Author Topic: Is pain an illness or an injury?  (Read 1053 times)

ste

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Is pain an illness or an injury?
« on: July 03, 2010, 04:26:07 PM »
During a bene the benerep asked me, “Why is the patient being seen?” In the absence of a patient encounter I replied, “Duno?” The benerep went on further to explain and emphasize the point that many claims get rejected because the patients are not being seen for an illness or injury. I noted this on the form and sent it to the provider.
A day later I have a patient encounter and submit a claim using valid dx codes for back pain and neck pain. I track the claim and everything seems to be going well until I am told the claim has been “sent for repricing” (Is repricing even a word?). In the next follow-up I am told the provider has been notified to give additional information to determine if the patient was seen for an illness or injury. Upon reporting this information to the provider, albeit the hour was well into beer thirty, a sort of panic mode kicks in and I receive a rapid reply asking, “What is an injury? What is an illness? What do they mean?”
My question is twofold. First, how do I avoid getting into this awkward situation in the future? Should I make it a policy to always have the patient encounter in front of me during a bene?  Second, how do proceed with the current predicament? Should I ask the insurance their definition of “illness or injury”? Or should I take a step back and look at the larger picture of medical necessity?
     

blhoffman

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Re: Is pain an illness or an injury?
« Reply #1 on: July 04, 2010, 10:53:11 AM »
Well, my first thought would be, as a claims processor, that didn't see any other codes but pain codes is why? What is the pain from? There has to be an underlying cause.

Such as, is the pain from having your hand crushed between 2 ton pipes and after multiple surgeries you are seeing the dr. for the pain that has not abated? (Happened to my brother). This would be pain from an Injury.

Or, do you have Fibromyalgia and you are being seen by the dr. to address the pain? Or Migraines. This would be a Illness.

I would definitely have the encounter before calling because it could also be possible the underlying cause was on the claim but never entered by the claims processor at the insurer. Things happen on both ends.

ste

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Re: Is pain an illness or an injury?
« Reply #2 on: July 04, 2010, 01:42:55 PM »
Very helpful. Thank you.

oneround

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Re: Is pain an illness or an injury?
« Reply #3 on: July 07, 2010, 12:42:37 PM »
Ditto on the last answer.  Usually when an carrier ask is the illness is related to an injury it is most likely because if it is then the payment will most likely be based upon the member's accident claus in the contract as well it helps to determine if any additional parties are responsible for payment.  Was it an work related injury, MVA or slip an fall and are mainly used to provide data for injury research and evaluation..  As in the firsdt example by BLH this code could be coded with the illness code of pain in the hand, 729.5 and the injury code of lets say, E916, Accident by falling object.  It is correct to always look for the underlying cause. 

When coding for pain  always code for the reason for the pain.  So pt. presents for RLQ abdominal pain due to acute appendicitis, the code for RLQ pain is 789.03 but because the pain is due to the acute appendicitis you would code it as 540.9 for the pain is 'due to'.

Good advisre BLH
Michael A. Reynolds, CPC, CCP-P, CPMB, OS
Project Manager
Corporate Compliance
Sharp HealthCare