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Feature: CODING & BILLING: NCPD Connection

Appropriate coding and billing in occupational health

Nyhus, Julie E. FNP

Author Information
doi: 10.1097/01.NPR.0000790492.94811.e1

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In 2019, 2.8 million nonfatal occupational injuries and illnesses were reported by private industries to the U.S. Bureau of Labor Statistics, with financial costs of work-related illnesses and injuries—including medical expenses, lost wages, and administrative expenses—exceeding $171 billion.1,2 Cost aside, NPs should be mindful of the personal burden borne by workers, which is even more staggering, often resulting in prolonged time off work, lost compensation, disability, and even death.

Although the most frequent causes of occupational injury vary by industry, the U.S. Bureau of Labor Statistics reports that the most common causes overall in 2019 were sprains, strains, and tears, of which 31% occurred to the back.3,4

This article explores commonly billed occupational injuries and illnesses.

Occupational health

Occupational medicine plays a unique role in healthcare, focusing on diagnosis, treatment, and prevention of work-related injuries and illnesses. A sizable number of occupational injuries and illnesses are seen by ED, primary care, and subspecialty providers each year.5-7 These medical providers are adept at the competencies specific to injury and illness care related to workers, such as obtaining a thorough occupational history while emphasizing functional recovery and return to work. Additional considerations include the needs of the employer, any governmental regulatory agency requirements, and the workers' compensation insurance carrier.7,8

Occupational injuries can occur from physical, biological, chemical, or psychosocial hazards such as temperature, noise, blood-borne pathogens, radiation, insect or animal bites, aerosols, violence, or burnout. The goal of treatment is to return the injured worker to preinjury medical status as quickly as possible.7 Patient history, physical exam, and the potential contribution of occupational exposures inform the need for diagnostics.7

Occupational illness is an exposure or event that occurs during working hours and causes or contributes to a condition or worsens a preexisting condition.7 The same decision-making process is used for diagnosing occupational illness as for any other illness and should include patient history and physical exam. Additionally, the NP should consider the need for diagnostics and the potential of occupational exposures that may have contributed to the current condition.7 Occupational illnesses can occur acutely or develop over time.

Occupational diseases and disorders

Certain conditions such as lung diseases, skin disorders, and musculoskeletal disorders can arise from occupational exposure, some leading to secondary problems or disabilities.9 It is estimated that about 20% of all musculoskeletal disorders are work-related.9 If a work-related disease or disorder is suspected, an initial history is completed with attention to discovering the relationship between current symptoms and possible work exposure.7 The NP should consider epidemiologic evidence such as coworkers with similar health issues and referrals to specialty providers.7 The long latency periods of many occupational diseases and disorders present a causation dilemma for both NPs and insurers.7,10 Only a small portion of occupational diseases or disorders are covered by workers' compensation because many workers' compensation laws, which vary by state, limit recognition of occupational diseases and disorders.7,11

Company responsibility

When an employee is injured at work, the company has the initial responsibility of ensuring the worker receives medical attention. The company should contact the workers' compensation insurance carrier as soon as possible and comply with ongoing requests for information.7

Balancing patient care and company expectation

Evaluation of the ill or injured worker requires the NP to make a determination about the worker's current ability to work, considering all hazards within the work and nonwork environments. These determinations will impact the worker's ability to receive compensation.10 Sometimes providers or facilities contract with corporations to provide a broader role of care for employees, including not only diagnosis and treatment of workers but also insights on reducing and preventing injuries, improving outcomes, evaluating risks, and providing safety recommendations.7 In many states, this has allowed occupational medicine to emerge as a specialty that is company-driven versus patient-focused.

Injury and injury evaluation

History. Evaluation of the ill or injured worker needs to be individualized, beginning with a medical history that includes baseline functional status, preexisting conditions, use of potentially impairing medications or substances, and psychological factors.7 Evaluation of the injured worker also includes assessing the genuineness of the injury and collecting observational signs from visit to visit to monitor consistency and correlation of findings.7 Evaluation of musculoskeletal injuries should include whether the injury is atraumatic or traumatic, chronic or acute, involves high or low velocity (higher velocity indicates more structural damage), and whether movement relieves or aggravates pain associated with the injury.7,10

Additional significant information includes:7

  • Past and present employment history including work tasks, exposures, duration of each job
  • Potential hazards and exposures, including route, duration, and intensity of exposure
  • Nonoccupational history including hobbies, sports activities, alcohol or drug use, home activities, past or present military service
  • Use of protective equipment (for example, clothing, safety glasses, respirators, gloves, hearing protection), and engineering controls (for example, ventilation, shielding, recent upgrades to safer equipment or chemicals)
  • Patient input on whether symptoms are better or worse at home

When occupational exposures are identified, further inquiries to determine the latency period, especially for chronic conditions, are needed. The time between possible exposure and symptom onset can help exclude other potential causes, be similar to that of coworkers, or reveal a change in work process or materials.7 To evaluate occupational exposures further, the NP can access the safety data sheet (SDS) from manufacturers and employers which provides the composition and associated adverse health reactions of workplace materials.8 The NP has the right to obtain proprietary ingredients missing on the SDS that are protected by trade secrets.8 When occupational exposures and/or disorders are identified, federal and state laws require obligatory reporting. Requirements vary by state and can be found on individual state websites or on the website of the Occupational Safety and Health Administration (OSHA).12

Physical exam. Physical exam enhances the benefits of the clinical interaction for both provider and patient, extending the value of diagnostic imaging, lab data, and history.13 When examining workers for injuries or illnesses, physical exam includes vital signs, height and weight, and body mass index, followed by a focused exam involving inspection, palpation, percussion, and auscultation of the specific body system related to the worker's complaint. When examining the worker for an acute injury, the physical exam helps the NP understand the mechanism of injury, which informs the pathology and symptoms.7,8

Diagnostics. Most standard diagnostics are typically covered by workers' compensation insurance, which may include standard X-rays, labs, and certain medications that originate within the clinic or hospital where the worker is being treated. When diagnostics such as advanced imaging or specialty referrals (orthopedics or pain management) are needed, communication with the employer and/or insurer is necessary to ensure coverage.7 The minimum requirement for labs and diagnostics are directed by clinical evaluation and necessity. Labs and diagnostics that are performed by the occupational health clinic are billed appropriately according to the corresponding diagnostic code associated with the reason for testing.

Familiarity with the American College of Occupational and Environmental Medicine (ACOEM) practice guidelines can reduce overuse of diagnostic testing when treating occupational injuries and illnesses.14 For example, low back pain is a common occupational health complaint, impacting almost 40 million US workers.15 Although history and physical exam will guide the NP in determining treatment, specific recommendations regarding acute nonspecific low back pain for injured workers are clearly outlined by the ACOEM. Top recommendations for treating nonspecific low back pain include avoiding initial X-ray evaluation and prescription opioids for treatment of chronic or acute pain for workers with or without safety-sensitive jobs such as those that include heavy equipment, motor vehicles, forklifts, or cranes.14

Diagnosis. Diagnosing occupational injuries or illnesses requires additional responsibilities on the part of the NP such as communicating to the worker regarding the possible implications (legal or otherwise) of a diagnosis, notifying workers' compensation insurance of the diagnosis along with the supportive basis of the provider's opinion, and reporting information to the appropriate labor or public health-related governmental agencies if applicable.7

Treatment. Although treatment for many occupational illnesses and conditions are the same as for nonoccupational disorders, additional considerations should include: protecting the worker from further exposure, the extent of the disorder, and the ability of the worker to continue working versus temporarily modifying duties.7 Information related to the functional requirements of the job is necessary in order to make determinations regarding return to work and modified duty.7 Being able to recognize work-related conditions that require referrals is crucial for successful recovery and return to work. Specific information on managing the medical care of work-related injuries and health problems can be found through the ACOEM, which periodically publishes position papers to guide occupational and environmental health providers in the determination and management of work-related diagnoses and their corresponding International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM) codes.14 The ACOEM guidelines support evidence-based medicine and serve only as a guide indicating good medical and ethical practices.14

When assessing the needs of a worker, there is no difference in approach between physicians and NPs. However, state NP practice authority laws vary and may restrict the typical duties of NPs caring for workers regardless of the clinical setting. To ensure thorough care of workers, referrals to occupational medicine specialists and/or other specialists, such as orthopedics or otolaryngology, may be warranted.7

- Select ICD-10-CM codes commonly used in occupational health16-19
ICD-10-CM Code Specificity
M54.2 Cervicalgia
M54.5 Low back pain
M54.6 Pain in thoracic spine
M54.8 Other dorsalgia
  1. M54.81 Occipital neuralgia

  2. M54.89 Other dorsalgia

M54.9 Dorsalgia, unspecified
S33.5 Sprain of ligaments of lumbar spine
  1. S33.5XXA . . . initial encounter

  2. S33.5XXD . . . subsequent encounter

  3. S33.5XXS . . . sequela

S39.012 Strain of muscle, fascia, and tendon of lower back
  1. S39.012A . . . initial encounter

  2. S39.012D . . . subsequent encounter

  3. S39.012S . . . sequela

S39.002 Unspecified injury of muscle, fascia, and tendon of lower back
  1. S39.002A . . . initial encounter

  2. S39.002D . . . subsequent encounter

  3. S39.002S . . . sequela

W01 Fall on same level from slipping, tripping, and stumbling
  1. W01.0XX ...without subsequent striking against object

  2. W01.10X ...with subsequent striking against unspecified object

  3. W01.110 ...with subsequent striking against sharp glass

  4. W01.111 ...with subsequent striking against power tool or machine

  5. W01.118 ...with subsequent striking against other sharp object

  6. W01.119 ...with subsequent striking against unspecified sharp object

W10 Fall on and from stairs and steps Other variables in this code series include: escalator, sidewalk curb, incline, other stairs and steps, unspecified stairs and steps
W11.XXX Fall on and from ladder
  1. W11.XXXA . . . initial encounter

  2. W11.XXXD . . . subsequent encounter

  3. W11.XXXS . . . sequela

W12.XXX Fall on and from scaffolding
  1. W12.XXXA . . . initial encounter

  2. W12.XXXD . . . subsequent encounter

  3. W12.XXXS . . . sequela

W13 Fall from, out of, or through building or structure Other variables in this code series include: window, balcony, bridge, floor, railing, roof, other building/structure, and not otherwise specified
W18 Other slipping, tripping, and stumbling and falls
  1. W18.30X Fall on same level, unspecified

  2. W18.31X Fall on same level due to stepping on an object

  1. W18.40X Slipping, tripping, and stumbling without falling, unspecified

  2. W18.41X Slipping, tripping, and stumbling without falling due to stepping on object

Y92 Place of occurrence of the external cause
  1. Y92.6 Industrial and construction area as the place of occurrence of the external cause

  2. Y92.8 Other places as the place of occurrence of the external cause

Codes require additional characters for further specification
Note: list is not all-inclusive of codes used in occupational health or of all codes within listed base codes.

Determining causation. NPs caring for workers play crucial roles in prevention, recognition, and treatment of injuries and illnesses. Yet, also of great importance, is the deduction of whether those injuries and illnesses are a result of work and therefore, billed to workers' compensation. Judgment as to causation can be evaluated generally and specifically.

General causation answers whether an agent or incident is capable of causing an injury, illness, or disorder and may be informed by methodologies such as but not limited to pathology, toxicology, or epidemiology. Specific causation requires the NP to consider whether an exposure endured by an individual worker is likely to cause the injury, illness, or disorder. Specific causation is informed by considering potential alternative etiologies, evaluation of the extent of exposure to the agent or condition, and examining temporal relationships such as latency. NPs may be required to provide an opinion in a legal setting regarding the factual basis and reasoning supporting their conclusions of causation.7

Billing

The ICD-10-CM is a morbidity classification published by a joint effort between the CMS and the National Center for Health Statistics.16 It is the standard billing code system used to submit diagnosis codes for workers' compensation insurance reimbursement.

ICD-10-CM codes

ICD-10-CM coding for back sprains, strains, and tears, which are frequently used in occupational health, are composite codes grouped by anatomic site and express the type of injury, injury site (including laterality, if needed), and encounter. M00-M99 are the base codes for musculoskeletal system and connective tissue, and S00-T88 are the base codes for injury, poisoning, and certain other consequences of external causes, including strains or sprains (see Select ICD-10-CM codes commonly used in occupational health).16

When codes such as M00-M99 and S00-T88 are used, coding for the encounter episode must be specific regarding the anatomic location, including laterality and nature of the injury/illness and supported by external cause codes to indicate etiology and place of occurrence—all of which are supported within the chart with detailed documentation.16

For example, the ICD-10-CM code S39.01 is the root code for strain of muscle, fascia, and tendon of abdomen, lower back, and pelvis and is used for workers who present with a strain in any of these areas.16 Next, it is necessary to increase specificity by adding the number that represents the affected body part and the letter that distinguishes the encounter episode. Therefore, if a patient presents for the first time with a lower back strain, the code to be used is S39.012A.16

Coding for encounter episodes should include initial, subsequent, or sequelae, if applicable. The concepts of initial and subsequent encounters are only relevant for diagnosis codes relating to fractures, wounds, sprains, burns, or general injuries, found within both coding series M00-M99 and S00-T88.16 Initial encounter is used when a patient is seen for new treatment of a condition, whereas subsequent encounter is used for routine care of a condition that already has a treatment plan.16 Initial encounters may require documentation of intent (accidental or unintentional, self-harm, and the like) and status (civilian, military, and the like). Sequelae encounters are used for complications that arise as a result of the injury.16

External cause and place of occurrence codes are used when coding occupational injuries from coding series M00-M99 and S00-T88.16 These secondary ICD-10-CM codes (W-codes, Y-codes) show etiology (fall, slip, sports injuries, motor vehicle crash, environmental exposure, and the like), and place of occurrence (for example, school, work, and the like).17 Trauma- or accident-related diagnosis codes between S00 and T88 require a valid external cause code to fully capture injury-related information.16 External cause codes are nonbillable but provide the level of detail required for workers' compensation reimbursement.16

W-codes, such as W00 to W19, indicate etiology of an injury due to tripping, slipping, falling, stumbling, or mechanical force.18Y-codes are used only at the initial encounter to document where and how the injury occurred. Y92 is a place of occurrence base code to indicate where the injury or illness occurred, which is crucial to worker's compensation claims.19 Y93 is an activity base code to indicate how the injury occurred.19 Neither W-codes nor Y-codes are exclusive to occupational health injuries.

For example, to complete the encounter for an initial visit for a patient with lower back strain caused by a fall from tripping over a board on the ground at a construction site for a new building during working hours, we submit code S39.012A to indicate the lower back strain, initial encounter. The external cause code W18.31XA indicates fall on same level due to stepping on an object, initial encounter.18 The external cause code Y92.61 indicates the location where the injury occurred: building (any) under construction as the place of occurrence of the external cause.19

Coding to the level of certainty known at the time of the encounter is crucial. However, if a definitive diagnosis is not established by the end of the encounter, it is appropriate to use an “unspecified” code, which means the condition is unknown at the time of coding, or to report codes for signs and/or symptoms.16,20 Coding specificity increases reimbursement and should include all diagnosis codes that identify the patient's current condition.16

Workers' compensation

Workers' compensation is insurance available to injured workers, those who become ill during the course of employment, and survivors of workers who are killed on the job.11 This coverage provides medical benefits and wage replacement—regardless of fault—in exchange for the worker relinquishing their right to sue their employer for negligence.11 Conversely, workers' compensation ensures that companies cannot retaliate against injured employees by reducing wages or terminating their employment. Incidents resulting in injury that occur during working hours default to workers' compensation; however, coverage for occupational disorders and illnesses (versus injuries) is limited by law within each state.7,11 Additionally, many states have different laws for each industry (construction, farming) based on varying risk of injuries.11

The framework for workers' compensation systems differs within each state.21 States require varying degrees of interventions when evaluating ill or injured workers.11 Interventions range from having a certified occupational health practitioner evaluating and treating workers at the worksite to workers being evaluated and treated by private practitioners in hospitals or clinic settings.11

Workers' compensation billing. Under ICD-10-CM, workers' compensation billing is a primary factor when submitting payment claims for two reasons: to ensure that 1) only treatments directly linked to the worker's job-related condition are being covered, and 2) secondary or tertiary diagnoses that indicate the circumstance under which the work-related injury was sustained are included.7 Most occupational health offices and services are structured so that claims going through workers' compensation are billed with either the NP's National Provider Identifier (NPI) or the facility NPI, depending on the organization and/or state.

Unique billing practices. In addition to diagnosis and treatment of occupational illnesses and injuries, occupational medical services often include health assessments consisting of preplacement, fit-for-duty, periodic employment, return-to-work exams, military health readiness exams, and Department of Transportation (DOT) physicals. These types of encounters are excluded from most commercial insurance plans and therefore billed directly to the companies or workers and do not require ICD-10-CM codes. When needed, the ICD-10-CM code Z02.4, encounter for examination for driving license, is a valid and billable code used in some clinics for the DOT exam, and the ICD-10-CM code Z02.9, encounter for administrative examination, is a valid and billable code used in some clinics for the military readiness exam.16

NPs serving in occupational care settings are positioned to share educational content on workplace health and safety; yet, even though the OSHA recommends programs to prevent workplace injuries and illnesses, these educational services are excluded from most commercial insurance plans and thus do not require ICD-10-CM codes as such services are billed directly to the companies.7

Implications for practice

Workers' compensation systems

Workers' compensation systems are complex and consist of legislation, regulation, a governmental administration body, financing or insurance mechanisms, medical and rehabilitation services, and disability management. Most occupational injuries and illnesses are attended to by practitioners within clinic or hospital settings; these frameworks are dictated by the workers' compensation system within each state. NPs who bill within the workers' compensation system must 1) ensure the state law authorizes an NP to perform the service being billed, and 2) learn the provider requirements of the state workers' compensation system. The state nurse practice authority, state workers' compensation system, and the healthcare organizations who serve workers provide direction to the NP on the need for specialized occupational training, collaborative practice agreements, and scope of practice.7,22

Legal implications

Obligations of the NP within the occupational health setting vary from state to state, yet are based on basic medical and ethical practices. NPs are encouraged to be candid with the employee, employer, and insurer regarding such practices and all suspected outcomes of the diagnosis. In several states, a diagnosis associated with occupational illness or injury requires providers to inform the employee and the workers' compensation insurer of both the diagnosis and the basis for diagnosis, necessitating accurate ICD-10-CM codes. Additional responsibilities may include reporting to labor-related government or public health entities.7

Training for occupational health

Although most states do not require specialized training for providers who participate in the workers' compensation system, all workers' compensation systems position the provider in the critical role of determining if an injury or illness is caused by work, diagnosing and treating the condition, and assessing the level of impairment and ability of the employee to return to work.7 These responsibilities include accurate diagnosis coding of work-related injuries/illnesses. Managing the nuances of workers' compensation requires familiarity with workers' compensation laws within the practicing state and with the nurse practice authority, which varies per state as the NP cannot bill for services outside the scope of practice.7,22

Additional training. NPs who seek to perform DOT exams must become certified medical examiners. The Federal Motor Carrier Safety Administration requires that the DOT medical exam be performed by a certified medical examiner who is listed on the National Registry.23 Additionally, NPs seeking to become credentialed to perform military health readiness exams must obtain specialized training.24

Conclusion

Treating the injuries and illnesses of workers includes completing a detailed work history, physical exam of the affected area, and critical evaluation of the presenting signs and symptoms relative to the mechanism of injury.7 However, to fulfill the critical role assigned to them, NPs must have a general knowledge of worksite conditions, including potential hazards, and an understanding of appropriate rehabilitation to achieve positive outcomes for workers.8

The NP providing healthcare services to workers is accountable to the employees, insurers, government entities, and employers.7 Responsibility to the workers includes identifying possible occupationally or environmentally induced conditions to ensure proper diagnosis and treatment, assessing the extent of impairment and ability of the worker to return to work while mitigating suffering, and ensuring maximum benefits. The NP must also consider the requirements of the insurer and employer in terms of minimizing lost work time, cost, and disability associated with occupational injury or illness. The NP is responsible for communicating with state and local government entities depending on the diagnosis. Finally, the NP must ensure accurate coding of work-related injuries or conditions to secure reimbursement.7,8

Within occupational health medicine, the NP has the opportunity to support a healthy workforce, which is crucial to sustainable economic and social development worldwide.

REFERENCES

1. Employer-reported workplace injuries and illnesses—2020 [news release]. Washington, DC: U.S. Department of Labor, Bureau of Labor Statistics; November 4, 2020. www.bls.gov/news.release/pdf/osh.pdf.
2. National Safety Council. Work injury costs. https://injuryfacts.nsc.org/work/costs/work-injury-costs/.
3. U.S. Bureau of Labor Statistics. Injuries, illnesses, and fatalities, table r9. 2019. www.bls.gov/web/osh/cd_r9.htm.
4. U.S. Bureau of Labor Statistics. Injuries, illnesses, and fatalities, table r13. 2019. www.bls.gov/web/osh/cd_r13.htm#iif_cd_r13p.f.1.
5. Tadros A, Sharon M, Chill N, Dragan S, Rowell J, Hoffman S. Emergency department visits for work-related injuries. Am J Emerg Med. 2018;36(8):1455–1458.
6. Bible JE, Spengler DM, Mir HR. A primer for workers' compensation. Spine J. 2014;14(7):1325–1331.
7. LaDou J, Harrison RJ, eds. Current Occupational and Environmental Medicine. 6th ed. New York, NY: McGraw Hill; 2021.
8. United States Department of Labor. Clinicians. www.osha.gov/dts/oom/clinicians/.
9. Guidotti TL, Ivanov ID. Global occupational health. In: Haring R, Kickbusch I, Ganten D, Moeti M, eds. Handbook of Global Health. Cham: Springer; 2021. doi:10.1007/978-3-030-05325-3_98-1.
10. Greaves WW, Das R, Green McKenzie J, Sinclair DC, Hegmann KT. Work-relatedness. J Occup Environ Med. 2018;60(12):e640–e646. http://acoem.org/acoem/media/News-Library/JOEM-Work-relatedness-Dec-2018.pdf
11. Congressional Research Service. Workers' compensation: overview and issues. 2020. https://fas.org/sgp/crs/misc/R44580.pdf.
12. Occupational Safety and Health Administration. State plans. www.osha.gov/stateplans.
13. Zaman JAB. The enduring value of the physical examination. Med Clin North Am. 2018;102(3):417–423.
14. American College of Occupational and Environmental Medicine. Practice guidelines. 2020. http://acoem.org/Guidance-and-Position-Statements/Guidelines.
15. Centers for Disease Control and Prevention. Low back pain among workers: the problem and what to do about it. 2019. https://blogs.cdc.gov/niosh-science-blog/2019/07/08/lbp/.
16. ICD-10-CM Official Guidelines for Coding and Reporting. FY2021 ICD-10-CM Guidelines. 2021. www.cdc.gov/nchs/data/icd/10cmguidelines-FY2021.pdf.
17. Centers for Medicare and Medicaid Services. ICD-10 Clinical Concepts for Family Practice. 2015. www.cms.gov/Medicare/Coding/ICD10/Downloads/ICD-10FamilyPracticeClinicalConcepts20170324.pdf.
18. Centers for Disease Control and Prevention. ICD-10-CM, external causes of injuries index, W00. 2021. https://icd10cmtool.cdc.gov/?fy=FY2021&q=w00.
19. Centers for Disease Control and Prevention. ICD-10-CM, external causes of injuries index, Y92. 2021. https://icd10cmtool.cdc.gov/?fy=FY2021&q=Y92.
20. Centers for Disease Control and Prevention. ICD-10-CM Official Guidelines for Coding and Reporting. FY2020 ICD-10-CM Guidelines. 2020. www.cdc.gov/nchs/data/icd/10cmguidelines-FY2020_final.pdf.
21. U.S. Department of Labor. Office of workers' compensation programs. www.dol.gov/agencies/owcp/dfec/regs/compliance/wc.
22. Buppert C. Nurse Practitioner's Business Practice and Legal Guide. 7th ed. Burlington, MA: Jones & Bartlett Learning; 2020.
23. FMCSA. National registry for certified medical examiners. 2020. www.fmcsa.dot.gov/medical/driver-medical-requirements/national-registry-certified-medical-examiners.
24. LHI. Military health readiness. 2021. https://logisticshealth.com/military-health-readiness.aspx.
Keywords:

billing; coding; DOT physicals; occupational health; occupational medicine

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