Comp medical bills – those devilish details

Earlier this week I attended the Maine Workers Comp Summit; spoke on the impact of health reform on workers’ comp. One of the sessions pertained to coding medical bills, and some of the intricacies thereof.
For one (me) who spends the majority of their time dealing with higher level, strategic and tactical issues and concerns, this deep dive into medical coding brought me back to my days as an HMO data analyst – and reminded me that there’s more than one devil in the details…
These days, its more important than ever to avoid paying for diagnoses that are not directly related to the work comp injury or illness, as those payments may well trigger higher MSA allocations. Reportedly, CMS’ Boston office has stated their position on a payer’s responsibility is rather definitive; if more than $300 is reimbursed for a condition, the payer ‘owns’ that condition.
An interesting issue – well, kind of interesting to those of us who find this stuff interesting – regards the lack of coding for left or right. several in the audience noted they’d had problems in the past when they paid bills for procedures/therapy on one arm or leg when it was the other appendage that was injured at work. Evidently, the provider had not, and does not have to, send medical records or notes for the non-comp condition, therefore the payer wasn’t aware of the other injury. So when the bill for the right knee/shoulder/hand came in, the bill reviewer/adjuster saw it was the correct body part and authorized payment.
This is most definitely not new news to anyone who’s spent a big portion of their waking hours immersed in the intricacies of coding, but served as a welcome reminder to the rest of us of the challenges inherent in what looks to be a very straightforward, if not simple, methodology.
What does this mean for you?
It’s far too easy to measure bill processing by throughput, but neglecting the quality and accuracy of the coding may well be missing the forest for the trees.