Code confidently for personal injury cases

Set the stage for honesty and transparency

IN PERSONAL INJURY (PI), coding, charging and billing are an art and a science.  

When done right, chiropractors are better able to help an attorney support a patient’s claim in a lawsuit. They are more likely to get paid in the end. And they are less likely to be challenged by the patient, the patient’s attorney or the defendant’s insurance adjuster.  

Let’s go over a few suggestions for how to set verifiable, reasonable fees, code properly and stay transparent as a diagnostician and documentarian.  

Verifiable, reasonable fees and attorney tactics

Nothing will come under more scrutiny in personal injury cases than the reasonableness of your fees and charges. Unfortunately, your fees will likely be attacked, even when they are reasonable, purely as a tactic.  

The insurance adjuster (the defense) will attack the patient’s attorney as a tactic to pay less in a settlement, often using analysis from defense-industry-biased software (such as Colossus). When the case has settled for less than the patient’s attorney wants, the patient’s attorney will then attack your bills for the first time, post-settlement. The buck keeps getting passed, and that buck keeps getting smaller each time it does. You can help nip this in the bud by establishing the reasonableness of your fees from the outset. The more you can defend your fees, the more likely you are able to: 

• Help the attorney defend your fees to the insurance adjuster 
• Take the wind out of that same attorney who later tries to argue that your bills aren’t reasonable down the road

Reasonable fees can be based upon a number of factors, such as:  

• Your area(s) of health care specialization 
• The geographical location where the services are rendered 
• The personalized treatment plan, including the range and types of procedures and specialized care you provide 
• Whether the treatment was medically necessary 
• The actual time spent administering the treatment 
• The application of proper treatment codes 
• Your credentials and level of training 

There are various sources you can use to evaluate your fees, such as usual, customary, reasonable (UCR) publications, or an online source, such as FAIR Health Consumer (fairhealthconsumer.org).  

Chances are, you will find that a lot, and maybe most or all, of your current fees are less than what UCR, Fair Health and other sources would designate as average fees for the codes you use.  

Here is how you can use this information to your advantage:  

• At the onset of treatment, give a fee comparison and other support of past full bill payments, redacting patient identifying information (HIPAA protections), to your patient and the patient’s attorney. The patient will see your fees are indeed reasonable for the marketplace. The patient’s attorney can then use this as evidence in demands made to the insurance adjuster.  
• Send monthly statements to your patient and the patient’s attorney. This helps you defend against after-the-fact, post-settlement attacks. After all, you can argue both the patient and attorney received the bill and a reasonable person would bring up issues right after receiving an objectionable bill. The attorney will find it difficult to retroactively argue your fees are now suddenly unreasonable.   

Code properly

Coding is both science and art in PI. Each code is based upon science, but which codes, combinations and modifiers you use in PI are the art. Here are six things to consider for coding in PI:

1. Using improper codes could bring down the value of the case in the adjuster’s eyes.  
2. You might have used modalities that were valid early on, but these treatments may not have been medically necessary later. Billing for the application of hot packs a patient could buy at the local pharmacy and apply at home might not be considered reasonable if continued for too long a period.  
3. More is not better in PI. If you have a laundry list of codes, this could be used against you by the defense attorney, who could argue you are padding your bills. Diagnose all injured body areas, of course. 
4. In PI, using trauma and trauma-related codes makes sense. Coding for trauma is often what a personal “injury” is all about, and it can elevate the value of a personal injury case to an adjuster.  
5. Never, ever upcode. If you apply additional codes to PI patients to pad the bill, you open your bill to attack. Worse, you may be guilty of medical billing fraud. 
6. Consider per-visit fees. Your fees-per-code might be reasonable, but is your total per-visit charge also reasonable?  

Be transparent

In today’s world of distrust over medical debt, mandates and disclosure requirements, you simply cannot be too transparent. You are better off over-complying, over-explaining and over-documenting than you are under-complying. In fact, transparency helps you defend yourself down the line. After all, if you are transparent, you can always say, “I told you so.” 

Beyond that, transparency fosters truth and builds trust, credibility and accountability. It’s the primary building block of ethics. Oftentimes, chiropractors are not transparent because they don’t want to rock the boat or they lack confidence. But consider what happens when you do not adopt transparency as a core value of your practice. If you aren’t radically transparent, how can you demand others, such as patients and attorneys, be transparent with you?   

As I coach and mentor small medical practices around the country in PI, I focus on knowledge, strategy, tactics and tools. As to transparency, start with the following areas:  

• Include this statement in your lien and on all your statements: “The patient owes the full charges regardless of the outcome of the case.” As well, tell your patient during the first meeting when you take a case on lien, you are not agreeing to be paid on contingency. You are merely agreeing to wait to be paid, but you and your team expect to be paid in full just as the attorney does for his or her hard work. Some jurisdictional exceptions apply, so be sure to check your state laws. 

• For the reasons explained earlier, send monthly statements to the patient and the attorney. When sending a discharge bill, consider including a fee comparison and bill support to show your fees as reasonable for your marketplace.  

• Comply with the relatively new federal law, the No Surprises Act (NSA), which compels transparency in medical billing so patients are not surprised by medical bills for which they have personal financial responsibility. To comply, give your patient a timely, written good faith estimate (GFE) spelling out your treatment plan and the what, when, how and how much this will or may cost the patient. The NSA applies to every uninsured and self-pay patient you have seen since Jan. 1, 2022. 

• “Self–pay” is broader than you think. Consider it as anything the patient would be surprised to learn they have to pay for, other than co-pays. A winning PI case is no guarantee that the patient is not self-pay. Neither is the presence of full application of medical expense coverage (Med Pay) or personal injury protection (PIP). Even in these areas, the patient may have to pay out of pocket, and so they are likely deemed as “self–pay.” In this case, NSA compliance applies.   

• Update your GFE any time the treatment plan changes, as many treatment plans do, and your prior estimate fell short by at least $400. 

• Have the patient sign and date the estimate, as well as the actual bill when issued at the office. Keep a copy for yourself and give a copy to the patient and the patient’s attorney. Every time you present a GFE or update, go over it with your patient. After all, due to the NSA, patients are becoming more involved, more knowledgeable, more trusting of you and a true partner in their medical care. (That’s not just a good thing. That’s a great thing.) 

When you are honest and transparent, guess what happens? You set the stage so the patient and attorney have an expectation of honesty and transparency on their ends as well. You do it right. And later, when it’s time for your patient or their attorney to pay your bill, there are far less shenanigans. 

MICHAEL COATES, ESQ., is a national authority on personal injury medical lien recovery and the founder of PIMadeEasy.com, which educates, coaches and trains medical providers and their staff to accelerate their success in personal injury. If you have questions, please reach out to Coates and his community through his free Facebook group, PI Made Easy Insiders, at facebook.com/groups/pimadeeasy.