ICD Codes and The Path to Payment

So, you are injured at work and after you visit the doctor you get a copy of the doctor’s bill in the mail and among all the information on the bill are these mysterious numbers. More than likely they are ICD Codes. Read on and contact our team to learn more about how ICD Codes may affect the payment of your claim.

What Are ICD Codes and what do they have to do with the payment of your claim?

Well, ICD stands for International Classification of Diseases. The IDC code is an ever-increasing toolbox of diagnosis codes used to track disease and mortality rates worldwide. Standardizing diagnosis codes helps improve the ability to track health initiatives, monitor health trends, and respond to health threats. Very lofty stuff, but for the injured worker it means simply this – having your doctor’s visit and the medication you are given covered by paid for.

The current system is ICD-10 and it was released by the World Health Organization in 1999. The United States did not adopt the new codes until 2015 at which time the Centers for Medicare and Medicaid Services (CMS) announced that it would be requiring the use of ICD-10 codes in Section 111 reports for work-related injuries. The use of the ICD-10 codes in Section 111 reporting allows for accurate coordination of benefits for claims submitted to Medicare for an injured worker’s treatment and it helps identify conditional payments made by Medicare related to the work injury.

Why should a worker care about ICD Codes?     

As an injured worker why should you be concerned about ICD codes? You could take a course to understand the intricacies of medical billing, but what really matters is how the aspects of using the proper billing code affects you on a personal level. In simple terms, your doctor evaluates what injuries you sustained, picks a diagnosis code to match your injury and chooses a billing code based on the complexity of your visit. Any tests ordered by your doctor must also be linked to the ICD-10 code.

Now when you file your claim with your employer’s workers’ compensation carrier, and assuming that your claim meets certain thresholds, the carrier as a responsible reporting entity (RRE) will report the matter to CMS pursuant to Section 111 of the Medicare, Medicaid, and SCHIP Extension Act of 2007 (which we will refer to simply as Section 111). The purpose of this reporting is to enable CMS to determine when other insurance coverage, such as your employer’s workers’ compensation coverage should pay for the medical treatment associated with your work injury. Moreover, it will allow CMS to identify what medical treatment it has to pay for once Medicare becomes responsible for coverage.

How do ICD Codes help ensure payment of your claim?

When CMS receives claims for treatment, it will compare the ICD codes submitted in the request to those contained in the Section 111 report. If the ICD codes for the requested treatment do not match up with the codes in the Section 111 report, CMS may deny paying for the claim. Thus, the inaccurate use of an ICD code could result in an unwarranted denial of a claim that would have otherwise been paid had the proper ICD code been used.

In addition to ensuring payment of proper claims, the use of the correct ICD codes also facilitates the accurate identification of conditional payments made by Medicare related to the work injury. When searching for conditional payments, CMS will use many codes that cover the same body part associated with the work-related injury. As a result, using the correct codes can reduce the chance that CMS will include unrelated claims when it seeks reimbursement of conditional payments.

Contact MSA Meds

It is not unreasonable to assume that there may be some incorrect ICD codes used in connection with the billing for medical treatment associated with your work-related injury, but mistakes can happen. There are thousands upon thousands of ICD codes available and as such the use of an incorrect code by your doctor’s billing department is a real possibility. That is why when MSA Meds administers your MSA account, we will review the bills submitted by your doctor to ensure that the proper ICD-10 codes are used before the bill is paid. This way MSA Meds ensures that the MSA account funds are used only to pay for medical treatment and items related to your work injury that are Medicare-approved. Contact MSA Meds today.