Chapter 9


Workers’ Compensation

Workers’ compensation plans are governed by state law and regulated by each state to cover work-related illnesses, injuries, and deaths occurring in a business headquartered in that state or whose primary work site is located in that state. Yet because private insurance companies are among those who may sell policies, workers’ compensation is not considered a true “government plan.” In some states, all employers must use managed care networks.

Although the laws differ for every state, some elements are common to all states. This chapter focuses primarily on the elements that are common to all states.

Employers with more than four employees are required to provide workers’ compensation benefits to their employees. Employers may buy coverage through state programs, private insurers, or by self insuring. The employer pays the entire premium.

Employees do not pay premiums for workers’ compensation coverage. The size of an employee’s benefit is based on the severity of the disability and the employee’s wages.

Without admitting negligence, the employer is responsible for work-related disabilities that employees suffer. Disabled employees are entitled to benefits without having to sue for them. However, in return for the benefits, employees give up the right to sue.

Disabled employees are typically paid benefits to replace wages on a weekly or monthly basis, rather than in a lump sum. In addition, medical care is covered for the work-related condition as long as the case is considered to be active. If a worker is killed by an on-the-job industrial accident, the law provides for payment of burial expenses, up to an allowed amount, and compensation for the surviving spouse and other dependents at the time of the worker’s death.

It is the employer’s responsibility to provide workers’ compensation coverage according to the laws of the state. It is the employee’s responsibility to report injuries in a timely fashion. Employees are responsible for filing accident reports and for asking for medical treatment through the employer’s workers’ compensation plan.

Workers’ compensation also provides coverage for treatment of disabilities, including long-term or permanent disabilities, for as long as the case is considered to be active. A physician visit for a follow-up evaluation usually must be done at least once a year by an authorized workers’ compensation provider in order for the case to remain active.

The disabled employee, not the employer, is responsible for scheduling the annual follow-up visit and for reminding the provider to obtain any necessary authorizations before the visit. It can be very difficult to reactivate a closed case, so it is a good policy to send reminder letters to workers’ compensation patients who have on-going disabilities to remind them to schedule follow-up visits.

There are two main types of workers’ compensation cases:

An industrial illness is an illness that occurs as the result of being exposed to chemicals or organisms in the course of employment. An industrial accident is an accident that occurs in the course of employment and results in an injury.

Worker’s compensation considers two factors in determining disability:

With partial disability, the person can perform some, but not all, functions of employment. A person with a partial disability usually can either work part-time or in a different capacity. With total disability, the person cannot perform enough functions to regain employment. Most states use some form of an impairment rating, often expressed as a percentage of impairment, to determine whether the disability is partial or total.

With temporary disability, the person is expected to regain the lost function. With permanent disability, the person is not expected to regain the lost function. Rehabilitation is often a major focus with workers’ compensation to enable an ill or injured employee to regain as much function as possible.

Some workers’ compensation policies are terminated when the patient becomes eligible for Medicare. In addition, if the ill or injured employee signs a settlement agreement, usually for a lump sum benefit, the case is then considered closed even though the illness or injury may persist. Once a workers’ compensation case is closed in that fashion, private medical insurance pays for medical care and there is no further compensation for lost wages.

With workers’ compensation, the physician relationship is between the insurance carrier and the physician. For legal purposes, there is no patient-physician relationship. No implied contract exists between the physician and the patient, and the physician is not legally obligated to the patient.


Medical information recorded by a physician regarding treatment for a work-related injury is often made available to the patient’s employer. Therefore physician documentation requirements are different than for other patient visits. Physicians must be careful to only record personal history details that are relevant to the treatment. They should only document information that is specific to the injury. Any medical finding regarding other medical conditions, especially if the physician is treating the patient for other medical conditions, should be documented in a separate part of the chart. Dividers are often used to segregate workers’ compensation chart notes and information from the rest of the chart. Some states require the use of a separate chart instead of a divider as an added measure of protection.

The rules for selecting evaluation and management (E/M) codes are also different for workers’ compensation. Unlike other E/M coding, each new injury is billed as a “new” patient visit. Telephone conference E/M codes may be used with workers’ compensation claims to bill for time spent talking with attorneys, the insurance company, etc. Usually, when using telephone conference codes, the plan of treatment cannot change and the physician cannot have seen the patient within 3 months nor anticipate seeing the patient within a month. The call must be documented, and the length of the call must be documented.

Authorizations are always required for workers’ compensation claims. Make sure the authorization is from the proper source:

Document who authorized the visit: record the name, position, and specifically, if he or she has the authority to give authorizations. For subsequent visits, get the carrier authorization in writing from the carrier. Document who the adjustor is, the claim number, the date of injury, and what the authorization allows the physician to do.

Specifics regarding authorization will vary by state. For example, in one state, every visit requires a separate authorization and every service performed during one visit requires a separate authorization. Except for emergencies and initial visits, the physician must be certified by the state to treat workers’ compensation injuries. The provider must complete a 5-hour course to obtain certification. Surgical assistants cannot be physician’s assistants (PAs), and anesthesia must be administered by an MD, not a PA, a nurse practitioner, or an advanced registered nurse practitioner.

MMI stands for maximum medical improvement and impairment rating. MMI is the point at which further improvement is no longer anticipated. The patient sometimes has a copayment responsibility once MMI is reached. Once again, requirements vary by state. For example, Florida requires use of the Florida Impairment Rating Guide and the rating must be expressed as a percentage.

Most procedures, including minor procedures, have global follow-up days that are included in the procedure and may not be billed separately. Initial visit codes for a surgical procedure include wound cultures, supplies, application of initial dressings, and splints or casts. Unless your state specifies otherwise, national guidelines are followed.

On subsequent visits, supplies are billed using 99070, and the invoice for the supply must accompany the claim, or the entire claim may be returned unpaid. Documentation must include the supplies used, the reasons for the supplies used, the number or amount used, and the cost of supplies. Claims for an x-ray procedure with modifier -26 (professional component) will be returned if an x-ray report is not attached.

When an insurance carrier calls to schedule an independent medical exam (IME), find out the volume of records to be reviewed. When the volume is excessive, get a written agreement for a higher dollar amount and bill by adding 99080 (by report) to report the additional amount of work. Payment should be received within 45 days of submitting a clean claim. Figure 9-1 shows an example of an IME letter.

Office notes and the treatment plan for each visit are sent to the workers’ compensation carrier in the same envelope with the claim, or, in some states, they may both be submitted electronically. The treatment plan is also sent to the industrial commissioner in most states.

CMS-1500 claim form requirements for workers’ compensation claims:

image The injured employee’s Social Security number is used for the “Insured’s ID Number” (Block No. 1a) even though the employee is not the policyholder.

image List the employer as the policyholder (block

    No. 4 and all related blocks, but skip the fields for gender and date of birth).

image Accident field—check “yes” for “Employment” (block No. 10a).

image Date of injury required (block No. 14).

image A code for the external cause of the injury must be listed in the “diagnosis” section of the claim form (block No. 21).

image Authorization number required for each visit and each service (block No. 23). (Usually there is no compensation if there is no authorization.)

image Attach medical records and authorization, if available.

image Do not need signature in block No. 31 for a worker’s compensation–certified physician—see the rules on the back of a current CMS-1500 claim form.

image Some states have additional requirements.


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