Workers Comp

    Posted 01-08-2019 10:29
    No I told them I had to look into it because I was not comfortable deleting codes. I will be talking to our CBO today now that I have some more information from both of you. Thanks

  • 5.  RE: Medicare and Workers Comp

    Posted 01-07-2019 18:35
    ​We have been asked by our business office to remove codes as well or change them to something else that is not reflected in the record, but MC has it on file or at least that is what I think is happening.  It is on my "try and figure out why" list.  We are an acute care hospital.

    Stacey Goodenough
    Manager of Medical Records / Privacy Officer
    Wayne Memorial Hospital

  • 6.  RE: Medicare and Workers Comp

    Posted 01-08-2019 10:46
    I work for a multi-specialty group and we see this often. If the patient was not treated for the complaints and was at the office for a different reason we do not attach those diagnoses to the claim. There are some instances where we have no choice to but to use the diagnosis that Medicare considers part of a third payer liability incident. In these cases we might appeal with records or contact the patient and we have even billed the work comp/auto insurance to get the denial from them which use use to appeal and that usually resolves the issue with Medicare. Happy billing! :) 
    Amy Martinez RHIT

  • 7.  RE: Medicare and Workers Comp

    Posted 01-17-2019 17:51
    UR did appeal based on treatment for opioid detox was from the opioid dependence from the back injury. I will post an update.

    Theresa Guerra, RHIT
    HIM Coder

  • 8.  RE: Medicare and Workers Comp

    Posted 01-24-2019 12:37
    I have this problem a lot with our Podiatry office because if we code for pain in limb and they've been in an auto accident or work comp that code is flagged. Everytime I have had to reach out to the patient and they have to get a signed letter from auto or work comp stating that the diagnosis needs to be excluded, as it has nothing to do with an accident. There is no time limit to my knowledge either on time they can go back. Had one Monday deny for pain that was linked to a car accident 5 years ago. Basically this all lands on the patient getting the appropriate info and submitting to Medicare. We can't help them with it.

    Miranda Seal
    Medical Biller