Understanding Workers' Compensation ICD coding for the provider’s office

1. Understanding Workers' Compensation ICD coding for the provider’s office June 26, 2019 Natalia Pilipchuk, Technical Medical Specialist

2. Objectives • To review BWC’s basics about claim determination • To review specific BWC coding requirements (injury description and specificity, site, laterality, 7th character, etc.) • To highlight coding differences between claim allowance and International Classification of Diseases (ICDs) for billing

3. BWC Basics for Claims Determination • For workers’ comp, claims determination is based on the injury description, not the ICD code. • Complete and concise documentation allows for accurate coding and reimbursement. • Injury acuity and severity is necessary for accurate claim allowance.

4. BWC Basics for Claims Determination • Symptom codes cannot be recognized as claim allowances. • Do not use ICD-9 codes.

5. BWC Basics for Claims Determination • ICD codes are used for: • Efficiency in claims administration. • Effective billing. • Allows BWC to comply with federal regulations. • Impacts subrogation.

6. BWC Basics for Claims Determination • Complete and specific ICD-10 codes • S56 *incomplete • S56.011A *complete • The 4th character “0” : site of the injury, flexor muscle of thumb at the forearm level • The 5th character “1” : the type of the injury, strain • The 6th character “1” : the laterality, right

7. Specific BWC Coding Requirements for Claim Allowance • For BWC allowances — 7th character “A” • Excluding fracture codes assigned based on the type of fracture and/or fracture complication (malunion, nonunion or delayed healing).

8. Specific BWC Coding Requirements • Type of injury: • Fracture • Multiple site burns • Open wound • Head injury with and without loss of consciousness • Sprain and strain • Traumatic vs. non-traumatic

9. Specificity for Common Injuries • Fractures: 7th characters reflect different allowances (e.g., open vs. closed fracture) • Burns: Do not use codes for multiple site burns. • Open wounds: Specify laceration, puncture or open bite (human/animal), with/without foreign body or tendon involvement.

10. Specificity for Common Injuries • Head injury: Specify loss of consciousness and time. • Sprain/strain: Specify one or both. • Traumatic vs. non-traumatic: Use S or T codes when caused by the injury. When caused by aggravation of pre-existing, use M category. (e.g., rotator cuff)

11. Important Highlights • BWC requirements differ from health care. • BWC only covers body parts and conditions affected by the injury. • Claim determinations are based on the injury description, not the ICD code. • Provider’s notes must be specific.

12. Important Highlights • When documentation is vague, allowances may differ from what the provider submitted in code assignment. • BWC does not recognize unspecified laterality or incomplete ICD codes. • BWC only recognizes the 7th character “A”, except for fractures.

13. ICD Groups for Billing • An ICD group = individual codes similar in nature and/or involve the same body part. • Includes codes with varying levels of specificity. • Codes in the same group can be used interchangeably for medical reimbursement.

14. BWC ICD Groups for Billing

15. ICD Resources www.bwc.ohio.gov

16. Provider Resources • Billing and Reimbursement Manual • Provider Fee Schedules • Provider eNews • Register for future webinars. • Review past taped webinars.

17. July 16 – Webinar • Navigating the 2nd Quarter Billing and Reimbursement Manual Update, featuring: • Health and Behavioral Assessment and Intervention Service. • Lumbar fusion. • Transcutaneous electrical nerve stimulation policy updates. • New Preamble.

18. Looking for reminders, updates, tips and breaking news on workers’ compensation? Follow us on social media! facebook.com/OhioBureauofWorkersCompensation facebook.com/ohiobwcfraud twitter.com/ohiobwc twitter.com/ohiobwcfraud linkedin.com/company/ohio-bwcOhio BWC (Official) ohiobwcblog.wordpress.com ohiobwcfraud.wordpress.com Youtube.com/bwcohio