March 2016 Final
3-1
HPP-Medical and Return To Work Management
CHAPTER 3
MEDICAL AND RETURN TO WORK MANAGEMENT
BWC defines medical management and cost containment services as those services provided by an MCO
pursuant to its contract with BWC, including return to work management services that promote the
rendering of high quality, cost-effective medical care that focuses on minimizing the physical, emotional,
and financial impact of a work-related injury or illness and promotes a safe return to work.
Through the use of managed care and return to work management strategies, an MCO shall provide
medical management and cost containment services that promote the rendering of high-quality, cost-
effective medical care that focuses on minimizing the physical, emotional, and financial impact of a
work-related injury or illness and promotes a safe return to work. The MCO shall provide medical
management and return to work/remain at work management services for the life of a claim, as long as
the employer remains in contract with the MCO. The MCO is responsible for the medical management
component of workers’ compensation claim management and shall:
Adhere to the most current version of the MCO Policy Reference Guide and provide medical
management and return to work/remain at work services for all workers’ compensation cases to
which it is assigned.
Support BWC initiatives such as but not limited to the return to work (RTW) goals of the agency.
Educate employers on the value of transitional /return to work services
Provide medical management and return to work services under the leadership of the MCO Medical
Director who assumes responsibility for all MCO medical management outcomes as outlined in the
MCO policy guide. The MCO Medical Director shall be involved in the development, monitoring and
quality assurance of policies and procedures for medical management and return to work/remain at
work services. The MCO Medical Director shall maintain a current, unrestricted license to practice,
and shall have either (a) a minimum of ten (10) years clinical practice experience or (b) Board
Certification if a Medical Doctor or Doctor of Osteopathy.
A. MCO MEDICAL MANAGEMENT RESPONSIBILITIES
SERVICE
DESCRIPTION
1. Claim Intake
MCO responsible for data collection and
validation (other than wage information)
necessary to support BWC claim determination.
Data collection and validation include contacting
the employer to verify facts and obtain employer
certification of the claim, and obtaining necessary
medical information from providers.
2. Alternative Dispute Resolution (medical
issues)
MCO completes timely dispute resolution
processes regarding medical and treatment issues.
3. Professional Nursing Services Authorizations
MCO performs authorization and ongoing
monitoring of professional nursing services.
March 2016 Final
3-2
HPP-Medical and Return To Work Management
SERVICE
DESCRIPTION
4. Caregiver Services Re-Authorization
BWC will review caregiver services for re-
authorization. The MCO determines the type of
Home Health Agency Nursing care in cases where
a caregiver is no longer able, or no longer chooses
to provide caregiver services. Replacement
“family or friend” is not an option. Coordination
of cases is to occur between MCO and BWC
when Caregiver services and Home Health
agency services are both approved in a claim to
prevent service overlap.
5. Home and Van Modification Authorizations
MCO is responsible for identifying the need for
home or vehicle modifications and referring to the
BWC Catastrophic Nurse Advocate (CNA). The
CNA will then develop a plan for home or vehicle
modifications necessary as the result of a
catastrophic injury. The CNA will work closely
with the MCO case manager and the necessary
vendors to ensure coordination of the services.
MCO is not responsible for authorizing home and
van modifications.
6. Utilization Review
in-patient services
outpatient services including surgery
high cost diagnostic services
physical medicine
MCO performs utilization review for all claims
for employers selecting the MCO.
7. Bill Review
clinical editing
integration of medical management and
bill payment systems
MCO reviews all bills using nationally accepted
clinical editing guidelines, clinical editing
guidelines identified in chapter 8, and integrating
medical management documentation.
8. Independent Medical Exams
MCO makes appropriate referrals for specialist
care and obtain second opinions as indicated, and
documents follow up of all IME
recommendations for medical treatment if
notified. Agreed medical examinations may be
completed for medical management at the MCO’s
expense. The exceptions noted for ADR/IME.
9. Provider Relations
MCO is responsible for maintaining arrangements
with providers or provider panel, for assisting
provider with BWC enrollment and certification
and insuring providers’ eligibility to participate in
HPP. MCO must also maintain Provider Relations
contact for BWC and for the public.
10. Out-of-State, Out-of-Country Medical
Management and Provider Management
MCO performs medical management, provider
payment and provider management services for
all claims for employers selecting the MCO.
March 2016 Final
3-3
HPP-Medical and Return To Work Management
SERVICE
DESCRIPTION
11. Medical-Claim Management
MCO provides medical claim management
services including obtaining medical information,
reviewing treatment plan with BWC approved
treatment guidelines and authorizing medical
services/supplies.
12. Additional Allowance
MCO is responsible for collecting medical
documentation to clarify requests for additional
allowances submitted on a C9. MCO collects and
evaluates medical information and makes a
recommendation to BWC regarding whether
medical information in the claim supports the
existence of the additional allowance requested.
MCO shall assist the employer in understanding
claim medical information when necessary.
13. Peer review
MCO performs peer review process for network
and non-network providers on utilization review
and treatment issues. MCO has peer review
processes for educating and disciplining providers
who are identified as outliers of normal treatment
patterns based on profiling and utilization trends.
MCO has a credentialing committee and
decertification processes for network providers.
The MCO is responsible for payment of peer
reviews.
14. Permanent Partial Disability (C-92) Review
and Exams
In cooperation with BWC, MCO educates treating
physicians on necessary medical documentation
for request for increase in permanent partial
disability.
15. Claim File Review
All file review requests are at the MCO's expense.
16. Quality Assurance
MCO maintains credentialing committee for panel
providers and a quality assurance committee for
panel and non-panel providers. MCO must
maintain quality assurance standards and practices
within their operations including a tracking
system and feedback mechanisms. The MCO
shall have a medical management quality
assurance program that includes the use of quality
assurance policies and procedures manual that is
updated at least quarterly, and that is in
compliance with URAC accreditation standards.
17. Sub-Acute, Long-Term Facility and Alternative
Care Management
MCO performs authorization, coordination of
care at appropriate level of setting and provides
on-going monitoring and quality assurance for
long-term care.
March 2016 Final
3-4
HPP-Medical and Return To Work Management
SERVICE
DESCRIPTION
18.
Vocational Management
MCO educates providers about return-to-work
goals, workers’ compensation issues, etc. The
MCO identifies the need for vocational services,
as necessary, for return-to-work goals. Note:
BWC will only reimburse Comprehensive
Occupational Rehab Programs (Work Hardening)
that are CARF accredited.
19.
Remain at Work (RAW)
MCO is responsible for identifying injured
workers and employers to participate in the
Remain at Work program. The MCO is charged
with coordinating between the employer, IW and
provider, as well as developing a case
management plan, as appropriate.
20. Return to Work (RTW)
MCO is responsible for documenting and
implementing a case management plan that
addresses RTW planning on all lost-time claims
where the IW has not returned to work regardless
of DOI.
21.
30-Day Assessment
MCO is responsible for working with the
customer service team Disability Management
Coordinator (DMC) in all claims in which the
injured worker has not returned to work 30 days
beyond the 50
th
percentile of the MoD Days
Absent benchmarks. Public employers’ claims
will be reviewed at 45 days. In conjunction with
the MCO and others, BWC will identify return to
work barriers and come to agreement with the
MCO regarding appropriate next steps. If the
agreed upon course of action is not carried out by
the MCO or no resolution can be attained, the
MCO will be asked to implement 30-Day
Assessment Recommendations developed by the
DMC. The MCO may appeal these
recommendations within 5 working days. There
are two levels of appeal. If the second appeal
supports the implementation of the Assessment
Recommendations, BWC will reclaim the
vocational portion of the claim and assess a
penalty.
March 2016 Final
3-5
HPP-Medical and Return To Work Management
SERVICE
DESCRIPTION
22. Treatment Standards/Guidelines
MCO maintains national standards for utilization
review functions and maintains BWC approved
treatment guidelines. BWC distributed the
following treatment guidelines to BWC certified
providers designated by BWC.
MCO staff began using Official Disability
Guidelines (ODG) in making their treatment
authorization decisions effective April 1, 2004.
The MCO shall follow up on treatment
reimbursement approvals for all inpatient services
and outpatient surgical services, all diagnostic
studies (excluding x-rays) and all therapies in all
claims subject to initial assessment/triage and/or
Medical Case Management within fourteen (14
days) of the treatment reimbursement approval, in
order to ensure that necessary care and/or
treatment is delivered in a timely fashion.
The MCO shall review the results of all approved
diagnostic studies (except x-rays) in all claims
subject to initial assessment/triage and/or Medical
Case Management within fourteen (14) calendar
days of completion to determine the necessity of
medical management services or notification to
the Bureau Customer Service Team of medical
support for payment or non-payment of temporary
total compensation or other circumstances
materially impacting Bureau claims management.
23. Medical Case Management
Medical case management is an essential
component in effecting a successful claim
outcome. Because the MCO’s share claim
operations duties with BWC, it is essential that
the role, responsibilities and activities of the
MCO’s be clearly defined so that each will be
able to interact effectively to reach optimal results
24. Case Management Plan
The case management plan is formed by a
compilation of all information that the case
manager has gathered from the injured worker,
the physician and the employer as well as any
other pertinent sources that impact the progress
and successful outcome of the claim resolution.
March 2016 Final
3-6
HPP-Medical and Return To Work Management
SERVICE
DESCRIPTION
25. Catastrophic Claim Program Coordinator
The MCO shall have a designated catastrophic
claim program coordinator, who shall be
responsible for directing the MCO's management
of catastrophic claims assigned to the MCO. The
catastrophic claim program coordinator shall be a
registered nurse, shall meet the Standard CM 4
qualifications for case manager supervisors as
required by URAC accreditation standards, and
shall meet all other qualifications set forth in the
MCO Policy Reference Guide.
In addition, this coordinator is required to have 2
years of Ohio BWC MCO case management
experience. Past clinical experience in critical
care is recommended, but not required. Must be
proficient in the MCO Policy Reference Guide,
and will attend all training designated by BWC
for the catastrophic claim program coordinator.
26. Vocational Rehabilitation Program Coordinator
The MCO shall have a designated vocational
rehabilitation program coordinator, who shall be
responsible for directing the MCO's management
of vocational rehabilitation services in claims
assigned to the MCO. The vocational
rehabilitation program coordinator shall meet the
Standard CM 4 qualifications for vocational
rehabilitation as set forth in Rule 4123-6-02.2 of
the Ohio Administrative Code, shall meet the
qualifications for case manager supervisors as
required by URAC accreditation standards, and
shall meet all other qualifications set forth in the
MCO Policy Reference Guide.
In addition, this coordinator is required to have 1
year of field vocational rehabilitation case
management experience, be proficient in the
MCO Policy Reference Guide, especially Chapter
4, and will attend all training designated by BWC
for the vocational program coordinator. Note: It
is not necessary for MCOs to make changes to
meet the 1 year experience requirement.
However, if this position becomes vacant at the
MCO, this position should be filled with an
individual who meets the requirement.
B. AUTHORIZATION AND DENIAL OF MEDICAL TREATMENT
March 2016 Final
3-7
HPP-Medical and Return To Work Management
A Clinician (as defined in Appendix G of the contract) shall make all treatment
reimbursement denial on behalf of the MCO.
1. Adherence to BWC approved Treatment Guidelines
The MCO services shall include implementation of the Official Disability Guidelines and
utilization review to evaluate the necessity and/or effectiveness of medical care.
All MCO medical case management staff members shall complete annual training on the
Official Disability Guidelines, utilization review and protocols.
a. Official Disability Guidelines
MCO staff shall use the Official Disability Guidelines (ODG) in making their
treatment authorization decisions.
The ODG are evidence based treatment guidelines that BWC and the MCOs will
be using to assist in medical and claims case management. ODG is a web-based
tool available to BWC and MCO staff on their desktops. BWC and MCO staff
will be able to easily search and find pertinent information necessary to everyday
issues in claims and medical case management.
Ohio providers can take advantage of the BWC negotiated price if they order on
the web www.WorkLossData.com or call the toll free number (800-488-5548).
2. Miller vs. IC – see Chapter 9
3. Emergency Department Reimbursement
It is common for injured workers to seek treatment in an emergency room after their
accident has occurred. Often, the specific conditions to be included in the claim are not
known at the time treatment was received. Therefore, a bill for emergency room services
may contain conditions that have not been allowed, which results in denial of the bill. To
address this circumstance, as long as the condition being billed is medically related to the
allowed injury, non-allowed diagnoses (including codes on BWC's invalid ICD code list)
on bills for services rendered within 72 hours of date of injury, including services
received in an emergency room, will pass through BWC’s payment system.
Treatment in the emergency department of a hospital must be of an immediate nature to
constitute an emergency. Prior authorization of such treatment is not required.
However, in situations where the emergency department is being utilized to deliver non-
emergency care, notification will be provided to the injured worker, the hospital, and the
provider of record that continued use of the emergency department for non-emergent
services will not be reimbursed by BWC/MCOs.
4. Therapy Visits
The maximum time allowable per visit for therapy services with timed procedure codes,
i.e., physical medicine and rehabilitation modalities and therapeutic procedures should be
no longer than one hour without prior authorization. If therapy services with timed codes
March 2016 Final
3-8
HPP-Medical and Return To Work Management
are billed over one hour/day, further medical review and approval must occur if services
were not authorized prior to payment being made.
5. Request for Medical Services
Requests for medical services that require prior authorization must be submitted by the
physician of record (POR) or treating physician to the appropriate MCO prior to initiating
any non-emergency treatment. The preferred method of submission is the BWC
Physician’s Request for Medical Service or Recommendation for Additional Conditions
for Industrial Injury or Occupational Disease (C-9) form; however, any other physician
generated document may be used, provided that the substitute document contains, at a
minimum, the data elements on the C-9 form. The POR or treating physician should
identify additional conditions to be allowed in the claims on item six of the C-9 form and
should spell out additional conditions with supporting documentation.
a. Authorization Guidelines
The following guidelines were implemented to help the MCO consider authorization,
promote safe and early return to work, and expedite the payment of medical bills:
1) The MCO must respond to the physician within three business days with a
decision regarding the proposed treatment request.
2) The MCO must return fax of the authorized, denied or pended medical services
request back to the physician within the required three business days. If faxing is
not feasible, the MCO is required to call the physician in order to communicate
the decision and follow-up in writing via mail.
3) If the MCO is unable to make a decision within three business days due to the
need for additional information, the MCO will send a request for Additional
Medical Documentation C-9 form (C-9-A) to the provider.
4) The MCO may request CPT codes but may not pend or deny the request for
treatment if the CPT codes are not provided. CPT codes are used to report
procedures or services that were delivered. CPT codes are not additional medical
documentation that an MCO may require to make a decision on a request for
treatment.
5) The provider must return the form C-9-A and any additional supporting
documentation to the MCO within ten business days. The MCO will contact the
provider via letter each time medical documentation, including the Physician's
Report of WORK ABILITY (MEDCO-14), Request for Additional Medical
Documentation for C-9 (C-9-A) or other documentation necessary to manage an
injured worker’s claim is requested but not received in the designated time
period for the medical documentation.
6) The MCO has five business days from the date additional information is received
to make a subsequent decision. The MCO must render a decision to allow or
deny the medical services request if the physician does not provide the MCO
with any requested documentation within ten business days for all active claims.
The physician must be notified by fax or phone of the subsequent decision. Note:
March 2016 Final
3-9
HPP-Medical and Return To Work Management
for inactive claims, the MCO may dismiss the C-9 (with no ADR appeal rights)
after the ten days if the medical requested on the C-9-A is not returned. If the
MCO chooses to dismiss the C-9 without prejudice after using the C-9-A to
request for medical documentation within the last 60 days, the MCO shall fax
both the dismissed C-9 and C-9-A to the service office to be imaged into the
claim file.
7) If the MCO is unable to make a decision within three business days due to the
need for a physician review and the requesting provider is notified, the medical
review must take place and a decision rendered by the MCO within five business
days. All MCO physician reviews shall be imaged into the BWC claim file with
the C9/ C9 determination letter. Again, the requesting provider must be notified
by fax or phone of the subsequent decision.
8) The MCO may pend a C-9 requesting a prosthetic if a Multi-Disciplinary Clinic
Evaluation (MDE) is being obtained. The MCO shall render a decision within
five business days of receipt of the MDE.
9) The MCO must respond to the physician within sixteen business days with a
decision regarding the proposed treatment request on an inactive claim (see
Reactivation in chapter 2).
10) The MCO must consider and communicate with POR possible alternative
treatments that may be eligible for reimbursement if requested by the provider,
based on the Official Disability Guidelines. Such alternative treatment
proposals/suggestions must be communicated in the decision letter to the
provider.
11) The MCO shall obtain beginning and estimated ending dates for inpatient
services if not provided on the request for medical services. Allowing the injured
worker to choose the health care provider does not limit the MCO’s authority
and responsibility to promote a safe and early return to work by assisting in
determining the earliest possible date for inpatient and/or outpatient services.
12) The MCO shall include a treatment authorization number for services approved
on the request for medical services.
13) Treatment reimbursement request denials and approvals outside of treatment
guidelines, pathways, or presumptive authorization must be made by a clinician.
Clinicians and non-clinicians may issue treatment request approvals within
treatment guidelines, pathways or presumptive authorization.
14) To expedite service delivery, timelines for approvals of routine diagnostics (x-
rays, CAT scans, MRI scans and EMG/NCV) should be no longer than two
weeks. Timelines for approvals of other medical treatments or services with no
specified timeframe on the request should be no longer than 30 days. Services
not able to be or not rendered in this time must have an update in IW claim notes
as to the rationale for the delayed service delivery. Services that run continuously
over a longer timeframe (such as facility placement) should not be approved for
more than six months maximum.
March 2016 Final
3-10
HPP-Medical and Return To Work Management
15) Approval of C-9s submitted by a PT or OT shall be valid for no longer than 30
days unless the approval specifies a longer period and such longer period is
supported by the prescription accompanying the C-9.
16) The MCO must check the enrollment status and provider type of the servicing
provider before services are rendered (unless the C-9 is retro) to confirm the
provider’s eligibility for payment for the services to be rendered. If the provider
is not eligible to render or receive payment for the services, the MCO must assist
the IW to find an eligible servicing provider. Failure to confirm servicing
provider eligibility for payment may subject the MCO to recovery for any
inappropriately approved services.
A medical service request will be considered approved and the provider may initiate
treatments when all of these criteria are met:
The MCO fails to communicate a decision to the physician within three
business days of receipt of an original medical services request or five
business days if the request was pended;
The physician has documented the medical services request completely and
correctly on a C-9 or other acceptable document;
The physician has proof of submission to the appropriate MCO;
Medical services are for the allowed conditions;
The claim is in a payable status.
In instances when a C-9 is not responded to within three business days and the
provider initiates treatment, the MCO will provide concurrent and retrospective
review of that treatment.
If it is found before, after or during delivery, that any approved medical treatment
reimbursement request is not medically indicated or necessary, is not producing the
desired outcomes, or the injured worker is not responding, the MCO will notify the
parties of its decision to discontinue payment of approved treatment that has not
already been rendered. Only charges for treatments already rendered will be paid. If
the provider, IW, or employer wish to dispute the decision, they may do so via the
ADR process.
The MCOs may dismiss without prejudice a C-9 when:
1) there is no evidence that the provider has seen and examined the injured
worker within the previous 30 days from the date of the C-9 submission,
unless there is proof that the injured worker requested a visit with the
provider;
2) the C-9 is submitted from a provider in state and out of state who is not
enrolled with BWC and who refuses to become enrolled, or who is enrolled
but not BWC-certified and is not eligible under any of the exceptions for
payment as a non-certified provider (emergency care, “grandfathered” pre-
HPP physicians of record, inadequate number of BWC-certified providers
available);
March 2016 Final
3-11
HPP-Medical and Return To Work Management
3) there is no supporting medical evidence for inactive claims or the medical
evidence is dated more than sixty days prior to the date of the request (refer to
Requesting a Claim Reactivation in chapter 2);
4) the C-9 is a duplicate and is not accompanied by evidence of new or changed
circumstances impacting treatment, and such evidence is not provided to the
MCO upon request via C-9A or equivalent;
5) the C-9 is on a claim for an employer participating in the $15,000 Medical-
only Program;
6) Claim is settled medical or medical and indemnity, and the dates of service
requested are on or after the effective date of the settlement;
7) The underlying claim has been disallowed or dismissed in its entirety, or the
only allowances in the underlying claim are for substantial aggravation of a
pre-existing condition, and the conditions have been determined in a final
administrative or judicial determination to be in a non-payable status;
8) The services or supplies being requested are never covered by the bureau
pursuant to other bureau statutes or rules;
9) The MCO has requested supporting medical documentation from the provider
necessary to the MCO's evaluation and determination, via C-9A or equivalent,
and such documentation is not provided to the MCO.
The injured worker, injured worker representative, BWC, and the provider shall be
notified when a C-9 is dismissed without prejudice for the aforementioned reasons
(only the provider and employer need to be notified for a dismissed C-9 in the $15K
program), however, the MCO shall not include appeal language in this notification as
the C-9 will not be appealable through the ADR process.
MCOs shall fax signed C-9s, along with all supporting medical evidence that was not
attached to the C-9 (i.e. IMEs, peer review), to the designated numbers for each
service office. Since medical documentation will be rolling from the MCO’s provider
fax line into the Medical Repository, MCOs are not required to re-fax the medical
attached to a C-9 to the service offices. The medical documentation will already be
indexed waiting for the arrival of the MCO’s C-9.
If the MCO receives a C-9 requesting treatment by a provider with a lapsed
certification, the MCO shall process the C-9 based on the Miller criteria. The MCO
shall contact the provider and the injured worker to educate them on the situation and
may use the following disclaimer language on the C-9 “Provider certification status
has lapsed. Approval of this treatment does not guarantee bill payment. For
information regarding becoming recertified contact 1-800-OHIO-BWC option 0-
3-0.”
b. Medical service request for a condition not allowed in the claim
If an MCO receives a request for consideration of an issue relating to the delivery of
medical services for a condition or part of the body that is not allowed in the claim,
the MCO may use a disclaimer (see 7c. Standardized Prior Authorization –
Disclaimers) if the condition is being adjudicated and the requested treatment is
March 2016 Final
3-12
HPP-Medical and Return To Work Management
medically necessary and appropriate for the requested condition(s), or the MCO may
deny the request for the reason that the condition or part of the body is not allowed in
the claim. The MCO may not ask the provider to withdraw the C9. The MCO must
check V3 on the date of the C9 decision and base its decision to approve/deny on
what is allowed in V3.
The provider may recommend an additional allowance on the C-9 with supporting
medical evidence, or the injured worker may file a motion (C-86) requesting an
additional allowance. The MCO is responsible for reviewing the medical information
in the claim, obtaining additional medical information as needed and documenting
whether the medical information available in the claim supports the existence of the
additional condition requested on the C-9. The bureau will review the
recommendation or motion and will consider the additional allowance. Once the
condition(s)/ICD-9 code(s) are updated to an “allowed” status (see chapter 2 -
Proactive Allowance), the Notification of Injury/Claim Status Changes letter is
systematically sent to the provider of record/treating physicians and the parties in the
claim. The CST will notify the MCO of the final decision by telephone or e-mail.
This will provide immediate feedback to MCO, so it can move forward with issuing
decisions on the treatment plan request. The MCO shall assist the employer in
understanding available medical information as necessary.
c. Retroactive medical service request
The MCO shall authorize, deny, or pend a provider’s proposed retroactive medical
service request (submitted on a C-9 or other appropriate form) within thirty (30)
calendar days from the MCO’s medical service request receipt date. However, when
processing a C-9, or other appropriate form, that includes retroactive and future
treatment request(s) the MCO shall follow the standard 3 business day time frame
authorization requirements for each treatment request. This would include the ability
to pend for additional medical documentation/review if necessary.
d. Provider compliance for BWC’s prior authorization policy
On April 1, 2005, MCOs began notifying physicians who failed to comply with prior
authorization policies and procedures. Per Rule 4123-6-02.3 (D)(8), BWC-certified
providers have agreed to “practice in a managed care environment and adhere to
MCO and bureau administrative procedures and requirements concerning provider
compliance, outcome measurement data, peer review, quality assurance, utilization
review, bill submission, and dispute resolution.” Failure to do so can negate the
MCO’s ability to work with the physician to effectively manage the injured worker’s
claim.
Providers received a standardized provider non-compliance education letter from the
MCO each time a Physician's Request for Medical Service or Recommendation for
Additional Conditions for Industrial Injury or Occupational Disease (C-9) or
physician generated document is received after the treatment or service has been
March 2016 Final
3-13
HPP-Medical and Return To Work Management
provided. This notice was revised in May 2007 and was required to be utilized in June
2007. The standardized letter (distributed to all MCOs) must:
Be personalized to the specific physician requesting the C9;
Have a copy of the retro C-9 or written request for medical;
Provide a specific MCO provider relations representative as the main contact for
information;
Include rationale explaining validation and why provider did not meet ‘just
cause’;
Image into provider claim via service office fax numbers
MCOs are no longer required to send educational letters to providers who have
submitted retro C-9s after the treatment or service has been provided without “just
cause”; however, the MCOs are still to keep track of such providers as set forth
below. “Just cause” reasons may include, but are not limited to:
Emergency treatment;
Provider not aware that services were for a workers’ compensation claim;
Provider non BWC certified and no established relationship with the IW;
Provider recently became BWC certified (within last 6 months);
Pending additional allowances with BWC or Industrial Commission;
Pending claim allowance with the BWC or Industrial Commission;
Treatment provided was within the presumptive authorization guidelines;
Treatment provided does not require prior authorization;
Other (provider provided other documented justification for just cause)
Each MCO will maintain information on each provider that is non-compliant with
BWC’s prior authorization policy. The MCO must submit the information monthly on
the BWC portal via the Compliance Referral list.
Complete directions for reporting non-compliance are available to all MCOs on the
Portal, MCO Home Page, under Shared documents , Provider Non-compliance
monitoring . All medical documentation non- compliance should be reported utilizing
the process in Chapter 6, of the MPRG.
e. Guidelines to address withdrawn medical service request
To address those situations when a requesting physician indicates that the C-9 request
is no longer valid and would like it to be withdrawn or disregarded, the MCO shall:
Respond to the C-9 request by noting at the bottom of the C-9 that the request has
been withdrawn and noting reason,
Contact the requesting physician’s office and indicate date;
Sign and date the C-9;
Document all discussion in notes;
March 2016 Final
3-14
HPP-Medical and Return To Work Management
Fax the C-9 to the provider and BWC.
Send notification letter to the injured worker as well explaining that the requested
treatment has been withdrawn and document in notes.
An example of a C-9 withdrawal may be when the MCO receives a C-9 for a surgery
request and then the IW notifies the MCO that either they do not want to proceed with
the surgery or they want to get a second opinion. The MCO then calls the POR to
discuss, indicates the IW’s concerns and the POR states to disregard the request and
will request again if needed later.
Another example might be if a POR requested a tens unit and/or supplies based on a
request from an ancillary provider and later learns, after follow up from the MCO to
obtain supporting medical documentation to determine that validity of the request,
that the request was unwarranted because the IW has an older claim and is not
currently receiving supplies for the tens unit.
f. C-9s for Specialists Consultations
Although most consults do not require authorization, many specialists are not
comfortable scheduling and performing consultations without an authorized C9.
While PORs, BWC and the MCOs have attempted to educate the specialists, many
will not accept the IW if the "approved" box is not checked the on the C-9.
Therefore, MCOs should check the appropriate box (approve or deny) on the C-9 for
these consultations to ensure appropriate services are rendered to the injured worker.
This will not change the way the MCO will use the disclaimer when the
claim/condition is not yet allowed (see standardized prior authorization - section C).
It is only checking the approved box for the consultation with the disclaimer
as appropriate.
g. Approval of direct service provider only:
Rule 4123-6-02(B) Provider Access to the HPP – generally notes the following: A
provider shall be certified or recertified by the bureau to treat injured workers if the
provider is a direct service provider and maintains basic credentialing criteria
under Rule 4123-6-02.2 of the Administrative Code; meets and maintains all other
applicable criteria under the workers’ compensation statutes and rules; and completes
and signs a provider application and agreement or recertification application and
agreement.
Therefore, the MCO shall authorize services to be rendered by a BWC certified
provider type eligible for reimbursement of that service requested. Service
Coordinators are not eligible to enroll or provide services to BWC’s injured workers.
6. Requests and Authorizations for Mental Health Services
a. Authorization
March 2016 Final
3-15
HPP-Medical and Return To Work Management
Information used to support requests and authorization for mental health services can be
submitted on the C-9 form.
Important: Ohio law protects the confidentiality of the mental health providers’ progress
notes; therefore, MCOs cannot request copies of this document. Requests for copies of
the progress notes with the deletion of any non-claim related information is also
prohibited. However, a detailed summary of the notes can be requested, which can be
used to support the C-9. Authorizations are to be granted for either a specific number of
sessions or period of time. MCOs are prohibited from authorizing “continuous” or
“indefinite” mental health treatment. Once the authorized limits have been reached, a
new C-9, accompanied by a detailed summary, must be resubmitted to the MCO for re-
evaluation of the treatment.
b. Psychiatric/Psychological Evaluation
If the psychiatric condition is allowed in the claim, an IW may be reimbursed for the cost
of the psychiatric/psychological exam if it was needed to obtain medical evidence to
support the allowance. Payment for psychiatric/psychological evaluation and/or treatment
may be considered, on a case by case basis, if one or more of the following applies:
A psychiatric/psychological condition is allowed in the claim;
A psychiatric/psychological exam is scheduled by BWC;
A psychiatric/psychological condition is subsequently added to the claim when
the injured worker or provider absorbed the cost of an examination performed to
provide evidence to support the motion.
An injured worker is participating in an approved vocational rehabilitation or
catastrophic treatment plan;
The evaluation is either part of an authorized pre-admission evaluation for an
approved chronic pain program or the injured worker is participating in an
authorized chronic pain program;
The evaluation/treatment is either part of an authorized detoxification or
substance abuse program.
7. Standardized Prior Authorization
a. Presumptive Approval
For dates of injury on or after Nov. 1, 2002 presumptive approval to provide services
will be extended from the first 45 days following an injury to the first 60 days
following an injury. The MCO shall adhere to the following standardized prior
authorization and presumptive approval guidelines.
For a period not to exceed 60 days following the date of injury, physicians of
record, or other approved providers licensed to practice medicine, osteopathy,
chiropractic, mechanotherapy, dentistry, or nursing as a certified registered nurse
anesthetist, clinical nurse specialist, certified nurse-midwife or certified nurse
practitioner as applicable have presumptive approval for providing the following
services when treating soft tissue and musculoskeletal injuries for allowed conditions
in allowed claims:
March 2016 Final
3-16
HPP-Medical and Return To Work Management
A maximum of 12 physical medicine visits per injured worker claim which may
include any combination of osteopathic manipulative treatment, chiropractic
manipulative treatment, and physical medicine and rehabilitation services
performed by a provider whose scope of practice includes these procedures,
including, but not limited to, doctor of chiropractic, doctor of osteopathic
medicine, doctor of allopathic medicine (MD), physical therapist, occupational
therapist, athletic trainer, or massage therapist. NOTE: BWC’s position is the
maximum time allowable per visit for therapy services should be no more than
one hour without prior authorization. If services are over one hour per day,
further medical review and approval must occur unless such services received
prior authorization.
A maximum of 12 physical therapy treatments within sixty days following the
date of injury may be reimbursed without prior authorization. The treatments
must be for allowed soft tissue and musculoskeletal conditions in allowed claims,
and even though prior authorization is not required, the criteria set forth in
paragraphs (B)(1) to (B)(3) of Rule 4123-6-16.2 of the Administrative Code (the
Miller criteria) must still be met for the treatments to be reimbursed.
Diagnostic studies, including x-rays, CAT scans, MRI scans and EMG/NCV
Up to three soft tissue or joint injections involving the joints of the extremities
(shoulder including acromioclavicular, elbow, wrist, finger, hip, knee, ankle and
foot including toes) and up to three trigger point injections. Injections of the
paraspinal region, including epidural injections, facet injections, and sacroiliac
injections are not included in the presumptive approval guidelines.
E/M services and consultation services.
The following criteria must be met prior to initiating any or all of the aforementioned
services:
The provider shall file the First Report of Injury (FROI) with the MCO.
The provider shall complete and file the C-9, with documentation, to the MCO.
The MCO will notify the provider within three business days acknowledging
receipt of the C-9 and that a review was completed to ensure that services being
rendered are medically necessary for the claim allowance. NOTE: The MCO
shall not deny reimbursement for presumptive approval services solely on
the grounds that the provider did not file the C-9 prior to delivering the
services. The MCO will contact the provider and explain that the C-9 is
necessary in order that a review can be completed to ensure that services
rendered were medically necessary for the claim allowance.
When the claim or condition for which treatment is being requested is not yet in
an allowed status, the MCO may use the disclaimer language when notifying the
provider (within three business days) that the MCO received the C-9 and a
review was completed to ensure that services being rendered are medically
necessary for the claim allowance.
The provider shall notify the MCO within 24 hours of treatment if the injured
worker will be off work for more than 2 calendar days
b. Standardized Prior Authorization Table
March 2016 Final
3-17
HPP-Medical and Return To Work Management
Important: Services listed in the standardized prior authorization table in Chapter
1 of the BWC Provider Billing and Reimbursement Manual and not indicated as
exceptions will still require prior authorization. Providers must submit a C-9 to
indicate services to be provided through formal authorization. Requests for
medical services that require prior authorization must be submitted by the
physician of record or treating physician. Provider types whose signature must
appear on the C-9 treatment request include all POR provider types (MD, DO,
DC, DDS, DMT, DPM, and Psychologist), optometrist, advanced practice nurse,
physician assistant, independent social worker, and professional clinical
counselor. Treatment requests from any other provider type should not be
processed.
Whether or not prior authorization is required, BWC will only
reimburse for services that meet all Miller Criteria.
Chapter 1 of the BWC Provider Billing and Reimbursement Manual may be accessed on
BWC’s website via the following link:
http://www.ohiobwc.com/provider/services/agreement.asp
The following EOBs were developed to provide an explanation to providers for bills for
services rendered under Presumptive and Standardized Prior Authorization guidelines
and were denied:
560
Payment is denied as documentation has not been received by MCO for
presumptive authorization to apply.
561
Payment is denied as prior authorization is required for epidural injections.
562
Payment is denied as these physical medicine/OMT/CMT services/visits exceed 12
in the initial 60 days and have not been authorized.
563
Payment for this procedure is denied as prior authorization is required for more
than three injections in the claim’s initial 60 days.
564
Payment is denied as these physical medicine/OMT/CMT services exceed the
initial 60 day time frame.
565
Payment is denied as prior authorization is required for psychiatric &/or chronic
pain programs.
566
Payment is denied as prior authorization is required as the diagnostic test exceeds
the claims initial 60 day time frame.
c. Disclaimers
Disclaimers may only be used on a C-9, or any other physician generated
treatment request, when the claim or the condition for which the treatment is
being requested is not yet in an allowed status. Disclaimer boxes shall not be
checked when authorizing treatment for allowed claims and conditions that are
within the statute of limitations. The following disclaimer language is part of the
C-9 form:
"This medical payment authorization is based upon a claim or additional
condition that is currently being adjudicated by BWC/IC as of the date of the
March 2016 Final
3-18
HPP-Medical and Return To Work Management
MCO’s signature. If the claim or additional condition is ultimately disallowed,
the services /supplies to which this medical payment authorization applies may
not be covered by BWC and may be the responsibility of the injured worker."
Note: For services that fall under the Presumptive Authorization guidelines,
MCO's may use the disclaimer language when notifying the provider (within three
business days) that the MCO received the C-9 and a review was completed to
ensure that services being rendered are medically necessary for the claim
allowance.
The following grid was designed to assist MCOs with appropriate treatment
request disclaimer application:
EDI
Claim/Condition
Status
Definition
Disclaimer
Yes
No
Comment
NC = NEW CLAIM
Claims are automatically placed in
this status immediately after the
claim number is assigned
Yes
AG = ALLEGED
Claim is pending a decision during
the investigation process
Yes
AA =
ALLOW/APPEAL
The claim has been allowed by
BWC Order and is being held for
the appeal period
Yes
AL = ALLOW
The claim is allowed. The appeal
period is expired and no appeals
were filed
NO
DP =
DISALLOWED/APP
EAL
The claim has been disallowed by
BWC Order and is being held for
the appeal period
Yes
DA =
DISALLOWED
The claim is disallowed. The
appeal period is expired and no
appeals were filed.
Not applicable
HR = HEARING
The claim is being set for hearing
due to the filing of an appeal. This
is only applicable to the initial
decision
Yes
HD = HEARING -
DHO
District Hearing Officer has
allowed the claim and is being held
for the expiration of the appeal
period.
Yes
DS = DISMISSED
Claim application has been
dismissed at the request of the
injured worker.
Not applicable
March 2016 Final
3-19
HPP-Medical and Return To Work Management
PM = PENDING
SETTLE MEDICAL
ONLY
Claim is pending settlement for
medical only portion.
Treatment cannot
be authorized when
a claim is in a
pending settled
status
PI = PENDING
SETTLE
INDEMNITY
Claim is pending settlement for
indemnity only portion.
Treatment cannot
be authorized when
a claim is in a
pending settled
status
PB = PENDING
SETTLE MEDICAL
& INDEMNITY
Entire claim is pending settlement.
Treatment cannot
be authorized when
a claim is in a
pending settled
status
SM = SETTLED
MEDICAL ONLY
Only the medical portion of the
claim has been settled. Indemnity
can continue to pay.
Not applicable
SI = SETTLED
INDEMNITY ONLY
Only the compensation portion of
the claim has been settled. Medical
bills can continue to pay.
NO
ST = SETTLED
MEDICAL &
INDEMNITY
The entire claim has been settled.
Neither medical bills nor
compensation can be paid.
Not applicable
8. Due Process
Treatment reimbursement decisions shall be communicated in writing, with an
appropriate explanation (including appropriate references to treatment guidelines in all
treatment reimbursement denials) and due process appeal language, within three (3)
business days from the MCO’s treatment reimbursement request receipt date as follows:
All treatment reimbursement decisions shall be sent to the Bureau and the provider;
Treatment reimbursement denials shall also be provided to the injured worker and his
or her representative, if any;
Treatment reimbursement approvals, including those approved via the alternative dispute
resolution (ADR) process, shall also be provided to the injured worker and his or her
representative, if any, and to the employer and its representative, if any, unless the
employer or representative has waived, in writing, its right to receive notice or the
employer is in a status other than Active, Reinstate, or Debtor in Possession. The
notification to the injured work and his or her representative shall include a clear
explanation of what treatment was approved for reimbursement, as well as any time
frame allotted for completion for the treatment.
In cases where an injured worker or employer representative has been identified to the
MCO, the MCO must confirm such representation in the claim via EDA or with the CCT,
March 2016 Final
3-20
HPP-Medical and Return To Work Management
and copy the representative(s). Additionally, in all instances where an MCO decision is
to deny authorization for services, such denial must be accompanied by clearly
documented rationale and supporting medical evidence (physician review) justifying such
denial.
For BWC auditing purposes, a note in the IW electronic file is not acceptable as proof
that a treatment reimbursement decision was faxed to all parties. A fax verification sheet
that includes at a minimum: the recipients fax number, date transmitted and quantity of
pages successfully transmitted is acceptable. Electronic signatures are acceptable,
however, typing someone's name and using a specific font type to provide an appearance
of being a handwritten signature is not acceptable. Handwritten signatures on paper are
always acceptable.
a. Provider Numbers on a C-9
BWC sometimes assigns a servicing provider number to an individual provider based
on his/her social security number with a two digit (-00) suffix. The MCO shall
validate the certification status and provider type of a provider prior to approving care
based upon the servicing provider number on the C-9. While the requesting provider
must be clearly identified on the C-9 form, the individual servicing provider number
is not required on the C-9The MCO shall work with the provider or injured worker to
identify and validate the certification status and provider type of the servicing
provider. The MCO may pend the C9 if necessary to obtain any additional necessary
information.
Although the provider file data is public information, the individual provider's social
security number is not public information. All provider numbers should never be sent
to injured workers, employers, and/or their authorized representatives. In response to
the concern generated by the provider community that injured workers, employers,
and their representatives are being given access to their social security number on the
C-9, the MCO is required to black out all the provider numbers on copies of the C-9
sent to those parties.
In addition, because a C-9 responded to by the MCOs and sent to BWC is captured in
the claim document repository and parties to the claim can view this document, the
MCOs are required to black out all provider numbers on the C-9 prior to submitting
it to BWC.
9. Physician’s Report of Work Ability (MEDCO-14)
The Physician’s Report of Work Ability (MEDCO-14) is a combination of return to work
information and recommendation for compensation. The Request for Temporary Total
Compensation (C-84) is most often used to report that an injured worker is still temporarily
totally disabled from work due to the injury. However, the Physician’s Report of Work
Ability (MEDCO-14) may also be used to extend compensation
The physician of record (POR) or treating physician must complete this standard form at
every visit when the injured worker has been placed under work restrictions or when the
injured worker is temporarily totally disabled. It is similar to forms used by MCO or
March 2016 Final
3-21
HPP-Medical and Return To Work Management
physician offices and will provide a permanent record for the physician’s file. The two-part
form allows injured workers to receive a copy for their records. By faxing a copy to the
MCO, employers will be able to be informed of work restrictions and explore work site
adaptations/modifications.
By obtaining the MEDCO-14 form, the MCO will reduce the need for phone calls requesting
information from several parties regarding the IW’s RTW progress along with providing
important information to the injured worker regarding their recovery and work limitations.
Injured workers will have immediate information that can be shared with their direct
supervisor when returning to the job. In addition, employers will be informed and see the
progress of all injured workers from the beginning of treatment until they are back on the job
and will be able to assist in successful return to work practices.
As is the case with the C-9, any physician-generated document may be used instead of the
MEDCO-14, if the substitute document contains, at a minimum, the data elements on the
MEDCO-14.
C. CHANGE OF PHYSICIAN
The MCO is responsible for notifying all parties to the claim of any physician of record
(POR) changes. The POR is the attending or authorized physician chosen by the injured
worker to direct treatment.
1. Eligible Providers
Providers eligible to be a POR include:
- Doctor of Medicine;
- Doctor of Osteopathic Medicine or Surgery;
- Doctor of Podiatric Medicine;
- Doctor of Chiropractic;
- Doctor of Mechanotherapy;
- Doctor of Psychology;
- Doctor of Dental Medicine or Surgery
2. Selection of a POR
The injured worker may select as physician of record (POR) an eligible provider who is
a:
BWC-certified provider
MCO panel provider
Non-bureau certified provider, subject to the injured worker's payment
responsibilities. NOTE: Injured workers with dates of injury prior to Oct. 20,
1993, may retain, without assuming payment responsibilities, a non-certified
provider as a POR if such a relationship already exists. If the IW decides to
change physicians, a BWC-certified provider must be selected or the IW will be
responsible for payment.
At the time of an injury, the injured worker may seek medical care directly from a
provider or may seek assistance from the MCO. If the injured worker has not already
March 2016 Final
3-22
HPP-Medical and Return To Work Management
sought medical care or selected a provider, the MCO may refer the injured worker to a
provider. The MCO shall inform the injured worker that he/she may select any specialty
of provider. The MCO shall ask if the injured worker has any preference as to the
specialty of provider and shall make any referrals accordingly. The MCO shall not
discriminate against any category of health care provider when referring the injured
worker to a provider. The injured worker may, however is not required to, seek medical
care from the referring provider.
The MCO may not dispute an injured worker’s selection of a POR nor shall the MCO
deny an IW's request for change of POR to a non-BWC certified provider. However, if
an IW requests a change of POR to a non-BWC certified provider, the MCO must clearly
communicate to the IW at the time of the request that the IW will be responsible for
payment and will have no recourse against the MCO, BWC, or the employer.
The MCO may not dispute an injured worker’s selection of a specific facility or provider
as indicated by their signature along with the POR referral. This instruction is based upon
Rule 4123-6-062 Employee access to the HPP; employee choice of provider, which
allows an injured worker to select a BWC certified provider.
An injured worker may only have one POR at any given time. In claims where more than
one physician treats the injured worker, there still can only be one recognized POR. To
change the POR, an injured worker must notify the MCO in writing. The notification
must include the name and address of new physician and the reason for requested change.
The injured worker also must sign the document.
For claims initially filed with the MCO and belonging to employers assigned to the
MCO, the MCO shall submit the POR to BWC via 148 within seven (7) Business Days
of the MCO’s receipt of notification of the injury or within three (3) Business Days of the
MCO’s receipt of information identifying the POR, whichever is later.
For claims initially filed with BWC or with another MCO, the MCO shall submit the
POR to BWC via subsequent 148 submissions within seven (7) Business Days of the
MCO’s receipt of the claim from BWC or within three (3) Business Days of the MCO’s
receipt of information identifying the POR, whichever is later.
The MCO shall notify BWC via subsequent 148 of any change in POR within three (3)
Business Days of the MCO’s receipt of notification of the change.
The POR must be an individual and not a group practice. When the MCO authorizes a
POR and transmits the data to BWC, the POR should be indicated by her/his individual
Provider ID number and not the group practice number. The CSS can update change of
POR on V3 however he/she will not process the request. This must be done by the MCO.
Note: The POR is the attending or authorized physician chosen by the injured worker to
direct treatment. The POR is an individual BWC certified provider who is a Doctor of
Medicine (provider type 67); Doctor of Osteopathic Medicine or Surgery (provider type
March 2016 Final
3-23
HPP-Medical and Return To Work Management
66); Doctor of Podiatric Medicine (provider type 70); Doctor of Chiropractic (provider
type 9); Doctor of Mechanotherapy (provider type 38); Doctor of Psychology (provider
type 72); or Doctor of Dental Medicine or Surgery (provider type 15). The individual
provider, who meets the criteria for one of these provider types, with an individual BWC
provider number, may be considered the POR. Hospitals and groups do not meet this
definition. If an injured worker presents for emergency treatment and does not designate
the individual physician provider who treated him or her as a POR, then that provider is
not the POR. The MCO will include that provider's information in the treating physician
section of the FROI and leave the POR field blank. The POR field is an expected field on
the FROI; however, it is not mandatory. Hospitals or facilities should never be entered in
the POR field.
D. MCO MEDICAL CASE MANAGEMENT PROGRAM, PROCESS AND
PERFORMANCE REQUIREMENTS
Medical case management is an essential component in effecting a successful claim outcome.
Because the MCO’s share claim operations duties with BWC, it is essential that the role,
responsibilities and activities of the MCO’s be clearly defined so that each will be able to
interact effectively to reach optimal results.
1. Requirements for MCO URAC Accreditation and Reaccreditation
The MCO’s are responsible for maintaining full unqualified accreditation status for their
case management programs throughout the term of their contract with BWC. It is the
decision of the MCO as to whether the 2 year or 3 year accreditation option is elected.
However, the 2 year option should not be selected for the sole purpose of avoiding the
random audit pool. BWC reserves the right to require an additional audit at the MCO’s
expense if there are concerns with the MCO’s case management accreditation status or its
case management processes.
Unless otherwise specified, references to URAC CM Standards below are to the URAC
Version 3.0 standards. BWC recognizes that some MCOs may be accredited under the
URAC Version 3.1 or 4.0 CM standards, which may differ slightly. Each MCO must
comply with the version of the URAC CM standards the MCO’s accreditation is based
on.
a. Costs
The MCO is responsible for all costs associated with maintaining full accreditation
and reaccreditation. The MCO is required to submit URAC documentation or
correspondence regarding any accreditation change to the MCO Business Unit,
Managed Care Operations of the BWC within two (2) days of receipt. The MCO
must also submit copies of all reaccreditation status letters to BWC. In some
instances, the BWC has defined specific service criteria in certain categories of case
management program components which are also addressed in the URAC program.
These categories are identified in the service specifications that follow. They are
intended to define the Ohio BWC service expectations in relation to the URAC
provisions.
March 2016 Final
3-24
HPP-Medical and Return To Work Management
b. Subcontracted Case Management Programs
MCO’s who subcontract their case management programs must do so only to an
MCO with an accredited case management program. In addition, the MCO must be
accredited by URAC in their Core Standards.
c. BWC /URAC Interface
BWC and URAC reserve the right to exchange information that is pertinent to the
MCO’s accreditation or to BWC’s regulatory authority.
2. Definition of Medical Case Management
URAC (Version 3.0) defines Case Management as: “A collaborative process of
assessment, planning, facilitation and advocacy for options and services to meet a
consumer’s health needs through communication and available resources to promote
quality cost-effective outcomes.”
URAC (Version 4.0) defines Case Management as: “A collaborative process which
assesses, plans, implements, coordinates, monitors, and evaluates options and services to
meet an individual’s health needs through communication and available resources to
promote quality cost-effective outcomes.”
Within the Ohio workers’ compensation program, this process includes identifying and
minimizing potential barriers to recovery, identifying and assessing future treatment
needs, evaluating appropriateness and necessity of medical services, authorizing
reimbursement for medical services, resolving medical disputes and facilitating
successful return to work or claim resolution for injured workers.
By definition, then, it requires multidisciplinary skill sets that enable the practitioner to
assess the impact of injuries, the psychosocial implications of threat to the income
stream, the features of the health service delivery system, medical treatment regimens,
disease management protocols, and realities of the workplace. Its core requirements are
assessment, planning and communication. Its target objectives are the right treatment at
the right time at the right cost in the right delivery method all aimed at the ultimate goal
of safe and timely return to work if at all possible.
3. Case Management Criteria (URAC Standard CM 14)
URAC addresses this topic with the question, “What prompts the case management
process to begin?” Their standard recognizes the contractual basis for customer
specification of case management activity. To that end, the BWC criteria for MCO
medical case management have been designed as follows.
Because the need for medical case management is a function of the relative risk of the
individual, the assignment of active, ongoing medical case management by a professional
nurse case manager is often a decision making process dependent on such case elements
as severity, complexity, or opportunity as well as duration of disability. In order to
promote consistency throughout the system, selection criteria have been established to
provide a minimum standard of service for both triage as well as mandatory follow-up.
March 2016 Final
3-25
HPP-Medical and Return To Work Management
Guiding principles:
►Referral for medical case management consideration will be initiated for those cases
in which:
the duration of disability is equal to or greater than 14 days
the injured worker remains out of work
the injured worker is at increased risk for delayed or incomplete recovery or
compromised return to work.
the medical expenses or utilization patterns are in excess of normal expected
values
►All cases in which the duration of disability is equal to or greater than 21 days will be
managed by a medical case manager unless criteria established for exclusion are met
(See Chapter 3 Section D- 8)
►All catastrophic cases will be managed by a MCO catastrophic nurse case manager in
collaboration with the BWC CAT nurse.
a. Medical Triage Requirements
All the following claims or diagnostic categories must be referred to a nurse or
clinician as defined in Appendix G no later than the close of the next Business
Day following the date on which the claim meets such criteria for initial
assessment/triage and consideration of Medical Case Manager assignment.
• All lost time claims with a disability period of 14 calendar days with lost
time continuing unless this initial assessment has already been performed
by a nurse or clinician
• All surgical cases
• This clinical assessment must be based on the information developed
through completion of the 3-point contact by a nurse or non-clinician
within five (5) business days of receipt of the case through initial intake or
referral from the claim processing area. In accordance with URAC
requirements, some basic data collection elements gathered by non-
clinical support staff may be utilized. However, this does not eliminate
the need for completion of the 3-point contact review by the nurse or
clinician as addressed in URAC Standard CM18 (Version 3.0).
• The decision to assign the case to the medical case manager or not must be
based on risk factors (e.g., RTW estimated date >50th percentile of MoD
Days Absent, age, occupation/job requirements, co-morbidities, medical
treatment plan, psychosocial factors, etc.)
• If the case is assigned to a Medical Case Manager following the case
management referral assessment, the Medical Case Manager may use the
services of non-clinical support staff for certain monitoring functions in
accordance with URAC standards. (For example non-clinical support staff
can document verification of appointment attendance, return to work on
the date expected. The non-clinical support staff will provide the
information to the medical case manager without any independent
assessment of clinical status or response to treatment.) However, the
initial care plan with targeted RTW date and summary of approved plan of
March 2016 Final
3-26
HPP-Medical and Return To Work Management
care must be completed by the nurse case manager and documented in the
case management system and BWC V-3 system. Updates to the care plan
must be made by the nurse case manager.
• If the claim is not assigned to the medical case manager for management,
the rationale for making the assignment to other than the medical case
manager must be documented in the medical case management notes.
• Utilization management services shall be provided for any cases which are
not assigned to a medical case manager. (This includes any cases which
meet case management discharge criteria, are closed to case management,
but eligible for workers’ compensation benefit consideration.)
• Case assignment and contact person must be sent to the BWC CSS in the
Case Management Plan
b. Mandatory Medical Case Management Assignment
The following diagnostic categories must be assigned to and case managed by
a medical case manager no later than the close of the next Business Day
following the date on which the claim meets such criteria for referral
excluding those claims which satisfy the discharge criteria presented in
chapter 3, section D-8 of this manual:
► All lost time claims with a disability period of 21 calendar days or
greater with lost time continuing
►All Catastrophic claims* ►Amputations
►Brain Injuries (Traumatic or Anoxic) ►Spinal Cord Injuries
►Eye injuries requiring hospitalization
►All claims with request for inpatient hospitalization
► All claims with psychiatric disorders allowed requiring hospitalization
►Claims with pre-existing or non-related significant co-morbidities (such
as diabetes, heart disease, mental health disorders, etc.) which negatively
impact the disability duration
*See Section G1 of this Chapter “Catastrophic claims” for the
definition of catastrophic claims.
4. The Case Management Coalition
Because the work process of the medical case manager is essentially that of coordinator,
communication is central to effective practice. The three parties that have the most
power to determine the outcome of every claim are the injured worker, the employer and
the medical provider. These are the central contacts for the medical case management
process, and, therefore, the mandatory contacts for the initial assessment. Attempts to
contact the parties must be documented on the assessment form and/or MCO notes.
In addition, since the BWC shares responsibility for successful management of the claim,
the Agency presents important communication linkages. These include: the Claim
Service Specialist (CSS), Medical Service Specialists (MSS), CAT nurses, Medical
Claim Specialist (MCS/Med only claims) and Disability Management Coordinator
(DMC).
March 2016 Final
3-27
HPP-Medical and Return To Work Management
Other sources, such as family members, specialty providers, community agencies, etc.
should be included as they emerge and are identified in the case.
5. Early Injury Assistance (EIA) Support Materials
As part of the data gathering process and as soon as practical, the MCO shall collect and
supply to BWC relevant information to assist the BWC in determining whether to send
EIA support materials to the IW. For all Lost Time claims, the MCO shall send a note
titled EIA Support Materials (or equivalent) with one of the below numeric values
indicating how the IW appears to feel about their injury. If the MCO determines, when a
claim changes over from Medical Only to Lost Time or at any time in the life cycle of the
claim, that the IW’s situation has changed and that receipt of the support materials would
improve the outcome for the IW, the MCO shall also send the EIA Support Material note.
BWC will send out support materials as appropriate based on the numeric value in the
note.
Number 1. My injury has caused such a major upset, I’m worried it may take a
long time to get back on my feet – if ever.
Number 2. This is a really hard time for me; but I am trying to hang on.
Number 3. This is a challenge but I’m actually coping pretty well with it.
Number 4. I’m pretty much OK now, but still dealing with minor inconveniences.
Number 5. I’m back to normal, working, and everything’s fine.
If the numeric value is 1, 2, or 3, the MCO shall determine how the IW feels about the
(workers’ compensation) insurance process (forms, letters, mailings, claim allowance,
medical treatment approval process, etc.) and include one of the following designations in
the same note:
VS – very satisfied
S – satisfied
OK – okay
DS – dissatisfied
VD – very dissatisfied
Below is the recommended script for determining this information; however, the MCO is
not required to use the script.
“[IW NAME] I'd like to know how you are doing overall. I’m going to read you a list
of 5 different descriptions of how you might be feeling these days. Pick the one that
fits your situation the best. I’ll read them all first, and then you choose one.
Number 1. My injury has caused such a major upset, I’m worried it may take a
long time to get back on my feet – if ever.
Number 2. This is a really hard time for me; but I am trying to hang on.
Number 3. This is a challenge but I’m actually coping pretty well with it.
Number 4. I’m pretty much OK now, but still dealing with minor inconveniences.
Number 5. I’m back to normal, working, and everything’s fine.
March 2016 Final
3-28
HPP-Medical and Return To Work Management
Which one describes your situation the best?” {Wait for response and repeat list of
answers as needed}
Follow-up question if the IW answered 1, 2, or 3 to the initial question:
“Now let’s talk about your satisfaction with how things have been going since you
were injured. The next question is about the workers’ compensation insurance claims
process you have experienced so far and is also a multiple choice question. But for
this question, I'd like you to tell me how you feel by picking one of the following
choices: very satisfied (VS), satisfied (S), OK, dissatisfied (DS), or very dissatisfied
(VD). I can repeat the choices whenever you want me to. Just let me know.”
“How satisfied have you been with the workers’ comp insurance claims process so far
– that means the forms you filled out, the letters, mailings, or other information you
may have received, and the claim allowance and medical treatment authorization
process?” {Wait for response and repeat list of answers as needed}
{If injured worker gives a different answer ask for clarification} “You said {their
words} ……. So does that mean you are VS, S, OK, DS, VD?”
{If the injured worker answers OK, dissatisfied or very dissatisfied request this
additional information} “I see. You said [OK, DS, VDS]. What happened that made
you say that – instead of being “satisfied”? {Wait for response} Can you tell me
briefly -- what would have made you feel better about it?”
6. Case Management Assessment (URAC Standard CM18)
Thorough assessment initially and continually throughout the course of the claim life is
essential to the case management process and is the foundation of the case management
plan.
a. Initial Assessment
Comprehensive information gathering is the foundation of the initial assessment.
Requirements are as follows:
At minimum, sources include the injured worker, the employer and the
treating physician
It must address:
►Age ►Work requirements
►Injury history ►Co morbidities
►Claim history ►Job environment (Supportive of RTW?)
►Current or proposed treatment regimen description
►Appropriateness of treatment
►IW compliance (If non-compliant, why?)
►Prognosis and expected duration of disability given age, occupation,
medical history, and any other pertinent factors – Reference Ohio Specific
Disability Duration Guidelines (OSDD) or ODG if OSDD does not
include diagnosis
March 2016 Final
3-29
HPP-Medical and Return To Work Management
►Injured worker’s understanding and expectations of injury, treatment
and return to work
►Possible obstacles to return to work
► Safety needs
►Attending physician’s understanding of the IW’s job requirements and
worksite situation
The initial assessment must be completed within five (5) business days of
receipt of the claim by the medical case manager.
The medical case management file must document contact with the injured
worker, employer of record and the physician.
Any circumstances which precluded contact with any of the primary individuals
must be documented in the file
b. Return to Work Letter
In order to ensure that return to work expectations are clear to the injured worker,
the employer and the physician, the medical case manager will conclude the
initial assessment process by estimating a realistic return to work date. The MCO
may communicate this target date by correspondence to all parties according to
the following selection criteria:
Claim is in allowed status (regardless of expiration of appeal period)
Injured worker has lost ≥ 14 calendar days
Injured worker remains out of work
Letter will be sent to injured workers of private employers
Claims assigned to Public Employers can be included at the discretion of the
MCO or requested by the PE employer only
The letter should not be sent to IWs with catastrophic claims
Methodology
• The Primary/Controlling ICD-9 code will drive the determination of expected
duration of disability
• The MoD Days Absent benchmarks will be the first order of reference
• If the ICD-9 diagnosis is not present in MoD, then the ODG reference will be
used
• The 30th percentile will serve as the reference target date for return to work
calculation
• Additional injured worker specific data obtained in the medical assessment
will be considered in determining whether the 30th percentile date is
reasonable for the specific worker’s situation
• These elements include but are not limited to:
• Multiple conditions or co-morbidities
• Age
• Type of employment
• Prognosis for recovery and ability to resume prior duties
• If prognosis is limited, availability of modified or transitional work
• The return to work reference date in a lost time claim should be applied from
the date of disability
March 2016 Final
3-30
HPP-Medical and Return To Work Management
• If the injured worker has remained at work in advance of a scheduled surgery,
after which lost time can be expected, the post-surgical date should be
considered
• Letter is addressed to the IW with copies to all parties
• Employer
• Physician of Record
• Legal Representatives (for IW and Employer)
• BWC
• MCO faxes copy of the letter to BWC Service Office imaging number and
enters V-3 note that includes the ICD-9 diagnosis of reference
• Medical Case Management continues to work toward the targeted return to
work date
7. Case Management Plan
The case management plan is formed by a compilation of all information that the case
manager has gathered from the injured worker, the physician and the employer as well as any
other pertinent sources that impact the progress and successful outcome of the claim
resolution.
The initial plan must be completed within three (3) business days of completion of
initial assessment. (It is noted that there may be occasions wherein the medical case
manager is unable to make contact with all three principles to the discussion. In such
an instance, a preliminary plan should be established with action steps to reach the
missing party included as an element of the plan.)
Goals are the first step in the case management process. These goals should be understood
by all members of the team (i.e., case manager, injured worker, physician, employer, claim
staff) and guide development of the interventions selected to achieve them.
The case management plan is action oriented and time bound and identifies the
intervention(s) and resources to be used in order to assist the injured worker to achieve the
goals specified within each phase of the plan. Accountabilities are established within the
case management plan so that all participants are aware of their respective responsibilities in
meeting the goals.
a. Initial Case Management Plan
The MCO must provide the following pieces of information to the BWC Claim Service
Specialist (CSS) on the initial case management plan:
MCO name and contact information for Nurse Case Manager;
IW name;
Claim number;
Alleged/allowed diagnosis;
Medical case management plan begin and end dates;
March 2016 Final
3-31
HPP-Medical and Return To Work Management
Documentation of attempts to complete 3-point contact and reason for inability to
contact if not completed. This should include contact information for primary contacts,
i.e., treating physician, discharge planner, etc.;
Catastrophic claims: to include the MCO case manager’s plan for onsite case
management visit (s); or the date, location, and contacts if the onsite visit has been
completed; or summary if the onsite visit was waived by BWC;
Summary narrative of injury, the IW’s health status, name of current care setting and
date of admission;
Treatment plan (current plan of care);
Barriers to treatment and recovery;
Short-term goals:
o Case Management interventions/action steps planned with target time frame for
completion. The action steps should be specific and correlate with case
management follow-up contact and planned re-evaluation (e.g., case manager
will complete onsite visit by xx/xx/xxxx to meet with injured worker, family
and the hospital discharge planner; case manager will contact employer of
record to discuss work restrictions and worksite accomodations by xx/xx/xxxx;
case manager will assist IW with finding a provider by xx/xx/xxxx); and
o Next planned action and date of follow-up
Long-term goals:
o Case Management interventions/action steps planned with timeframe for
completion; and
o Next planned action and date of follow-up
NOTE: Short term and long term goals will include the MCO case manager’s plan to
manage transitions of care/plan to coordinate care across care settings, including any
planned onsite visits.
Last day worked;
Return to Work (RTW) objective according to hierarchy (including estimated date for
RTW);
Barriers to RTW; and
Workplace accommodation availability.
b. Updates to Case Management plans
The case management plan is a dynamic tool and, as such, it is formed and changed as a
result of the progress of the case and the associated ongoing assessment of the case
manager. Since the case management plan is IW specific, the frequency of the updates is a
function of the case management action plan itself and the update intervals determined by
planned follow-ups as well as spontaneous events in the life of the claim. The MCO must
provide the following information to the BWC Claim Service Specialist (CSS) on the
updates to the initial case management plan as they occur:
Summary narrative of changes in IW medical status;
Current care setting;
March 2016 Final
3-32
HPP-Medical and Return To Work Management
Changes in medical treatment plan;
Whether prior goals were achieved;
Changes to short term or long term goals;
New short term or long term goals;
Change in estimated RTW and reason.
c. Interface with BWC claim operations
The MCO must share the case management plan with the CSS assigned to the claim by
faxing a copy of the plan to the imaging fax number of the service office within two (2)
business days of completion or revision of the plan. The MCO must provide a summary
of onsite case management visits in V3 notes using a standard note title “MCO Onsite
Case Management Visit”. Since the case management plan is the foundation for return
to work planning, the case manager is encouraged to discuss any case that presents
special circumstances or considerations, or particularly, need interventions from BWC
for either the injured worker or the employer.
The plan must be labeled: “[MCO name] Case Management Plan” with Claim number
attached so that it will be appropriately indexed into the BWC’s system.
NOTE: This document will be available in BWC’s website for access by parties to the
claim. Therefore, content should reflect respect for sensitive information.
Some MCO’s have requested that a standardized plan format be developed and utilized
by all MCO’s. BWC will support this initiative and will actively participate in the
development with the MCO Business Council Quality of Care Subcommittee.
Staffings between the MCO and the BWC presents the ideal situation for collaboration.
These staffings may be formal or informal. BWC is encouraged to involve the MCO case
manager in formal staffing of claims with higher levels of complexity or risk for extended
disability. The MCO is encouraged to initiate formal or informal staffing with the CCT
when progress in the claim is compromised or the expected progress is not realized.
d. Thirty (30) Day Assessment
The Disability Management Coordinator will review all claims in which the injured
worker has not returned to work thirty (30) days beyond the 50
th
percentile of MoD Days
Absent benchmarks.
Return to work barriers will be identified in these claims and, if the barriers appear to be
valid, BWC and the MCO will come to mutual agreement about a future course of action.
If the MCO does not follow through with these steps, the BWC Service Office Manager
will submit “Thirty (30) Day Assessment Recommendations” to the MCO via e-mail. If
BWC and the MCO still cannot arrive at a mutual solution, the MCO may appeal the
thirty (30) Day Assessment Recommendations within five (5) working days to the Rehab
Administrative Designee e-mail box.
Note: The case management plan may be used to meet the requirements of the MCO’s
March 2016 Final
3-33
HPP-Medical and Return To Work Management
RTW plan which is used to communicate the MCO’s plan with respect to the 30 day
assessment.
8. Ongoing Evaluation and Management
Timeframes for successive contacts and case updates vary with the circumstances (goals and
treatment milestones) of each case. It is the responsibility of the case manager to redate
cases for follow-up according to each subsequent assessment of goal achievement or lack
thereof. Contacts must match the continuum of care which, in turn must match a
reassessment of progress.
Some elements of the ongoing evaluation(s) include:
Is the IW progressing as expected?
If progress is not consistent with expectations, why not?
Are there indications for a change in treatment plan or medical service (e.g., IME,
second-opinion, specialist referral)?
At the conclusion of this re-evaluation, the case manager repeats the case management plan
process (see Section 6.2) and communicates updated information to the BWC CSS. The
action plan is updated and the case re dated for the next contact as reflected in the action
plan. This process continues until claim resolution.
9. Case Management Discharge Criteria
The criteria for case closure include but are not limited to the following:
When the goals of successful claim resolution have been achieved
When the opportunity for further progress is negligible.
Return to full duty or modified duty ( Note: The case should remain open for 30
days following return to work at which time the MCO will contact the IW to assure
that he/she is able to maintain this status.)
Settlement of the medical benefits components of the claim
Full settlement of the claim
Death of the injured worker
The IW has reached MMI status as deemed by the IC or BWC (Ongoing medical
management, however, continues under the UM/UR service of the MCO)
Rehabilitation services are being rendered and the goals of the medical service plan
have been achieved. (Ongoing medical management, however, continues under the
UM/UR service of the MCO.)
The claim is disallowed by BWC
Order of Permanent Total Disability. (Ongoing medical management, however,
continues under the UM/UR service of the MCO. Case should be referred back to
medical case management if referral criteria are met due to questionable utilization
patterns.
The IW is not longer working due to retirement or disability separation. MMI has
been achieved, no compensation is being paid. (Ongoing medical management
continues under the UM/UR service of the MCO.)
Job abandonment; the IW has been released to return to work, compensation has
been terminated, and/or the employer or MCO is unable to locate the IW.
March 2016 Final
3-34
HPP-Medical and Return To Work Management
The injured worker refuses participation in the case management process including
telephonic contact. However, the claim will remain assigned to the case manager for
employer collaboration and medical monitoring services due to a level of acuity or
risk factors of the claim. Circumstances must be documented accordingly consistent
with URAC requirements for case management definition and interface with BWC
claim operations
Employer and claim is transferred to another MCO
When the treatment status and return to work status does not require case
management services based on the professional judgment of the medical case
manager or clinician and the IW’s acute overall medical condition is stable and is
documented accordingly
The rationale for case management closure must be documented in case management notes
and the claim file. Documentation must include any recommendations for continuing claim
management by BWC claim operations or MCO UM/UR staff. Case management closure
requires that notification be given to the assigned BWC Catastrophic Nurse Advocate on all
catastrophic claims via e-mail, telephonic notice and/or staffing. If the BWC Catastrophic
Nurse Advocate does not agree with the decision to close case management, case
management closure will be deferred until a time mutually agreed upon by the MCO and the
BWC Catastrophic Nurse Advocate. In the unlikely event a mutually agreed time cannot be
determined; BWC catastrophic supervisory staffing may be requested to determine CM
closure.
March 2016 Final
3-35
HPP-Medical and Return To Work Management
E. REMAIN AT WORK PROGRAM
According to Rule 4123-6-19 BWC shall take measures and make expenditures, as it deems
necessary, to aid injured workers who have sustained compensable injuries or contracted
occupational diseases to remain at work.
1.
Remain at Work (RAW) Services
Remain at work is the process of assisting injured workers in maintaining employment
and avoiding lost time following an industrial injury. An injured worker’s participation
in RAW services is voluntary.
2.
Eligibility
An injured worker is eligible to participate in a remain-at-work program when:
The injury results in 7 or less days off work due to the allowed conditions in the claim
which is certified by the employer or is allowed pursuant to a bureau or industrial
commission order; and,
It is documented by the employer, the injured worker or physician of record that the
injured worker is experiencing problems that are work-related and result from the
allowed conditions in the claim. A C9 from the POR or notes in claim file by
Managed Care Organization (MCO) documenting contact with the employer, injured
worker or POR would fulfill this requirement.
3.
Referrals
Anyone can refer an injured worker for RAW services; however, the MCO shall
determine the need for services and document those needs in the notes they enter into the
claim file and BWC’s Web site.
The MCO will gather and assess claim information to determine the type of RAW
services appropriate for the claim.
4.
Services Provided in a Remain at Work Program and Billing Codes
RAW services include one or any combination of (but not limited to) the following:
Transitional Work with PT/OT if focused on job progressions and offered on-site
(WO637);
Ergonomic study (W0664);
Ergonomic implementation (W0513)
March 2016 Final
3-36
HPP-Medical and Return To Work Management
Functional Capacity (CPT code);
Job analysis (W0645);
Physical therapy, on-site (CPT Code);
Occupational therapy, on-site (CPT code);
Physical reconditioning (W0648);
Gradual Return to Work (no billing code);
On the Job Training (OJT) (billing codes for the specific services provided in OJT
may be used);
Job Modification (W0663 when reimbursing provider but not when employer
provides the Job Modification);
Tools and Equipment (W0665); and
Remain-at-Work Vocational Rehabilitation Case Management (VRCM) (Z codes as
listed in Chapter 4, Reimbursable Services, “Vocational Rehabilitation Case
Management”). Remain at Work case management services are available but are not
required to give it a Remain at Work “status”.
Effective 2-15-10 Providers of the following services: ergonomic study, ergonomic
implementation, job analysis and transitional work may be reimbursed for travel and
mileage using codes Z3050 RAW service – Other Provider Travel and Z3052 RAW
Service – Other Provider Mileage.
Note: Job Club, Job Search/Development and Job Seeking Skills Training Services are
not RAW services
5.
Billing and RAW services
Although the above services are traditionally associated with Surplus Fund (i.e.
“W”codes), if offered as a RAW service, they will be charged to the employer’s risk.
The bureau will not reimburse an employer for remain at work services that are provided
“out of pocket” by the employer. The MCO is required to advise the employer in writing
if resources are available to the organization at no charge such as via the BWC ( i.e.
ergonomic assessments) or via Opportunities for Ohioans with Disabilities (i.e. job
modifications, tools and equipment) prior to “encumbering fees”. Written information
regarding those services will allow the employer to make informed decisions prior to
encumbering fees. The bureau will not reimburse an employer for remain at work
services that are provided “out of pocket” by the employer.
If the claim is subsequently disallowed, BWC will not be responsible for the cost of
RAW services that were provided.
Note: By Report codes—For vocational rehabilitation services reimbursed by report,
the MCO must request a V3 note approving payment from Rehab Policy as there is not
a DMC for medical only claims. The request must be sent via password protected email
March 2016 Final
3-37
HPP-Medical and Return To Work Management
and include information from the “Vocational Rehabilitation By Report Request ”
template, found as an appendix of Chapter 4.
6.
RAW and Established Transitional Work Programs
RAW programs are sometimes easier to provide in an established Transitional Work
Program, but a Transitional Work Program does not have to be in place to offer RAW
services.
7.
Initiation of Services
To ensure payment for the services they provide, PT/OT providers should staff all RAW
referrals with the MCO before the initiation of services. It cannot be assumed that
Presumptive Approval is still available for the particular claim. (See section on
Presumptive Approval in Chapter 3). A C-9 must be submitted prior to the
implementation of PT/OT services.
Vocational Rehabilitation Case Management (VRCM) services do not require C-9’s;
however, the MCO must give prior approval before these services are implemented.
VRCM should staff the referral with the MCO and at the initiation of the services and
periodically to track injured worker’s progress.
8. Remain at Work Services terminate when:
A bureau, IC or court order subsequently disallows the claim, or
Injured worker declines to participate, or
The claim changes to a lost time claim because the injured worker has missed 8 or
more days due to the allowed conditions in the claim. However, in this situation, the
injured worker may be referred, if eligible, for surplus funded services under
vocational rehabilitation. [Note: if the claim changes to lost time solely due to a %
PP award granted pursuant to Ohio Revised Code 4123.57(A), the injured worker
may complete those RAW services previously authorized; however, no new services
may be authorized]. the lump sum settlement date becomes effective, or
injured worker successfully maintains employment and no further services are
needed.
9. Initial and Final RAW Report
Initial RAW Report: The MCO shall enter a note into the claim file that includes the
problems the injured worker is experiencing on the job and the RAW services being
provided. The MCO shall provide continuous claim monitoring until closure at which
time they shall submit a final RAW report.
Final RAW Report: Is due within 5 business days of notification of the completion of
RAW services, the MCO must enter a note in the claim file. This note should indicate
injured worker’s work status, (i.e. released for full duty original job or full duty different
job) and the date RAW services were completed.
March 2016 Final
3-38
HPP-Medical and Return To Work Management
F. PRIMARY ICD-9-CM (PRIMARY DIAGNOSIS)
Establishment of a primary diagnosis code is necessary for improving the management of
claims through the identification of the condition that is driving them.
1. Why are Primary ICD-9 codes required?
Primary ICD-9 codes are required for:
Effective medical management;
Reliable management reporting;
Establishment of accurate reserves.
2. Additional Information
The Primary ICD-9 is:
Identified for allowed conditions only;
The cost driver of the claim for medical services/treatment and compensability;
Injury/condition that is the cause of the injured worker’s inability to work;
The diagnosis that determines medical services/treatment and compensability;
The most severe injury/condition;
Dynamic in nature as medical conditions arise.
Only one primary ICD-9 can be identified for all lost-time or medical-only claims. The
physician of record and the MCO establish and identify the primary ICD-9. The MCO
must identify the initial primary ICD-9 via 148 transmission and notify BWC whenever
the primary ICD-9 changes within 2 business days from receipt of changed information.
G. CATASTROPHIC CLAIMS
The Health Partnership Program (HPP) places emphasis on a consistent, cooperative
approach to catastrophic case management by MCOs and BWC. Each catastrophic claim is
different, which necessitates highly individualized management.
Beginning January 1, 2003, the MCOs designated a catastrophic claim program coordinator,
who shall be responsible for directing the MCO's management of catastrophic claims to the
MCO.
Qualifications: The catastrophic claim program coordinator shall be a registered nurse and
shall meet the qualifications for case manager supervisors as required by URAC standards.
Experience: In addition, the catastrophic claim program coordinator is required to have at
least 2 years of previous Ohio MCO case management. Experience in critical care: It is
recommended, but not required, that coordinators have experience in critical care, and
knowledge of home care, social services and rehab services.
Training: Coordinator must be proficient in the MCO Policy Reference Guide, and will
attend all training sessions designated by BWC for the catastrophic claim program
coordinator.
MCOs are responsible for notifying the MCO Business & Reporting Unit within 2 business
days of any changes to this information and updating the MCO portal.
March 2016 Final
3-42
HPP-Medical and Return To Work Management
The MCOs are unique in their strategies for managing catastrophic claims. For example,
adjustment counseling services, normally available in a vocational rehab plan, may well be
provided in catastrophic claims to assist an injured worker in overcoming disability related
life situations or depression. Regardless, BWC mandates that a seamless, customer-oriented
case management process is in place that assures effective and efficient care and services are
delivered to injured workers.
In order to obtain this goal, MCOs shall designate a core group of Catastrophic Case
Managers. The number of Catastrophic Case Managers designated will be at each MCO’s
discretion based upon the number of catastrophic claims the MCO has. Catastrophic Case
Managers are not excluded from managing non-catastrophic claims; however, all
catastrophic claims that are in case management must be managed by a Catastrophic Case
Manager. MCOs shall keep a current list of their CAT CM’s with contact information on the
BWC portal and update any changes to that list within 2 business days.
Qualifications: The Catastrophic Case Manager shall be a registered nurse and have at least
1 year of previous Ohio MCO case management experience. The catastrophic case manager
must be proficient in the MCO Policy Reference Guide.
The Catastrophic Claim Program Coordinator will have direct oversight of the management
of the MCO’s CAT cases and the MCO’s Catastrophic Claim Program. That is not to say,
however, that the Catastrophic Coordinator cannot also be a Catastrophic Case Manager.
Catastrophic Coordinators should be aware of what is happening in the MCO’s catastrophic
claims and be a resource for the MCO Catastrophic Case Managers or BWC CNA on
catastrophic related questions and issues.
1. Definition
A catastrophic claim is a claim in which there is a serious injury resulting in limited mobility
and/or cognition related to the allowed conditions in the claim, that severely limits the ability
of the injured worker (IW) to perform activities of daily living, and has a high probability of
resulting in permanent disability.
Catastrophic claims require aggressive case management and collaboration between the
MCO and BWC due to the severity of the injury.
Catastrophic injuries may include but are not limited to:
Brain injuries, moderate to severe;
All major extremity amputations, fractures, crush injuries, loss of use of one or more
limbs;
Spinal cord injuries such as paraplegia, quadriplegia, hemiplegia or diplegia;
Total occupational blindness;
Severe burns, second-or third -degree burns on more than 25 percent of the body;
Actual anticipated hospitalization in excess of four weeks, i.e., ventilators, ICU,
psychiatric hospitalization;
Severe occupational diseases and bloodborne pathogens (not end stage); toxic exposure
with long term complications; and
Any other medical diagnoses identified by the MCO and CNA.
March 2016 Final
3-43
HPP-Medical and Return To Work Management
2. Expectations
Managing a catastrophic case requires that all services be coordinated in a timely manner, as
required by the needs of IWs and their families. Expectations of catastrophic case
management include proactively:
Expediting claim allowance for prompt payment of medical and indemnity benefits;
Providing an on-site advocate for the IW;
Insuring the delivery of appropriate, quality medical services; and
Preventing any further disabilities or impacts to IWs and their families.
3. BWC Catastrophic Nurse Advocate (CNA)
A CNA with specialized experience in the management of catastrophic injuries will be
assigned to a BWC Customer Service Office that covers a specific region (A list of the
CNAs can be found on the MCO portal). This nurse will primarily advise and support the
MCOs to facilitate the establishment of key claim services, thus fulfilling a vital role as an
IW advocate. As such, the CNA will interact with any person involved with an
IW’s claim. Duties encompassed by the advocate include, but are not limited to
partnering with MCOs to, as necessary, support the MCOs activities of:
Identifying problems;
Staffing case dispositions with CST/providers;
Assisting with completing BWC forms;
Coordinating discharge planning;
Advising MCOs, IWs and families of local resources;
Identifying necessary services and interventions;
Recommending vocational services if appropriate after staffing with CST;
Forwarding provider concerns to BWC Credentialing unit;
Determining appropriateness of adjustment counseling (CNA authorizes adjustment
counseling in certain cases in conjunction with the MCO. Usually includes up to 10
sessions, but up to 20 sessions maximum in rare instances); and
Determining the appropriateness of long-term residential placement.
A CNA will provide guidance to MCOs and CSTs.
The CNA facilitates resolution of issues affecting catastrophic case management through
CST and MCO staffing. Additionally, the CNA serves as a liaison to the Brain Injury
Advisory Committee (BIAC) to assist in resolving legislative inquiries, provides direction
to the CST, monitors trends and facilitates communication among all customer groups. The
CNA does not negotiate rates or approve medical services as these are medical case
management issues handled by the MCO.
4. Requirements
a) MCOs will provide case management for all catastrophic claims.
Case management for all catastrophic claims is essential and required for all
active CAT claims. The MCO staffs with the CNA, as appropriate, to facilitate
medical management. The CNA staffs with the Customer Service Team (CST)
for claims determination.
March 2016 Final
3-44
HPP-Medical and Return To Work Management
b) MCOs must identify potential catastrophic claims.
MCOs are unable to populate the field in V3 when they identify potential catastrophic
claims. When an MCO is notified or identifies a catastrophic claim, the MCO will
contact the assigned CNA by telephone or email within one business day of identifying
a potentially catastrophic claim (refer to Catastrophic Nurse Advocate Roster on the
MCO Portal for CAT Nurse assignment and their back up for staffing coverage).
c) MCOs will submit a case management plan to BWC as outlined in the MCO
Case Management Plan in Chapter 3, Section D(7) of this document.
Subsequent plans will be submitted as required by Rule 4123-6-20.
d) MCOs, CSTs and CNAs shall conduct an informal staffing within one to three
business days of notification. Subsequent staffing to be held based upon the
severity level of the claim.
It is imperative that the MCO, CST and CNA share information regarding the
circumstances of the claim. In particular, the severity of the claim must be discussed
so an appropriate course of action can be determined.
e) BWC will complete the initial determination on claims identified as catastrophic
within 48 hours of notification if possible.
Due to the severity of catastrophic claims, the determination of the claim must be
expedited so medical benefits and indemnity payments can be initiated. Speedy
determination will help minimize the impact of the claim to IWs and their families. It
is important to remember, however, that only the IW is eligible to receive care.
Treatment for family members, whether medical or psychological, is not part of the
claim. The MCO and/or CNA will staff family member concerns with the employer
to see if crisis intervention can be paid for by the company.
f) The MCO and CNA will staff all catastrophic claims that are in case
management on a quarterly basis, and will review all claims flagged with the
catastrophic indicator annually.
Due to the severity of catastrophic claims, communication between the MCO and
the CNA must occur regularly until the IW stabilizes and case management is
closed. Additionally, the MCOs should routinely submit plans of care that will assist
the CST with disability determinations. If communications do not occur, the CNA
must initiate telephone contact with the MCO as needed.
Furthermore, a V3 diary will keep the claim file active and afford a method by which
the CNA can identify and address subsequent issues.
g) The CNA is responsible for notifying the CST when the claim is no longer
considered catastrophic.
Fundamentally, the goal of medical case management is to minimize the impact of the
claim on the IW. In instances when this is successfully achieved and a claim no
longer meets catastrophic criteria, the CNA will place a note to this effect in V-3
which will generate a diary to the CSS.
March 2016 Final
3-45
HPP-Medical and Return To Work Management
h) The CNA is responsible for removing the V3 catastrophic indicator when the
claim is no longer considered catastrophic.
Removing the catastrophic indicator is imperative to maintaining data integrity for
not only the claim, but also for tracking all catastrophic claims. Removing the
indicator will trigger an outbound EDI 148 transmission to the MCO. The Team
Leader/MSS can remove the catastrophic indicator upon notification from the CNA.
i) BWC will use management reports to track catastrophic claims.
Management reporting is essential to evaluating BWC’s and the MCOs’ catastrophic
case management. Measures that are necessary to effectively analyze these entities’
performance may include but not limited to:
Timelines (i.e., initial determination within 48 hours of notification or time
between date of filing and notification to the CNA);
Claim costs in relation to the primary diagnosis;
Claims submitted to Alternative Dispute Resolution (ADR), including the
dispute type and outcome;
Number of claims identified, including those that have had the catastrophic
indicator removed; and
Claim costs in relation to the assigned MCO.
j) If the MCO learns that an IW has died, it shall immediately notify the CAT nurse
and any vendor involved in the deceased IW’s claim.
5. Catastrophic Case Management Plan (CCMP)
While a CCMP contains some elements of a case management plan, as outlined in
Section D(7) of this chapter, it should not be considered to be the case management
plan. A CCMP may be considered and reviewed with the BWC catastrophic nurse
advocate (CNA) for appropriateness on catastrophic claims that are chronic and result
in a disabling condition. A CCMP is not appropriate for IWs residing in assisted living
facilities, nursing homes or TBI facilities as there is usually a plan of care developed by
the facility. CCMPs are to be used as tools to assist in the ongoing medical management
of a catastrophic injury and are normally used in instances of extenuating circumstances
(i.e. IW is out of state).
A Catastrophic Case Management Plan (which is distinct from the legally required plan
of care) is used to address the long-term needs of severely disabled IWs. It is necessary
to consider the concerns of the IW’s family members; however, family members are
not part of the workers compensation claim. The MCO Catastrophic Case Manager
and/or the CAN should staff family members’ concerns and discuss them with the
employer to see if the employer is willing to pay for crisis intervention.
The MCO’s Catastrophic Case Manager and the assigned BWC CNA determine the
necessity for a CCMP. The MCO shall research if a prior Life Care Plan exists for
litigation purposes and adapt such a plan for BWC purposes. All conditions allowed in
the claim shall be addressed on the CCMP and must contain the current status of
the allowed condition or must indicate that the allowed condition has completely
March 2016 Final
3-46
HPP-Medical and Return To Work Management
resolved as of a certain date.
The Catastrophic Case Management Plan (CCMP) shall include, but it is not limited to,
the following critical elements:
a) Medical services:
Physician of record, specialist’s evaluations. List all appropriate specialists deemed
necessary based on claim allowances and literature review.
No recommendations for psychological intervention shall be placed on a
CCMP without an allowed condition in the claim, with the exception of
adjustment counseling as determined per Section G3 of this Chapter. A
psychological/psychiatric evaluation may only be recommended in the CCMP if the
claim is specifically allowed for a psychiatric condition, or adjustment counseling is
determined to be appropriate per staffing with the CNA under Section G3 of this
Chapter “BWC Catastrophic Nurse Advocate (CNA)”. If there is no psychological
condition specifically allowed in the claim and issues are identified, the person
preparing the CCMP must contact the BWC CNA to staff the issues.
All medications must be listed with dosage, frequency, route and indications and
side effects that may require additional medical evaluation or laboratory testing, if it
is necessary due to specific drugs.
Recommendations for dental services shall not be placed on a CCMP without
an allowed dental condition in the claim. Dental evaluation and/or treatment can
be considered only if the claim is specifically allowed for a dental condition
secondary to medication use or actual physical damage at time of injury. If a
problem is identified, the person preparing the CCMP must contact the BWC- CNA.
b) Home/Vehicle Modifications:
The BWC Catastrophic Nurse Advocate (CNA) is the primary authorization source
for home and vehicle evaluations and modifications.
In situations where the MCO receives a request for authorization of home or
vehicle modifications, the MCO should immediately notify the BWC CNA.
Home/vehicle modifications should not be placed on a CCMP plan without prior
approval by the BWC catastrophic nurse. Home/vehicle modifications should be
based on BWC policy and the date the modifications were completed should be
listed on the CCMP. Recommendations regarding home/vehicle modifications
identified by the life care planner should be referred to the CNA for a decision and
not placed on the plan.
If approved by the CNA, the estimated cost of each additional modification
and how it will benefit the IW must be included on the CCMP. All dates of
home/vehicle modifications should be listed on the CCMP.
c) Therapies
All therapies should include date of initial evaluation and therapies completed to
March 2016 Final
3-47
HPP-Medical and Return To Work Management
date, including the servicing provider and his/her phone number.
d) Durable Medical Equipment
All DME that is being used by the IW must be listed along with the cost
for each item and anticipated replacement date and cost. Wheelchair evaluation(s)
and all DME must be based on BWC/MCO policy. The CCMP must include the
last date of purchase, cost and the normal anticipated time for replacement and/or
repair. The MCO must update the plan with date of purchase and cost whenever
new equipment is necessary.
e) Rehabilitation
The CCMP must address if the IW is currently in a vocational
rehabilitation plan, has completed vocational rehabilitation. All beginning and
ending dates and name of person providing the service and the cost must be included
in the CCMP.
f) Activities of Daily Living
Items including, but not limited to, cell phone, memberships, adaptive clothing, and
computers are not normally considered medical equipment or medically necessary
items and are not reimbursed by BWC. These items shall not be mentioned in the
CCMP.
g) Educational and recreational programs:
The CCMP should include all educational opportunities in which the IW is
participating.
h) Supportive Care
Home maintenance services which include home repair, house cleaning,
laundry service, meal preparation, snow removal, lawn care , pet care, and
garden care, are not reimbursable per BWC/MCO policy and should not be
included in a CCMP.
Transportation needs of the IW should be included and based on BWC/MCO
policy.
Monthly charges for services and/or equipment should not be placed in a
CCMP. The service can be addressed but should not include a monthly
allowance.
i) Return to Work: Return to work goals should be included on the CCMP.
The BWC CNA must approve the need for a CCMP and will document the need in V3.
Once the need for a CCMP has been approved, the MCO will be notified by E-mail. The
MCO must contract with a BWC certified provider within 60 days. It is important that the
MCO’s Catastrophic Case Manager selects and instructs the provider and works closely
with him/her to insure that a quality, timely CCMP is provided. The MCO also must
inform the provider of the name of the BWC CNA that is assigned to the claim.
The CCMP must be completed within 60 days of referral from the MCO to the provider.
March 2016 Final
3-48
HPP-Medical and Return To Work Management
The CCMP shall include at the beginning of the report that all services in the plan are
subject to BWC/MCO policy and based upon medical necessity in relation to the
allowed conditions of the claim. The provider writing the CCMP shall work with the
BWC CNA and the MCO and be familiar with the unique differences required for
providing a CCMP. All CCMPs must be reviewed with the CNA before they are
discussed with the IW or the IW’s family and before implementation.
A CCMP is a rarely used tool for managing a catastrophic claim and requires an annual
MCO review based upon an assessment of the IW’s condition. Although plans can and
do change, their integrity must be maintained by both current and future MCOs involved
with the claim. A plan can neither be arbitrarily revised nor abandoned if the MCO
assigned to the claim changes (e.g., due to open enrollment or mergers). The MCO shall
review the completed CCMP at a minimum of once a year and provide updates to the
BWC Catastrophic Nurse, and denote this review in claim notes. Only treatments and
supplies related to the current allowances in the claim are included in the CCMP. The
current MCO must follow BWC/MCO policy for consideration of equipment, supplies,
treatment, etc. In all cases, the substantive goals in the plan must remain intact for the life
of the IW. Inclusion in the CCMP does not automatically guarantee approval of
requested items. The MCO is responsible for authorization of services/supplies and
notifying parties to the claim.
To write a CCMP, the provider must possess at least one of the following credentials and
will be enrolled as a provider type 76:
Certified Occupational Health Nurse (COHN);
Certified Rehabilitation Counselor (CRC);
Certified Insurance Rehabilitation Specialist (CIRC);
Certified Vocational Evaluator (CVE);
Certified Rehabilitation Nurse (CRRN);
Certified Case Manager (CCM); and/or
Certified Disability Management Specialist (CDMS);
American Board of Vocational Experts Certification (ABVE)
These credentials alone do not automatically qualify a provider to complete a CCMP. The
MCO shall be responsible for choosing a BWC certified provider that is also certified as
a Life Care Planner by the International Commission on Health Care Certification
(ICHCC) or has experience developing quality Life Care Plans.
The CCMP is part of the cost of the claim and is charged to the employer’s risk (i.e., the
employer’s experience), not to the Surplus Fund. Reimbursement for the CCMP must be
billed using Level III HCPCS code Z1000 at current BWC fee schedule rates. The
CCMP shall be billed one time only, using the completion date as the date of service.
The MCO will work with the provider throughout the development of the plan and shall
obtain a copy of the completed CCMP no more than 60 days after the date the MCO
requested the CCMP. If the CCMP is not complete, the provider shall send the
March 2016 Final
3-49
HPP-Medical and Return To Work Management
incomplete plan along with a request for a specific number of days and the reason they
are requesting an extension of the completion date. No additional reimbursement will be
made for the extended time unless it is determined by the MCO and the BWC CNA that
payment above the fee schedule is warranted.
6. Emergency Response Systems
A catastrophic IW choosing to live at home rather than in a nursing home may require
home health nursing care assistance/supervision up to 24 hours a day due to work-
related injuries. An IW may be so severely physically impaired that he/she is not able
to call for emergency assistance. There are occasional situations where an IW could use
an emergency alert system for a limited period of time each day (minimum of 8 hours
per day), thus providing autonomy for the IW and eliminating the necessity of home
health care for one shift of nursing care each day.
Eligible criteria for an emergency response system include:
Claim for IW has previously been designated as a BWC catastrophic claim;
IW is not capable, due to injuries allowed in the claim, to summon help
independently in an emergency situation;
IW is home alone for a minimum of an 8-hour period (no agency or caregiver
services or anyone else with the IW);
IW is capable of using the service.
An emergency response system requires prior authorization and the request must be
submitted by the POR or treating physician on a C-9 form or another physician generated
document that contains the data elements on the C-9 form. MCO is required to staff the
need for an emergency response system with the assigned BWC catastrophic nurse and
obtain approval from the catastrophic nurse prior to authorization of service.
The MCO is required to enroll the provider of emergency medical response system as
type 79 after approval has been given by BWC catastrophic nurse.
Initial authorization is limited to a maximum of three months. Continued evaluation and
authorization required each 3 months based on medical necessity. MCO will notify the
catastrophic nurse when the monitoring has been discontinued.
BWC’s responsibility for reimbursement is limited to the initial activation fees and the
monthly monitoring fee. BWC is not responsible for any other costs or services for
subsequent installation/de-installation, additional pendants/equipment for family
members, or damages incurred to the IW’s residence caused by forced-entry in an
emergency situation. The provider will be required to bill for the system each three
months on CMS-1500 or C-19 Service Invoice using the following Z codes:
Z5601 Emergency Response System Initial/Installation Fee;
Z5602 Emergency Response System Monthly Maintenance Fee.
There are different types and brands of emergency response systems. A vendor who is in
March 2016 Final
3-50
HPP-Medical and Return To Work Management
close proximity to the IW may be an appropriate choice.
7. Residential Care/Assisted Living
MCOs shall perform a thorough assessment of level of care needs and develop a plan of
care that focuses on the individual needs of the IW. This assessment must include an
evaluation of the cost effectiveness of Residential/Assisted Living care required for the
IW as well as the ability of the facility to meet the medical treatment, safety, supervision
and activity of daily living needs of the IW. Note: An Assisted-Living Assessment
Screening Tool is available on MCO Portal – shared documents
– Policy alerts folder.
The Residential/Assisted Living Care Facility must be a BWC certified provider or
meet the criteria for same before recommendation for placement of the IW in a
Residential/Assisted Living Facility.
If necessary, the MCO shall assist the facility in becoming BWC certified.
An evaluation of the IW must be completed to determine his/her needs. The
screening tool found on the portal must be used to assess the level of care needs of
the IW. The rationale for the placement decision must be included on the assessment
form. This assessment documentation must be imaged into the claim. In addition to
assessing the IW, the assisted living facility should also be assessed in relation to
quality of care and services as well as the ability to meet the particular needs of the
individual IW before placement into the facility. The following criteria are suggested
for facility consideration:
o What is the staff to resident ratio?
o What health and wellness services are available?
o Is the location convenient to friends and family?
o Are activities planned for residents?
o Is 24-hour nursing care available?
o Do services and quality of living meet your standards?
o Is the value comparable to cost?
o What are the residency criteria?
o Will assisted living improve the quality of life for the IW?
The MCO shall staff the claim with the BWC CAT nurse after completing the
assessment of the IW and the facility. The staffing summary must include a cost
comparison of the Residential/Assisted Living arrangements recommended for the
IW as well as the determination of appropriateness of placement. NOTE: Although
the placement approval is the responsibility of the MCO, collaboration with the
BWC CAT nurse is encouraged.
As with any high cost claim, services or Residential/Assisted Living care shall not
be authorized for indefinite periods of time. The Residential/Assisted Living
placement shall be reviewed, including the bills, at least every three (3) months for
the first six months of placement or when new services are requested. If continuing
placement is requested and approved beyond the initial six (6) month period,
subsequent level of care reviews shall be reviewed at least every six (6) months or
when new services are requested.
Any changes in living arrangements shall be staffed with the CAT Nurse before
March 2016 Final
3-51
HPP-Medical and Return To Work Management
they are authorized. The care plan and services provided must be for the allowed
conditions in the claim.
The per diem, all inclusive fee for residential care/assisted living, must be billed with code
Z0180 not to exceed the current BWC fee schedule amount. The MCO will request a
written copy of the services included in the daily/monthly charge and it must be copied into
the IW’s claim.
March 2016 Final
3-52
HPP-Medical and Return To Work Management
H. EXPOSURE OR CONTACT WITH BLOOD OR OTHER POTENTIALLY
INFECTIOUS MATERIALS WITH OR WITHOUT PHYSICAL INJURY
The current Exposure or Contact with Blood or Other Potentially Infectious Materials (OPIM)
With or Without Physical Injury Policy has been clarified regarding the specifically assigned
ICD-9 codes that are to be used and the billing and reimbursement issues surrounding the current
policy.
Federal Occupational Safety and Health Administration (OSHA) in many cases mandates
employers to pay for all costs associated with exposure to blood or Other Potentially Infectious
Materials (OPIM), regardless of the presence or absence of a physical injury. OSHA does not
mandate how the employer pays for all costs associated with the exposure. BWC will handle
exposure claims in the same manner as all other claims. Employers may be cited if they are
found to be non-compliant.
If the claim is allowed for a physical injury (e.g. needlestick, cut or open wound etc.), the
provider will submit the bills for testing, counseling, prophylactic treatment and any required
ongoing testing, counseling and treatment to the MCO/BWC. The MCO will accept the
CDC/OSHA standards for treatment and will not require prior authorization or deny payment for
any/all preventative treatment that is required for possible exposure to blood/OPIM, according to
CDC protocols.
BWC makes the claim determination:
If a First Report of Injury (FROI) is received by the MCO for an incident of exposure to blood or
other potentially infectious materials (OPIM) with or without a physical injury, the FROI must
be filed with BWC, in accordance with the Ohio Revised Code. The FROI meets OSHA’s
requirements for filing exposure incidents. This will assist the employer by eliminating the need
to file two (2) forms.
Pursuant to Ohio Revised Code, a worker must have “contracted” a disease from a workplace
exposure or there must be a physical injury. Claims for exposure to blood or other potentially
infectious materials (OPIM) only are non-compensable in Ohio; therefore, claims that show no
evidence of a physical injury will be disallowed.
1. Claims filed for exposure to blood/OPIM without a physical injury:
If a claim shows exposure to blood or OPIM, but no evidence of a physical injury,
such as spit in the eye, urine splash on the body surface, blood on the skin, or an air
borne material, the claim will be disallowed according to Ohio law.
ICD-9 code 994.9 “Effects of other external causes” will be the specifically
assigned code for all claims filed for exposure to blood or other potentially infectious
March 2016 Final
3-53
HPP-Medical and Return To Work Management
materials (OPIM) without a physical injury. In addition the ICD-9 code will be
defined as exposure to blood/OPIM.
The BWC order will inform the employee that the claim was disallowed according to
Ohio law due to no physical injury. The BWC order will also state that in some
cases, the employer may be required under Federal OSHA standards to pay for the
cost of treatment.
If the claim is disallowed due to no physical injury, and the MCO receives a bill
from the provider, the MCO shall not send the bill to BWC, but shall send the
rejected bill, as usual, following the procedure defined in the MCO Policy Reference
Guide, back to the provider. The MCO must keep a copy of the rejected bill.
2. Claims filed for exposure to blood/OPIM with a physical injury:
If the claim shows exposure to blood or OPIM and there is evidence of a physical
injury, such as needlestick, cut or open wound, the claim will be allowed for the
injury, but not the exposure. BWC assigns open wound codes 870 through 893,
according to the specific body part that was injured.
If the claim is allowed for a physical condition, reimbursement will be made for all
office visits, Emergency Department visits, treatment such as suturing, cleaning of the
area and prophylactic treatment required according to current Centers for Disease
Control (CDC) protocol. This may include, but is not limited to, office visit(s), tetanus,
HIV or hepatitis testing, suturing, dressing, counseling, preventive medication and
follow-up testing/treatment. Providers may use Preventative Medicine Individual
Counseling CPT codes only when billing for these services as required per CDC/OSHA
guidelines for these claims only. Providers will be reimbursed according to the current
fees in effect on the date of service.
Note: Periodic audits will be conducted to ensure correct use of these codes.
The MCO will accept the CDC/OSHA standards for treatment and will not require
prior authorization or deny payment for any/all preventative treatment that is required
for possible exposure to blood or OPIM, according to CDC protocols.
3. Employee contracts a disease after exposure:
In the event a worker actually contracts a disease following exposure to blood or
other OPIM, the claim will be handled as an occupational disease claim.
Exposure to Blood or Other Potentially Infectious Materials
With or Without Physical Injury Grid
Exposure Without Physical Injury
Exposure With Physical Injury
MCO files FROI
MCO files FROI
BWC disallows the claim. Examples of exposure
without physical injury include spit or splash of
blood or Other Potentially Infectious Materials
(OPIM). BWC will specifically assign ICD-9
code 994.9 and identify the exposure as
BWC allows the claim for the physical
injury. Examples of exposure with a
physical injury include needlestick or
open wound. The exposure to blood or
OPIM is never allowed.
March 2016 Final
3-50
HPP-Medical and Return To Work Management
blood/OPIM. The BWC order will state that the
claim is disallowed, due to no physical injury and
that the employer may be responsible for payment
of bills according to Federal Occupational Safety
and Health Administration (OSHA) guidelines.
For more information regarding OSHA guidelines
and compliance, visit their web site at
www.OSHA.gov. or the Ohio Bureau of
Occupational Safety & Health, Division of Labor
& Worker Safety.
The MCO will accept the CDC/OSHA
standards for treatment and will not
require prior authorization or deny
payment for any/all preventative
treatment that is required for possible
exposure to blood/OPIM, according to
CDC protocols.
If the claim is disallowed due to no physical
injury, and the MCO receives a bill from the
provider, the MCO shall not send the bill to
BWC, but shall send the rejected bill, as usual,
following the procedure defined in the MCO
Policy Reference Guide, back to the provider.
The MCO must keep a copy of the rejected bill.
If the provider sends the bill to the
MCO, the MCO will send all bills for
the entire service to BWC. This
includes the office visit(s), HIV or
hepatitis testing/treatment, tetanus
injection, suturing, dressing,
counseling, preventative medication
and follow-up testing/treatment.
Providers may use Preventative
Medicine Individual Counseling CPT
codes only when billing for these
services as required per CDC/OSHA
guidelines for these claims only.
Payment will be made to the provider
at the current fees in effect on the date
of service.
If the employee contracts a disease after being
exposed, at work, without a physical injury and
the claim filed was not allowed, the employee
may file a new claim. The claim may become
allowed for the disease, as an occupational
disease claim.
If the employee contracts a disease
after being exposed, at work, with a
physical injury and the claim filed was
allowed, the employee may file a new
claim or file to have the claim amended
for the disease. The claim may become
allowed for the disease, as an
occupational disease claim.
4. Exposure to Blood and Other Body Fluids Under SB 223
As stated in the current Exposure or Contact With Blood or Other Potentially Infectious
Materials With or Without Physical Injury Policy; Federal Occupational Safety and
Health Administration (OSHA) mandates employers, that are obligated by OSHA, to pay
for all costs associated with exposure to blood or other potentially infectious materials
(OPIM), regardless of the presence or absence of a physical injury. Private employers are
mandated to follow OSHA. However, public employers are not mandated to follow
OSHA.
March 2016 Final
3-51
HPP-Medical and Return To Work Management
Senate Bill 223, effective March 14, 2003, insures that a peace officer, firefighter, or
emergency medical worker when coming into contact with the blood or other body fluid
of another person in the course of and arising out of the peace officer’s firefighter’s or
emergency medical workers employment shall have the costs paid for post-exposure `
medical services consistent with current standards of medical care existing at the time of
the exposure. This applies to State Fund (private and public) and Self Insured public
employers for of peace officers, firefighters and emergency medical workers employed or
volunteering for self-insured public employers.
Per the statute (Ohio Revised Code 4123.026), BWC: ". . .shall pay the costs of
conducting post-exposure medical diagnostic services . . . to investigate whether an
injury or occupational disease was sustained by a peace officer, firefighter, or emergency
medical worker when coming into contact with the blood or other body fluid of another
person . . . through any of the following means:
(1) Splash or spatter in the eye or mouth, including when received in the course of
conducting mouth-to-mouth resuscitation;
(2) A puncture in the skin;
(3) A cut in the skin or another opening in the skin such as an open sore, wound, lesion,
abrasion, or ulcer."
BWC or a self-insuring public employer, will pay for post-exposure medical care for
peace officers, firefighters, or emergency medical workers who, in the course of and
arising out of their employment, if the worker has a cut in the skin or other open sore,
wound abrasion or ulcer that comes into physical contact with another person’s blood or
body fluid and does not sustain a physical injury. If the worker is splashed with another
persons blood or body fluid on shin that is intact (does not have an open wound) will not
be paid for medical care by BWC or the Self Insuring Employer.
SB 223 claims do not include exposure to air-borne diseases. It specifically states that a
worker (as specified in the bill) must come into contact with the blood or other body fluid
of another person from a splash or spatter in the eye or mouth, including when received
in the course of conducting mouth-to-mouth resuscitation; a puncture in the skin; or a cut
in the skin or another opening in the skin such as an open sore, wound, lesion, abrasion,
or ulcer.
Examples:
The claim is not compensable under SB223 if:
The worker (as specified in the bill) is only in the presence of someone (air borne
exposure) that has TB or other infectious disease but there is no physical contact with
blood or other body fluid contact via a splash or spatter in the eye or mouth or in the
course of mouth-to-mouth resuscitation, skin puncture or cut in skin or another opening
such as open sore, wound, lesion, abrasion or ulcer.
The claim is compensable under SB223 if:
March 2016 Final
3-52
HPP-Medical and Return To Work Management
The worker (as specified in the bill) comes into physical contact with the blood or other
body fluid of another person who has TB or other infectious disease via a splash or
spatter in the eye or mouth or in the course of mouth-to-mouth resuscitation, skin
puncture or cut in skin or another opening such as open sore, wound, lesion, abrasion or
ulcer.
SB 223 applies to State Fund (private and public) and Self Insured public employers for
peace officers, firefighters, and emergency medical workers employed by or volunteering
for the self- insured public employer.”
As used in SB 223, a “Peace Officer” generally will be a sheriff, deputy sheriff, marshal,
deputy marshal or member of an organized police department. Peace Officers will
generally work for city, county or state public employers and they are not limited to
“traditional” law enforcement officers. Certain park rangers, tax and liquor agents,
officers of metropolitan housing authorities or transit authorities, and others are also
considered peace officers. For more detail, refer to Section 2935.01 of the Revised Code
or contact the Legal Operations department if there is a question.
A “Firefighter” generally means a firefighter, whether paid or volunteer, of a lawfully
constituted fire department.
An “Emergency medical worker’” generally means a first responder, emergency medical
technician-basic, emergency medical technician-intermediate, or emergency medical
technician-paramedic, certified under chapter 4765. of the Revised Code, whether paid or
volunteer.
SB 223 changes the definition of what is paid in claims involving a peace officer,
firefighter, or emergency medical worker; however, it does not change what is allowed or
the definition of injury in Ohio. In accordance with Ohio law, BWC will disallow the
claim for exposure and place it in a disallowed/inactive status. The MCO will not be able
to update the claim via the 148. All updates must be made by the BWC CSS.
Providers will report exposure incidents on the FROI to the assigned MCO or online at
www.ohiobwc.com as they would any other workplace incident for a state fund claim.
The MCO must be aware of the employers and occupations that will be impacted by
this policy. To assist BWC with identifying these claims for "special processing"
providers or MCOs should indicate "ALLEGED EXPOSURE to BLOOD or BODY
FLUID” in the Description of Accident section when completing the FROI. In addition,
the MCO shall file the claim with BWC in the same way as all other claims, (i.e., medical
only or lost time). Once the claim is identified as an exposure claim, the MCO will be
notified by BWC via e-mail of the claims assigned to that MCO that have been
disallowed for Exposure without physical injury to Blood /OPIM (ICD-9 diagnosis code
994.9)
The MCO shall accept the Centers for Disease Control /OSHA standards for treatment
and shall not require prior authorization or deny payment for post-exposure medical care
March 2016 Final
3-53
HPP-Medical and Return To Work Management
or preventative medicine services that may be required as a result of possible exposure to
blood/OPIM, according to CDC/OSHA protocols.
Reimbursement will be made for all office visits, Emergency Department visits, tetanus,
HIV or hepatitis testing, suturing, dressing, physician evaluation/management (including
counseling), prophylactic medication and follow-up testing/treatment required according
to current Centers for Disease Control (CDC) protocol. Providers will be reimbursed
according to the current fees in effect on the date of service.
Bills will be sent to the assigned MCO as usual. Reimbursement will be made if the claim
is allowed for the physical injury. Claims that do not have a physical injury allowed but
do have physical contact documented will be paid under the SB223 payment for claims
that are disallowed Though the claim will be in a disallowed status, the MCO shall not
inappropriately reject these bills upfront. The MCO shall price the bill at $0.00, attach
EOB 256 (claim is disallowed), and submit to BWC. Claims that have no physical injury
and no physical contact documented will not be paid. The MCO must follow standard
billing protocols.
BWC will flag these claims in Cambridge for manual bill processing to permit payment
even though the claims have been disallowed. BWC will review each bill and apply the
necessary EOBs, including EOB 879: Payment Being Made in a Disallowed Claim for
Testing or Other Services due to Alleged Exposure (SB223).
If the claim is allowed for a physical injury (e.g. needlestick, cut or open wound etc) the
provider will submit the bills for testing, physician evaluation and management
(including counseling), preventative treatment and any required ongoing testing and
treatment to the MCO. The MCO will accept the CDC/OSHA standards for treatment
and will not require prior authorization or deny payment for any/all preventative
treatment that is required for possible exposure to blood/OPIM, according to CDC
protocols.
If the claim is allowed due to a physical injury or the claim is disallowed due to no
physical injury and physical contact with blood or body fluids, reimbursement will be
made for all office visits, Emergency Department visits, tetanus, HIV or hepatitis testing,
suturing, dressing, physician evaluation/management (including counseling),
prophylactic medication and follow-up testing/treatment required according to current
Centers for Disease Control (CDC) protocol (i.e. 6 months or a year after the exposure).
Providers will be reimbursed according to the current fees in effect on the date of service.
In the event a peace officer, firefighter, or emergency medical worker, actually contracts
a disease following exposure to blood or body fluid a new claim must be filed and the
claim will be handled as an occupational disease claim.
March 2016 Final
3-54
HPP-Medical and Return To Work Management
SB223-Exposure Claims
Effective for dates of occurrence on or after March 14, 2003
Exposure and Physical Contact
with Physical Injury
Exposure and Physical Contact
without Physical Injury
Exposure and No Physical
Contact and without Physical
Injury
A Peace Officer, Firefighter or EMT
has been exposed to blood or body
fluids and has sustained a physical
injury
A Peace officer, fire fighter or EMT
has been exposed to blood or body
fluids but did not sustain a physical
injury.
A Peace officer, fire fighter or
EMT had an air born exposure, but
did not sustain a physical injury.
Checklist
Checklist
Checklist
The Worker:
Was physically injured;
Had other person’s blood or
body fluid splashed on:
o
His/her eyes or mouth.
o
Puncture of the skin.
o
Cut or opening in his/her
skin (sore, etc.)
The Worker:
Was NOT physically injured;
Had other person’s blood or
body fluid splashed on:
o
His/her eyes or mouth.
o
Puncture of the skin.
o
Cut or opening in his/her
skin (sore, etc.)
The Worker:
Was NOT physically injured;
Did NOT have physical
contact with another person’s
blood or body fluid;
Was exposed to an air borne
condition such as Tuberculosis
(TB) Whooping Cough and /or
Meningitis or other infectious
disease without physical
contact with blood or body
fluid.
MCO Processing
MCO Processing
MCO Processing
If the provider sends the bill to the
MCO, the MCO will send all bills
for the entire service to BWC. This
includes the office visit(s), HIV or
hepatitis testing/treatment, tetanus
injection, suturing, dressing,
counseling, preventative medication
and follow-up testing/treatment.
Providers may use Preventative
Medicine Individual Counseling
CPT codes only when billing for
these services as required per
CDC/OSHA guidelines for these
claims only. Payment will be made
to the provider at the current fees in
effect on the date of service.
BWC or a self-insuring public
employer will pay for post-exposure
medical care for peace officers,
firefighters, or emergency medical
workers who, in the course of and
arising out of their employment, are
exposed to blood or other body
fluids of another person and do not
sustain a physical injury.
If the provider sends the bill to the
MCO, the MCO will send all bills
for the entire service to BWC. This
includes the office visit(s), HIV or
hepatitis testing/treatment, tetanus
injection, suturing, dressing,
counseling, preventative medication
and follow-up testing/treatment.
Providers may use Preventative
Medicine Individual Counseling
CPT codes only when billing for
these services as required per
CDC/OSHA guidelines for these
claims only. Payment will be made
to the provider at the current fees in
effect on the date of service.
This claim is disallowed and the
worker did not have physical
contact with blood or body fluids.
In accordance with OH Laws
medical bills will not be paid
If the employee contracts a disease
after being exposed, at work, with a
physical injury and the claim filed
was allowed, the employee may file
a new claim or file to have the claim
amended for the disease. The claim
may become allowed for the disease,
If the employee contracts a disease
after being exposed, at work,
without a physical injury and the
claim filed was not allowed, the
employee may file a new claim. The
claim may become allowed for the
disease, as an occupational disease
March 2016 Final
3-55
HPP-Medical and Return To Work Management
as an occupational disease claim. claim.
Medical Claims
Specialist
SB223 Workflow
(Revised 11/2004)
Claim is filed with BWC
Medical
No
Only?
Yes
Claim assigned to
appropriate Field
Service Office
Claim assigned to MCS
END
MCS investigates
claim.
Is IW’s occupation
Firefighter, Peace
Officer or EMT?
No
Follow OPIM
Exposure workflow
Yes
Update occupation window in V3 with
Peace Office, Firefighter, EMT/SB223
Exposure with
physical injury?
Exposure to
blood/body fluids
without injury?
Exposure with No
contact, No injury?
Issue V3 allowance
order for physical
injury only & select
local print
Issue V3 denial order
SB223 denial insert
contact with blood &
select local print
Issue V3 denial order
SB223 denial insert
no contact/no injury &
select local print
Enter V3 note SB223
Enter V3 note SB223
Enter V3 note SB223
Issue SB223 letter
Exposure with injury V3 ad
hoc
Attach fact sheet
with letter
Issue SB223 letter
Exposure with contact
to blood V3 ad hoc
Attach fact sheet
with letter
Issue SB223 letter
Exposure – no
contact/no injury
V3 ad hoc
Attach fact sheet
with letter
Contact HPP
(workflow A)
END
March 2016 Final
3-56
HPP-Medical and Return To Work Management
I. BIOTERRORISM EXPOSURE POLICY
All state fund claims alleging potential non-accidental exposure to anthrax or
other biological agent will be automatically referred to BWC’s medical advisor
for an occupational disease medical review. Where the worker tests negative for
anthrax, BWC will disallow the claim in accordance with Ohio law. In the event a
worker actually contracts anthrax, the claim will be handled as an occupational
disease claim.
Emergency medical diagnostic services necessary to investigate the claim and
confirm or rule out an anthrax diagnosis will be paid by BWC as occupational
disease claim investigative costs. Prophylactic antibiotic therapy, initiated in
accordance with Ohio Department of Health and the Centers’ for Disease Control
protocol, will also be reimbursed by BWC. Reimbursement for prophylactic
antibiotic therapy initiated prior to substance testing will be considered on a case
by case basis and BWC may limit reimbursement in these cases.
Each case involving non-accidental alleged or real exposure to anthrax or other
biological agent will be handled by a centralized claims team, led by BWC’s
physician medical advisor and specially trained claims staff to ensure BWC
resources are deployed prudently. Only workers who come into direct contact
with the potential anthrax or other biological agents in the course of their
employment and are instructed by emergency response personnel to seek
emergency treatment will be covered by this policy.
Each MCO will be notified by BWC via e-mail of the claims assigned to that MCO that
have been disallowed for Alleged Exposure to Anthrax (ICD-9 diagnosis code 989.89).
Injured workers will be notified of the special procedures for their claims by way of a
letter. Providers are told to send bills to MCOs. BWC will flag these claims in Cambridge
for manual bill processing to permit payment even though the claims have been
disallowed. If your billing system is unable to cut checks for disallowed claims, please
contact the BWC MCO Business Unit immediately.
Please take the following steps for any bills received for these claims:
1. Do not inappropriately reject bills at MCO level - rejections are allowed only for
missing or invalid mandatory elements such as claim number, diagnosis code,
procedure code and place of service codes. Non-allowed or non-covered procedure
codes and diagnosis codes are valid codes, although they are not usually
payable. These bills need to be in the BWC’s bill payment system.
2. MCO should submit the bills priced at $0.00 with EOB 256 (claim is disallowed).
Attach EOB 270 ( ICD-9 is disallowed) , if provider billed with 989.89
Attach EOB 276 (ICD-9 is not allowed), if provider billed with something other
than 989.89.
March 2016 Final
3-57
HPP-Medical and Return To Work Management
3. Do not attach informational or override EOBs. Once BWC receives the bills, we will
review each bill and apply additional EOBs if needed.
4. Send an email to HPPSSU@bwc.state.oh.us. advising that bills have been submitted
to BWC; be sure that the e-mails are not misdirected to HPP adjustments or to other
BWC addresses. Failure to send email notification to HPPSSU@bwc.state.oh.us
may delay the processing of the bills.
5. Please contact BWC immediately if you are unable to determine how to handle a
specific bill.
J. HOME AND VEHICLE MODIFICATION
The BWC Catastrophic Nurse Advocate (CNA) will develop a plan for home or vehicle
modification. The CNA will address all home and vehicle modification requests for all
claims regardless if the equipment being requested is for a catastrophic claim and will issue a
determination. The CNA will work closely with the MCO case manager and the necessary
vendors to insure coordination of the services.
If the MCO receives a request for home and/or vehicle modification(s), the MCO shall
respond to the provider and injured worker in writing, according to C-9 processing
timeframes, that the request is being forwarded to the specific CNA assigned to the service
office where the claim is located. If the MCO receives a request for other services/supplies
on the same C-9, the MCO shall review and respond to the non-home and vehicle
modification services request within the C-9 processing timeframes.
The BWC Catastrophic Nurse Advocate is the primary authorization source for home and
vehicle evaluations and modifications.
In situations where the MCO receives a request for authorization of home or vehicle
modifications, the MCO should immediately notify the BWC CNA.
Reimbursement of home and vehicle modification services is made by either BWC or the
MCO depending upon specific service and provider type.
Actual home and vehicle modifications are performed by a vendor, billed with a specific
W code and paid by BWC.
Other services provided by a vendor require W codes for billing. These services are paid
by BWC. Exception: Scooter/wheelchair lift and installation (W4000) including
anchoring the lift to the vehicle or attachment of a hitch is authorized and paid by the
MCO. An installation that requires additional vehicle modification
requires review/authorization by BWC
Services billed by out-patient hospital require the use of revenue codes with appropriate
CPT codes and are paid by the MCO.
Services billed by in-patient hospital require revenue codes only and are paid by the
MCO.
The following list outlines specific billing, coding, and reimbursement information:
Description of
Provider
HCPCS/CPT
Revenue
Fee
Billing
Bill To
March 2016 Final
3-58
HPP-Medical and Return To Work Management
Service
Type
Code
Code
form
Driving
evaluation PT,
OT or certified
driving
instructor
Non-
facility
W0500
NA
By
report
(BR)
C-19 or
HCFA
1500
BWC
Driving
evaluation OT
Facility
Outpatient
97003
OT
Hospital's
outpatient
reimburse
ment
rate*
UB-92
MCO
Driving
evaluation PT
Facility
Outpatient
97001
PT
Hospital's
outpatient
reimburse
ment
rate*
UB-92
MCO
Driving
instruction for
modified
vehicle- PT, OT
or certified
driving
instructor
Non-
facility
W0549
NA
By
Report
(BR)
C-19 or
HCFA-
1500
BWC
Driving
instruction for
modified vehicle
PT
Facility
Outpatient
97535
PT
Hospital's
outpatient
reimburse
ment
rate*
UB-92
MCO
Driving
instruction for
modified vehicle
OT
Facility
Outpatient
97535
OT
Hospital's
outpatient
reimburse
ment
rate*
UB-92
MCO
PT/OT
evaluation for
home/vehicle
modification
Non-
facility
W0678
NA
By
Report
(BR)
C-19 or
HCPC
S 1500
BWC
PT evaluation
for home/vehicle
modification
Facility
Inpatient
NA
PT
Hospital's
inpatient
reimburse
ment
rate*
UB-92
MCO
OT evaluation
for home/vehicle
modification
Facility
Inpatient
NA
OT
Hospital's
inpatient
reimburse
ment
rate*
UB-92
MCO
Home
Modification
(includes
permanent ramp)
Vendor
W0675
NA
By
Report
(BR)
C-19 or
HCPC
S 1500
BWC
Vehicle
Modifications
Vendor
W0679
NA
By
Report
C-19 or
HCPC
BWC
March 2016 Final
3-59
HPP-Medical and Return To Work Management
(BR)
S 1500
Home and
Vehicle
Modification
Repairs
Vendor
W0677
NA
By
Report
(BR)
C-19 or
HCPC
S 1500
BWC
Portable Ramp
Rental or
Purchase
Vendor
W0676
NA
Current
Fee
Schedule
C-19 or
HCPC
S 1500
BWC
Lift, vehicle, 3-4
wheeled chair
with manual
swing
Vendor
W4000
NA
Current
Fee
Schedule
C-19 or
HCPC
S 1500
MCO
Lift, vehicle, 3-4
wheeled chair
with motorized
swing
Vendor
W4001
NA
Current
Fee
Schedule
C-19 or
HCPC
S 1500
MCO
* Please refer to Hospital Reimbursement methodology in chapter 3 of BWC’s Billing
and Reimbursement Manual for past and current payment methodology information.
K. HOME INFUSION
MCOs shall negotiate a per diem rate for all home infusion therapy services. This rate
includes nursing services, medical supplies, medication, and pharmacy services. All-
inclusive per diem rates may be negotiated with the following BWC certified providers:
a) A Medicare certified Joint Commission accredited, community health
accreditation program (CHAP) accreditation , or an accreditation through an
organization that has been granted deeming authority by the Centers for Medicare
or Medicaid Services home health agency which has its own state pharmacy board
licensed fluid therapy pharmacy; or
b) A state pharmacy board licensed fluid therapy pharmacy which holds JCAHO
Joint Commission accreditation as a certified home infusion therapy provider with
nurses either employed by the pharmacy or contracted by the pharmacy through a
Medicare certified or Joint Commission accredited home health agency.
The negotiated per diem rate is expected to be equal to or lower than the BWC fees for
the individual components. Billing for home infusion therapy, either by a home health
agency or by a pharmacy, must be submitted to the MCO on a CMS-1500 or a BWC C-
19 Service Invoice. Bills may not be submitted to the Pharmacy Benefit Manager. The
following Level III HCPCS codes are to be used when billing for home infusion therapy:
W9010 All-inclusive per diem rate, parenteral nutrition;
W9020 All-inclusive per diem rate, enteral nutrition;
W9030 All-inclusive per diem rate, antibiotic home infusion therapy;
W9040 All-inclusive per diem rate, pain management home infusion therapy;
W9050 All-inclusive per diem rate, fluid replacement home infusion therapy;
W9060 All-inclusive per diem rate, chemotherapy home infusion therapy;
W9070 All-inclusive per diem rate, multiple home infusion therapies.
March 2016 Final
3-60
HPP-Medical and Return To Work Management
When a bill is submitted for home infusion services using an all-inclusive negotiated rate,
the negotiated rate code includes all charges for nursing services, medication, medical
supplies, and pharmacy services, unless the code is for a service unrelated to the infusion
therapy.
Example: Services and supplies for which the fee maximum might be considered when
negotiating a rate for home infusion therapy for an injured worker with an indwelling
heparin well, and who has an order for ampicillin sodium 500 mg q6h x 10 days, are:
W0105 Skilled Nursing Visits - initial daily assessment
W0100 Home Health Agency Registered Nurse, per 15 minutes
J0290 Ampicillin Sodium 500 mg, 4 x day
A4245 Alcohol wipes, per wipe, 8 x day
A4215 Sterile needle, 4 x day
W9006 Sharps container needle disposal
E0776 IV pole (generally rental for one month is equivalent to one-tenth purchase
price)
L. HOME HEALTH AGENCY SERVICES
1. Eligible Providers
To be enrolled and certified by BWC, home health agencies must be certified by
Medicare, accredited by the Joint Commission, accredited by the Community Health
Accreditation Program (CHAP), or accredited through an organization that has been
granted deeming authority by the Centers for Medicare and Medicaid Services.
2. Services
a. Skilled Nursing, Hourly Nursing, Home Health Aide, and Social Worker
Billing for home health services must be submitted to the MCO on a CMS 1500 or C-
19 Service Invoice using the appropriate Level I (CPT®) codes for physical,
occupational or speech therapy and Level II or Level III HCPCS codes, listed in
Chapter 2 of the Billing and Reimbursement Manual, for other services including
skilled nursing, hourly nursing, home health aide, and social worker visits.
b. Home Health Codes
The following codes specific to services provided by home health agencies were
implemented for dates of service beginning 1/1/2006:
W2704 Home health agency worker providing direct care, mileage per mile,
beginning with 51
st
mile round trip.
W2705 Travel time, home health agency professional worker each 6 minutes
W2706 Travel time, home health agency non-professional worker each 6 minutes
The MCO should select the BWC certified Home Health Agency that is closest to the
injured worker’s residence.
March 2016 Final
3-61
HPP-Medical and Return To Work Management
Mileage
Payment of mileage is limited to those home health agency workers who are
providing direct care to the injured worker.
Mileage will be reimbursed beginning with the 51
st
mile for a round trip for an
injured worker. No mileage will be reimbursed for the first 50 miles of a round
trip
Mileage is calculated as follows:
mileage calculation begins from home health worker’s home base to IW
home, and ends with return trip from IW home to home health worker’s
home base or next client whichever comes first or
Mileage begins from home health workers previous point of service to IW
home and ends with return trip from IW home to home health worker’s
home base or next client whichever comes first.
Travel Time
Payment of travel time is limited to those home health agency workers who are
providing direct care to the injured worker.
Travel time is calculated as followed:
Time begins from home health worker’s home base to IW home, and ends
with return trip from IW home to home health worker’s home base or next
client whichever comes first or
Time begins from home health workers previous point of service to IW
home and ends with return trip from IW home to home health worker’s
home base or next client whichever comes first.
Note: The mileage and travel time codes may not be billed in conjunction with the
all-inclusive per diem home infusion therapy codes or hospice codes.
M. INTERPRETER SERVICES
As part of a joint resolution of the Industrial Commission of Ohio (IC) and Bureau of
Worker’s Compensation (BWC), interpreter services are available throughout Ohio for
hearings, medical examinations, rehabilitation, and consultations for individuals who are
deaf or hearing impaired and communicate using American Sign Language or for
individuals with a foreign language barrier. Approval of interpreter services is a claims
function and not medical management of the claim. Interpreter services are provided and
paid for as part of the cost of administering the claim to ensure that an IW is afforded
Due Process of Law. This policy revision is intended to provide guidelines for approving
interpreter services for foreign language speaking and hearing impaired injured workers
for BWC services that are reasonable to assist the IW in the recovery of his/her injury.
This policy revision will identify separate guidelines for approving interpreter services
for injured workers with a foreign language barrier and for services for deaf or hearing
impaired IWs as deafness is a disability under ADA.
March 2016 Final
3-62
HPP-Medical and Return To Work Management
General Guidelines for approval of Interpreter Services
It is difficult to determine or define every instance and the length of time that should be
allowed for IWs to receive interpreter services in situations that do not involve Due
Process. Injury management of the claim, including discussion with the IW’s employer,
will assist the Customer Care Team in determining the IW’s available resources;
therefore, providing only those interpreter services that are “reasonable, necessary and
appropriate”. The local CCT is familiar with community resources and is encouraged to
approve services with providers within the community or location of the IW. This will
reduce the costs associated with interpreter’s travel time.
All requests for interpreter services that are eligible for reimbursement by BWC must be
made directly to the Claims Services Specialist (CCS) except in cases that involve
vocational rehabilitation. If the IW is participating in a vocational rehabilitation plan, the
Disability Management Coordinator (DMC) must approve and monitor the extent of the
services.
The IC is only responsible for IC related interpreter services, such as hearings and
reimbursement will only be made for interpreter services approved by the IC for IC
related Services. The IC may be contacted by calling 1-800-521-2691or (614) 752-
4036); TDD number: 1-800-686-1589.
BWC shall refer requests for IC hearings or other IC services to the IC.
MCOs shall refer all requests for interpreter services immediately to the IW’s assigned
CSS/DMC. This is especially important if the request is made on a C-9. It will be
necessary for the MCO and the CSS/DMC to coordinate interpreter services approval in
conjunction with the medical treatment, to prevent delays and facilitate communication
with the IW and the provider. As previously noted, approval of interpreter services is a
claims function and not medical management of the claim. Therefore, the CSS or DMC
shall approve or deny interpreter services and shall place a note in V3, stating that
interpreter services were discussed and it was determined to allow or deny the interpreter
services were discussed and it was determined to allow or deny the request. The
CCT/DMC will work with the MCO to facilitate communication of the IW’s needs for
interpreter services and what is “necessary and reasonable.” “Necessary and reasonable”
services are based on the individual situation of each IW as determined by the
CSS/DMC. BWC’s Claims, Medical and/or Rehab Policy units will help staff cases as
needed upon request. Requests for interpreter services should be acted upon
immediately to prevent delays in treatment.
Approval of interpreter services that require Due Process
Interpreter services will be provided to injured workers and employers who are unable to
communicate because of a hearing impairment or foreign language barrier in the
following situations:
IC hearings;
Independent Medical Exams.
March 2016 Final
3-63
HPP-Medical and Return To Work Management
When the injured worker needs an interpreter for an ADR IME that is required by
the MCO, BWC will pay for both the IME and the interpreter services. It may be
necessary for more than one ADR IME in the life of a claim. The MCO will contact
the IW’s assigned CSS/DMC, who will make arrangements for the interpreter
services, in the same manner as all other interpreter services.
Approval of interpreter services for situations that do not require Due Process
In the course of managing an injury, it may be necessary to assist the IW with
communication by approving interpreter services in situations that do not involve Due
Process of Law for issues related to the allowed conditions in the claim:
In the investigation or administrative needs of the claim;
To explain workers compensation benefits;
For a medical specialist consultation that has been requested by the Physician of
Record (POR);
To assist the IW who is participating in a vocational rehabilitation plan. In
most cases interpreter services will not be necessary for the entire time span of the
vocational rehabilitation plan. Interpreter services within the IW’s home
community should be used whenever possible. The DMC must approve and
monitor the extent of the services.
To expedite treatment in a catastrophic injury claim. The Catastrophic Nurse
Advocate (CNA) will work with the CSS/DMC to explore all options and
document their findings to explain why interpreter services are needed.
BWC will typically not approve Foreign Language Interpreter Services in the
following situations:
Communication with durable medical equipment (DME) suppliers;
Physician of Record (POR) routine office visits; (The IW has a choice of
selecting his/her POR and is responsible for communicating with his/her
physician.)
Physical or Occupational Therapy
BWC Shall approve Sign Language Interpreters for deaf or hearing impaired IWs
who use sign language, when requested, in the following situations:
Communication with durable medical equipment (DME) suppliers;
Physician of record (POR) routine office visits;
Physical or Occupational Therapy
BWC will not approve Foreign Language or Sign Language Interpreter Services for
an injured worker receiving hospital based services as the hospital is responsible for
providing these services. Hospitals may inform BWC that an injured worker may
require interpreter services when discharged. This is especially true for planned
hospitalizations. This will prevent delays in treatment. If the IW has been approved for
hospital based services and requires an interpreter, the CSS/DMC should notify the
hospital social services or other department designated for obtaining interpreters,
concerning the IW’s need for assistance to facilitate communication. The CSS/DMC
should inform the hospital to call him/her if interpreter services will be needed soon after
March 2016 Final
3-64
HPP-Medical and Return To Work Management
the injured worker is discharged. Coordination of interpreter services for injured
worker’s that need the services, is a necessary part of eliminating time lost for the injured
workers care and return to work.
Utilize BWC’s Customer Contact Center to provide phone services such as calling a
doctor’s office, completing a FROI, and explaining compensation. The Customer Contact
Center provides Spanish voice communication for every call and is available to make
phone arrangements with BWC Bilingual Employees throughout the state for people who
need other foreign language interpretation. The Customer Contact Center can assist the
CSS/DMC in contacting the IW by using a TTY or TDD, for the deaf or communicating
between the CSS/DMC and an IW who speaks a foreign language. The Customer Contact
Center may utilize the Ohio Relay Service to communicate with both deaf/hearing
impaired and Spanish speaking individuals. It is important to note that Customer Contact
Center Personnel are not available to accompany the IW; however, telephonic interpreter
services are an accepted cost effective method to assist injured workers who speak a
foreign language.
The IW, employer, MCO, CSS or DMC may contact BWC Customer Contact Center
in the following ways:
Telephone Number: 1-800-OHIOBWC (1-800-644-6292);
TTY Number: 1-800-BWC-4-TDD (1-800-292-4833);
Fax Number: 1-877-520-OHIO (6446);
Mailing Address: BWC Customer Service, 30 W. Spring Street, L- 10,
Columbus, OH 43215-2233;
E-mail: Send a message (Contact Us) @ www.ohiobwc.com
Who may request Interpreter Services:
Requests for interpreter services may be made to a BWC CCT or DMC by the IW, IW’s
family or acquaintance, the provider, Physician of Record (POR), or MCO. Requests by
a specific interpreter or by the IW for a specific interpreter to provide service for a
specific IW must be evaluated and determined to be necessary by the CSS/DMC. The
length of time and number of times should be approved.
The extent or length of time approved for interpreter services should be based on
interpreter services that are necessary and reasonable. “Necessary and reasonable”
services are based on the individual situation of each IW as determined by the
CSS/DMC. Necessary and reasonable services are provided at critical junctures in the
claim and to insure recovery. However, it is not always necessary and reasonable for an
IW to have an interpreter present at each appointment or for the entire length of an
appointment throughout the life of a claim. BWC must pre-approve all BWC related
requests for interpreter services and payment will be made by BWC to the provider as
outlined in this policy. Retro approval of interpreter services shall be made only for
unusual circumstances.
Procedures for the CSS/DMC or Exam Schedulers
March 2016 Final
3-65
HPP-Medical and Return To Work Management
After the CSS/ DMC or exam scheduler approves or denies the interpreter services a
letter must be sent to the IW and copies sent to all parties. If a party objects he/she may
file a Motion.
The CSS or DMC or exam scheduler shall approve or deny interpreter services and shall
place a note in V3, stating that interpreter services were discussed. The CSS or DMC or
exam scheduler, that approved interpreter services, shall contact or call the appropriate
interpreter provider to make arrangements for all interpreter services approved for BWC
purposes.
It will be necessary for the CSS/DMC or exam scheduler to sign the C-19 with his/her
(A) number before imaging the document and faxing a copy to MB&A. (This is the same
workflow as the C-60 travel reimbursement procedure.) The original C-19 does not need
to be sent to Medical Billing and Adjustments (MB&A).
The CSS/DMC or exam scheduler will need to instruct the provider of the Interpreter
Services to send the bill to his/her attention instead of sending it to the address noted on
the C-19.
Vocational Rehabilitation:
Vocational Rehabilitation plans requiring interpreter/translator services must be approved
by the DMC prior to plan implementation. This requirement is in Chapter 4, Section M,
of the MCO Policy Reference Guide “DMC Authorization of Special Voc Rehab Plan
Types.” MCOs will receive additional instructions regarding the need for DMC
authorization of pre-plan services.
The DMC should provide oversight of vocational rehab services (both pre-plan and plan
services) to assure that the IW receives necessary and reasonable services. “Necessary
and reasonable” services are based on the individual situation of each IW as determined
by the DMC. Sign language interpreter services for deaf or hearing impaired injured
workers will be approved, when requested, for POR, Physical or Occupational Therapy
appointments occurring during rehabilitation programming. BWC’s Rehab Policy unit
will help staff cases as needed upon request of the DMC. In general, necessary and
reasonable services are provided at critical junctures in the rehabilitation process, such as
the initial interview with the IW and when the IW signs the rehab agreement.
If a bi-lingual vocational rehab case manager is used, that case manager will not be
reimbursed additionally for interpreter services.
MCO Scheduled Examinations and Responsibility:
The MCO is responsible for payment of both the examination and the interpreter services
if the injured worker needs an interpreter for an examination that is scheduled by the
MCO. The MCO may use its own interpreter services or may request assistance from
BWC.
If an MCO approves interpreter services in error without BWC approval, the MCO shall
be responsible for reimbursement to the provider. Payment will be transferred from the
March 2016 Final
3-66
HPP-Medical and Return To Work Management
MCO’s administrative account into the provider account to cover the exact payment
issued from the provider account to pay for the services provided. Supporting
documentation for the transaction must be maintained for audit trail purposes.
Payment for Interpreter Services:
Family members, friends, medical, health care and vocational providers and/or
community volunteers may provide interpretation for IWs but are not eligible for
enrollment or to receive reimbursement.
BWC’s Medical Billing and Adjustments:
BWC Medical Billing and Adjustments (MB&A) must verify approval of all interpreter
services (BWC & IC) before processing the bill. Interpreter services that are not
approved by BWC or the IC will be denied for reimbursement using EOB 353, “Payment
is denied as prior authorization is required for this service.”
Billing Instructions, Codes and Fees:
Current fees can be found on BWC's website www.ohiobwc.com by going to Medical
Providers/Look-ups/Fee Schedule Look-up, then entering the listed codes. BWC
providers are expected to bill their usual and customary rate. Reimbursement will be at
the provider billed amount or at the BWC fee, whichever is lower. Inquiries about
unresolved billing issues should be directed to BWC’s provider Relations Department at
1(800) OHIOBWC, 1-800-644-6292, option 0-3-0.
Bills must be submitted on BWC’s C-19 Service Invoice that can be found on BWC’s
website under Medical Providers, forms. Instructions for completing the form can also
be found on BWC’s website, under medical providers, services, billing and
reimbursement manual, chapter 4.
All Interpreter Services (BWC or IC) must to be billed with the appropriate code(s) listed
below on a C-19 Service Invoice (C-19).
W1930 Interpreter Services, per fifteen (15) minutes.
W1931 Interpreter Wait Time, per six (6) minutes, Maximum of 30 minutes per date of
service (including waiting for an IW that does not show up for appointment).
W1932 Interpreter Travel Time, per six (6) minutes (including travel time for an IW
that does not show up for appointment).
W1933 Interpreter Mileage, per mile.
Enrollment of Providers of Interpreter Services:
Providers delivering Interpreter Services for BWC/IC approved services will be enrolled
as provider type 99 (other). When an MCO requests enrollment of the interpreter, the
MCO must include the approved vocational rehabilitation plan and interpreter’s
qualifications with a non-certified enrollment form. Providers of Interpreter Services may
enroll using the Medco-13A Form found on the web site, www.ohiobwc.com.
N. SMOKING CESSATION PROGRAMS WITH OR WITHOUT FDA APPROVED
SMOKING DETERRENT DRUGS
March 2016 Final
3-67
HPP-Medical and Return To Work Management
1. Smoking Deterrent Programs
An MCO may consider reimbursement of smoking cessation programs with or without
FDA approved smoking deterrent drugs when the guidelines below are met.
Reimbursement of smoking deterrent drugs used in conjunction with a smoking cessation
program is included within the fee for the smoking deterrent program.
BWC and the MCO responsible for medically managing the claim may consider
reimbursement eligibility for smoking cessation programs in the following situations:
for injured workers whose allowed pulmonary condition impairs their ability
to meet established treatment and return to work goals;
or
for the maintenance of pulmonary function in injured workers who have an
allowed pulmonary condition.
Reimbursement of FDA approved smoking deterrent drugs will only be considered when
used within an MCO approved/accredited smoking cessation program. This positive
behavioral modification program would include education and counseling regarding
nicotine addiction and the use of nicotine replacement products, relapse prevention
strategies, stress management techniques and/or other appropriate services that would
treat an allowed pulmonary condition or improve the allowed pulmonary condition to
enable the injured worker to return to work.
2. Reimbursement Guidelines:
BWC will not provide reimbursement for prescription smoking deterrent drugs outside an
approved program. The drugs are included in the total program reimbursement. BWC’s
pharmacy benefits manager () will not reimburse smoking deterrent drugs.
Providers of smoking cessation programs are required to enroll as a BWC certified
provider and bill for services on either the HCFA1500 or the BWC Service Invoice (C-
19). Bills must then be submitted to the managing MCO for reimbursement.
Note: Smoking deterrent drugs that are not FDA approved will not be reimbursed and
shall not be billed to BWC or the MCO.
3. Reimbursement Codes
a. Services for smoking cessation with prescription drugs
Services for smoking cessation with prescription drugs may be reimbursable, when
the allowed lung condition presents a barrier to meeting established treatment and
return to work goals and when the Miller Criteria have been met. These services must
focus on behaviorally oriented education and counseling regarding nicotine addiction
and the use of nicotine replacement products, relapse prevention strategies and
behavioral modification techniques and/or other appropriate services that would
improve the allowed condition and enable the injured worker to return to work. The
HCPCS Level III code for reimbursement is W5000
b. Services for smoking cessation without prescription drugs
March 2016 Final
3-68
HPP-Medical and Return To Work Management
Services for smoking cessation, without prescription drugs when the lung condition
presents a barrier to meeting established treatment and return to work goals or when
the Miller Criteria have been met. These services must focus on behaviorally oriented
education and counseling regarding nicotine addiction, relapse prevention strategies
and behavioral modification techniques and/or other appropriate services that would
improve the allowed condition and enable the injured worker to return to work. The
HCPCS Level III code for reimbursement is W5001.
O. NURSING HOME NEGOTIATED RATE GUIDELINES
1. Per Diem Rate
The following services and supplies are generally included in the nursing home per diem
rate, either intermediate or skilled:
Room and board, including oral diet and supplements;
Basic personal hygiene items and services, including soap, shampoo, wash basins,
tissues, underpads;
Basic psychosocial services;
Occasional non-prescription medications;
Durable medical equipment, unless prescribed for the exclusive use of the injured
worker;
Disposable, non-reusable medical supplies;
Wheelchairs and other ambulatory aids unless prescribed for the exclusive use of the
injured worker;
Laundry services;
Maintenance therapy, including basic range of motion exercises and assistance with
ambulation;
Activity programs.
2. Basic Nursing Home Per Diem Billing Codes:
HCPCS Code W0170 Skilled Nursing Care
HCPCS Code W0180 Intermediate Level Care
3. Negotiated Nursing Home Per Diem Billing Code:
HCPCS Code W0176 Negotiated Per Diem
4. Negotiated Rates
In extenuating circumstances when the injured worker’s condition requires services and
supplies over and above those reimbursed using the per diem codes W0170 or W0180,
nursing homes may request a negotiated rate. The MCO is responsible for nursing home
rate negotiations with both panel and non-panel providers. Use HCPCS Code W0176 to
bill for negotiated nursing home per diem rates.
The services/supplies must be medically necessary for treatment of the work-related
injury. The injured worker’s physician must order the services/supplies.
Supplies that may be considered in a negotiated rate include:
Wound-care products;
March 2016 Final
3-69
HPP-Medical and Return To Work Management
Ostomy supplies;
Urinary catheters and catheter supplies;
Tube feeding supplies;
Respiratory therapy supplies;
Other medically necessary supplies.
Additional payment also may be approved if the injured worker requires services beyond
those described as basic services, including:
Respiratory therapy;
Extensive wound care;
Other medically necessary services.
Physical, occupational and speech therapy may be included in the negotiated per diem
rate or may be billed separately, at the discretion of the MCO, using the appropriate
HCPCS codes in addition to the basic per diem rate code.
Medications are not included in the negotiated per diem rate. The supplying pharmacist
must bill for the medications.
Medical, dental, podiatry, optometry, transportation, radiology and laboratory services
are not included in the negotiated rate. The servicing provider must bill for these services.
Nursing home service approvals should not be for more than 6 months at a time.
5. Legend Drugs
Legend drugs are not payable to nursing home providers. However, a pharmacy located
within a nursing home may be eligible for reimbursement of legend drugs if the
pharmacy meets the eligibility requirements for being a pharmacy provider, as stated in
the Provider Billing and Reimbursement Manual. Nursing homes must bill over-the-
counter medications and all medical supplies, including IV supplies, as part of the
intermediate or skilled per diem rates.
Hospitals operating on-site nursing homes may dispense legend drugs to the nursing
homes’ residents from the hospital pharmacy. However, the hospital pharmacy must be
able to meet the requirements for becoming a pharmacy provider, including the ability to
electronically bill PBM, BWC’s pharmacy benefits manager.
P. HOSPICE
BWC enrolls hospice providers as Provider Type 30 - Home Health Agency. Hospices must
be licensed by the state and be Medicare/Medicaid certified to become providers. Criteria for
hospice services eligibility includes:
Request for hospice care must be at POR direction.
The need for hospice care must be directly related to the claim allowance.
The injured worker must be terminally ill with an estimated life expectancy of less than
six months.
March 2016 Final
3-70
HPP-Medical and Return To Work Management
Aggressive treatment has been stopped. All future treatment will be palliative (for the
comfort of the patient).
Services should be authorized for no more than 90 days at a time. All services and supplies
must be provided for patient comfort rather than for treatment.
In home hospice care that includes all services and supplies necessary for the patient’s
comfort – may include nursing care, counseling services, massage, art, music,
bereavement therapies, supplies.
Respite hospice care that may be provided in hospice facilities or in nursing homes or
hospitals with which the hospice provider has a contract to provide respite care.
Acute hospice care for pain management in hospice facilities or in nursing homes or
hospitals with which the hospice provider has a contract to provide acute pain
management services.
All services and supplies are reimbursed to the hospice provider at an all inclusive per diem
rate. The per diem rate is paid regardless of the number of services or the time spent
providing those services. The hospice provider reimburses the facility (nursing home,
hospital, etc.) with which it has a contract. The following billing codes are used to bill for
hospice services:
Z0500 – in home hospice care per diem
Z0550 – respite hospice care per diem
Z0560 – acute hospice hospital care for pain management per diem
R. WEIGHT CONTROL DRUGS.
BWC does not reimburse for weight control/loss drugs dispensed by a pharmacy provider.
BWC and the MCO may consider reimbursement of weight control/loss drugs only when
used as part of an approved/accredited weight control program.
S. CHRONIC PAIN PROGRAMS
All Chronic Pain Programs are required to be BWC certified. Chronic pain programs must
include all of the following overall objectives:
Improve general physical conditioning in order to achieve return to work readiness, if
appropriate;
Improve overall function for return to work readiness, if appropriate;
Increase comfort/decrease pain rating by use of pain management skills;
Decrease dependency on the health care system;
Identify/clarify vocational goals; if appropriate;
Reduce inappropriate use of narcotics and other medications that may cause
dependence or addiction.
In order to be considered for a chronic pain management treatment program, the IW must
receive authorization for and must undergo a comprehensive multidisciplinary evaluation that
includes:
March 2016 Final
3-71
HPP-Medical and Return To Work Management
medical history and physical/neuromuscular examination to include review of
medications;
review of past, pertinent medical records;
psychological evaluation;
physical therapy evaluation;
occupational therapy evaluation
cardiac stress test, if necessary;
specialist consultation(s) as necessary.
Injured worker eligibility indicators include:
Injured worker is symptomatic of excessive pain behaviors disproportionate to the
compensable injury or condition.
Injured worker has not responded to traditional medical treatment or to an extended
course of individual therapy modalities. If an injured worker has not responded to
traditional medical treatment or to an extended course of individual therapy
modalities, it is recommended that the injured worker be referred to a BWC certified
CARF accredited multidisciplinary pain management program for evaluation to
determine appropriateness for entrance into the program. The ideal time frame for
referral is six months to three years post injury, but referrals should not be limited to
those time frames.
Injured worker's use/abuse of alcohol or drugs is not so excessive that it is likely to
interfere with full participation in the program.
Injured worker is not currently experiencing any acute medical problems, is not
anticipating any medical or surgical intervention and is considered medically stable to
participate in a multidisciplinary, physically challenging program.
Injured worker has previously completed no more than one BWC certified
CARF/Joint Commission accredited multidisciplinary pain management program.
Injured worker is demonstrating significant emotional distress as a result of the
allowed injury, such as depression, anxiety or impaired interpersonal, familial,
occupational or social functioning; however psychological dysfunction is not so
severe as to interfere with full program participation.
Injured worker has expressed interest and desire to participate in a chronic pain
management program with a goal of returning to work, if appropriate. If no return to
work goal exists, there must be an expectation of documentable cost savings through
decreased reliance on health care resources as a result of participation in the program.
Diagnosis allowed in the claim may be, but is not limited to ICD-9 chronic pain
diagnoses listed:
719.4 - pain in joint (fifth digit identifies body part)
307.89 - other psychalgia or pain disorder associated with both
psychological and general medical condition
337.21 - RSD, upper limb
337.22 - RSD, lower limb
724.6 - chronic lumbosacral sprain/strain (already allowed for
lumbar/lumbosacral sprain/strain)
722.8* - postlaminectomy syndrome ( fifth digit identifies back level)
March 2016 Final
3-72
HPP-Medical and Return To Work Management
729.1 - fibromyalgia
Inpatient programs are appropriate only when the injured worker's condition is such that a
highly supervised and monitored program is essential for success. One or more of the
following criteria must be met in order for an inpatient program to be approved.
IW requires weaning from prescribed medication before any possible benefit of the
pain management program could be realized.
IW exhibits personality/behaviors such that effective participation would be unlikely in an
unsupervised/unmonitored setting.
IW needs a structured environment for psychological support and/or medical
monitoring.
IW's pain behaviors are reinforced in the home to the point that it is necessary for the
IW to be removed from the home in order to effectively succeed in a pain program.
Outpatient programs are appropriate when the injured worker's condition does not
warrant the highly supervised environment of an inpatient program. Outpatient with
lodging may be warranted if the IW resides more than 25 miles from the chronic pain
program facility, or the IW is involved in dysfunctional home, family or relationship that
contributes to and exacerbates pain behaviors. Outpatient without lodging is appropriate
if the IW resides within 25 miles or less of the pain program facility, has a supportive
home/family structure, does not significantly rely on medication, and does not use illicit
drugs or misuse alcohol.
Only BWC certified chronic pain programs may bill chronic pain program per diem
codes. Certified chronic pain programs may be certified by BWC if they have CARF
accreditation if they are free standing, or if hospital based, are CARF or Joint
Commission accredited.
Chronic pain program per diem codes include:
W1000 CARF/Joint Commission accredited BWC certified chronic pain program,
per day -non-hospital based pain management program, per diem
W1001 CARF/Joint Commission accredited BWC certified chronic pain program
pre-admission evaluation- non-hospital based pain management program, per diem
W1002 CARF /Joint Commission accredited BWC certified chronic pain program,
per half day (four hours or less) non-hospital based pain management program, per
diem
The following local Level III HCPCS procedure codes are used when the chronic
pain program (billing facility) has a contractual agreement with other facilities to
provide travel, meals, and or lodging to the injured worker:
Z0600 Vocational rehabilitation or chronic pain program, not claimant
reimbursement, travel
Z0601 Vocational rehabilitation or chronic pain program, not claimant
reimbursement, meals
Z0602 Vocational rehabilitation or chronic pain program, not claimant
reimbursement, lodging
March 2016 Final
3-73
HPP-Medical and Return To Work Management
For chronic pain program per diem billing and for billing the level III codes to provide
travel, meals and or lodging in a chronic pain program, the 11-digit BWC provider
number of the group practice to whom the payment is to be made must be included in
box 25 and 33 of the CMS-1500.
Services provided by a chronic pain program must be billed with the appropriate per diem
code with the exception of the following services that may be billed separately:
physician services;
psychologist services;
physical therapy or occupational therapy services not included in the scheduled
pain management program
For services billed separately from the chronic pain program, the 11-digit BWC provider
number of the individual treating practitioner must be included in box 25 of the CMS-
1500 and the 11-digit BWC provider number of the group practice to whom the
payment is to be made must be entered in box 33.
The following drug screen codes will be reimbursed without MCO prior authorization
when an injured worker is in an MCO approved, BWC certified pain management
program or is being treated by a physician in the management of chronic non-malignant
pain related to allowed claim conditions.
HCPCS code G0431-- Drug screen, qualitative; multiple drug classes by high complexity
test method (e.g., immunoassay, enzyme assay), per patient encounter
HCPCS Code G0434--Drug screen, other than chromatographic; any number of drug
classes, by CLIA waived test or moderate complexity test, per patient encounter
80102© Drug confirmation, each procedure
83925© Opiate(s) drug and metabolites, each procedure (e.g. morphine,
meperdine)
The drug screens are covered with MCO discretion. The codes should be reviewed by the
MCO for medical necessity and allowed condition relatedness prior to payment (allowed
or denied).
Note: Reimbursement of drug screens performed by employers or drug screening of
injured workers performed in the emergency room at the time of injury continue to be
non-covered by BWC.
1. ICD-9-CM Codes for “Pain”
For BWC purposes, ongoing pain symptoms of at least 12 months duration post completion of
conservative care or last definitive surgical procedure (laminectomy, fusion, etc.) provided there
has been ongoing medical care and attempts to identify and treat the source of the pain by the
injured worker will be considered as a major criteria for any of the BWC recognized chronic pain
diagnoses.
March 2016 Final
3-74
HPP-Medical and Return To Work Management
“338 Pain, not elsewhere classified” instructs the user to “use additional code to identify: pain
associated with psychological factors (307.89)”. This code excludes generalized pain (780.96)
and “localized pain, unspecific type” which is coded to pain by site. It also excludes pain
disorder extensively attributed to psychological factors (307.80). Since this code is nonspecific
and requires an additional code, BWC does not recognize this code.
“338.0 Central Pain Syndrome” includes Dejerine-Roussy syndrome, myelopathic pain
syndrome, and thalamic pain syndrome (hyperesthetic). These are not common pain syndromes
seen in workers’ compensation and BWC does not recognize this code.
“338.1 Acute Pain” includes fifth digit designations for “338.11 acute pain due to trauma”,
“338.12 acute post-thoracotomy pain”, “338.18 other acute postoperative pain”, and “338.19
other acute pain”. As noted all of these codes describe acute pain whose treatment should be
reasonably covered by other diagnoses or the authorization of procedures to treat the diagnoses.
Therefore, these codes are not recognized by BWC.
“338.2 Chronic Pain” specifically excludes “355.9 causalgia”, “355.71 causalgia lower limb”,
“354.4 causalgia upper limb”, “338.4 chronic pain syndrome”, “729.1 myofascial pain
syndrome”, “338.3 neoplasm related chronic pain”, and “337.20-337.29 reflex sympathetic
dystrophy”. 338.2 “Chronic pain” itself lacks specificity or infer a causal relationship to work
injury or treatment to work injury. Therefore, code 338.2 is not recognized by BWC.
The other codes under 338.2 which have a fifth digit are recognized by BWC and include the
following codes which can be allowed when the condition and medical document meet diagnostic
criteria. These codes include “338.21 chronic pain due to trauma”, “338.22 chronic post-
thoracotomy pain”, “338.28 other chronic postoperative pain” and “338.29 other chronic pain”.
To enhance the specificity of the code “338.29 other chronic pain” and identification of the body
part involved in the allowance, BWC will indicate the body part in the narrative for the code. For
example, an allowance for chronic low back pain that meets claim allowance criteria may be
designated by BWC as “338.29 other chronic pain – lumbar region”. For the most part, this code
will be reserved for those claims meeting the criteria for chronic pain in which there have been no
operative procedures or no other code for chronic pain is appropriate.
“338.3 Neoplasm related pain (acute) (chronic)” described as cancer associated pain, pain due to
malignancy either primary or secondary, or tumor associated pain will be recognized by BWC
when the claim has a specific neoplasm allowed in the claim and the condition meets other
criteria for claim allowance.
“338.4 Chronic pain syndrome” is described as chronic pain associated with significant
psychosocial dysfunction. Since this code is no more specific than “338.2 Chronic pain” and by
description has “significant psychosocial dysfunction” which in most cases should require
psychological/psychiatric treatment, BWC will not recognize this code. However, individuals
with these findings should/may be considered appropriate for allowances of one of the other
chronic pain codes combined with “307.89 Other psychalgia or pain disorder associated with both
psychological and general medical condition” or a more specific psychiatric code such as “296.2
major depressive disorder, single episode”.
March 2016 Final
3-75
HPP-Medical and Return To Work Management
“307.80 Psychogenic pain, site unspecified” (described as “Pain Disorder Associated with
Psychological Factors” in DSM-IV-TR
1
) is to be used when psychological factors are judged to
have the major role in the onset, severity, exacerbation, or maintenance of the pain. General
medical conditions play no role or a minimal role in the onset or maintenance of the pain. Since
the role of the medical condition is minimal, it would be difficult to link the psychological factors
to the work injury. Therefore, this condition will not be recognized by BWC as it relates to
chronic pain conditions.
In addition to these ICD-9 Codes for 338, the 2007 version of ICD-9-CM has “780.96
Generalized pain” for pain Not Otherwise Specified. Since this code is primarily a symptom code
that is nonspecific and since the codes described above are more specific, BWC does not
recognize this code.
As a result of these newer codes being recognized by BWC, “724.6 chronic lumbosacral
sprain/strain” when the claim already has an allowance for lumbar/lumbosacral sprain/strain will
no longer be utilized since these claims will now be allowed for “338.29 other chronic pain” with
BWC staff inserting the description of the body region affected.
In summary, the following codes will be recognized by BWC to represent allowances for
conditions primarily manifest by chronic pain when allowance criteria are met:
Previously recognized:
pain in joint (fifth digit of code identifies specific body part)
other psychalgia or pain disorder associated with both
psychological and general medical condition
Reflex Sympathetic Dystrophy (RSD), upper limb
Reflex Sympathetic Dystrophy (RSD), lower limb
Postlaminectomy syndrome
Fibromyalgia
Recognized as a result of ICD-9-CM (2007 Version):
Chronic pain due to trauma
Chronic post-thoracotomy pain
Other chronic post-operative pain
Other chronic pain
Neoplasm related pain (acute) (chronic)
(Note: BWC Staff will indicate in the code descriptor the body part/region considered
responsible/involved in the chronic pain.)
(Note: While BWC does not recognize “338.4 chronic pain syndrome” described as chronic pain
associated with significant psychosocial dysfunction, any of the codes listed above may be
additionally allowed for “307.89” or another psychiatric ICD-9 Code if the allowance criteria are
met.)
No longer recognized by BWC in future claims:
Chronic lumbosacral sprain/strain (claim already allowed for
lumbar/lumbosacral sprain/strain)
a. Pain in Joint (Chronic) ICD-9 Code: 719.4 (fifth digit identifies body part)
1
American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text
Revision. Washington, DC, American Psychiatric Association, 2000.
March 2016 Final
3-76
HPP-Medical and Return To Work Management
Definition:
Ongoing pain symptoms of at least 12 months duration post completion of conservative
treatment or last definitive surgical procedure provided medical records indicate there has
been ongoing medical care and attempts to identify and treat the source of pain. Such
attempts should include appropriate diagnostic studies and consultations.
Note: This diagnosis is a secondary diagnosis of ongoing symptoms after completion of
treatment in an individual who is significantly limited due to pain in a joint allowed in the
claim. It requires a primary diagnosis recognized as allowed for the specific joint. It
should not be used when a more specific and appropriate diagnosis is available to
explain symptoms such as osteoarthritis, chondromalacia patellae, or adhesive capsulitis.
Injured worker should be at maximum medical improvement in relation to the allowed
condition of the joint.
Subjective:
Symptoms of pain of varying nature, intensity, and character localized to joint with
primary allowed condition.
Treatment must be shown to have been present for at least 12 months following
completion of conservative or last surgical treatment.
May have other symptoms such as but not limited to joint swelling, buckling,
decreased motion, or instability. Symptoms including pain should not involve
multiple sites such as polyarthralgias, fibromyalgia, or systemic connective tissue
diseases.
Objective:
None
Diagnostic Tests:
Diagnostic studies and medical records show absence of other appropriate diagnoses
to account for painful condition including but not limited to osteoarthritis, recurrent
injury such as torn meniscus, tendonitis, adhesive capsulitis, or degenerative
condition of cartilage. Medical records should document diagnostic studies and/or
consults to try to determine the source of pain.
b. Chronic lumbosacral sprain/strain ICD-9 Code: 724.6
This code is to be used for instability or ankylosis of lumbosacral or sacroiliac joint(s).
For allowances of chronic pain in these areas (lumbosacral and/or sacroiliac joint(s), use
diagnosis code 338.29.
Definition:
Ongoing pain symptoms of the lumbosacral region of at least 12 months duration post
completion of conservative treatment provided medical records indicate there has been
ongoing medical care and attempts to identify and treat the source of pain. Such attempts
should include appropriate diagnostic studies and consultations.
Note: This diagnosis is a secondary diagnosis of ongoing symptoms after completion of
treatment in an individual whose activity is significantly limited due to pain. It requires a
primary diagnosis recognized as allowed such as lumbosacral sprain/strain and lack of
invasive surgical intervention such as laminectomy, discectomy, or fusion. It should not
March 2016 Final
3-77
HPP-Medical and Return To Work Management
be used when a more specific and appropriate diagnosis is available to explain symptoms
such as degenerative disc disease, spondylosis, or spondylolisthesis. Injured worker
should be at maximum medical improvement in relation to the allowed condition of the
lumbar spine.
Subjective:
Symptoms of pain of varying nature, intensity, and character localized to low back
with primary allowed condition having received conservative treatment and
evaluation for more specific cause of pain such as herniated disc, etc.
Treatment must be shown to have been present at least 12 months following
completion of conservative treatment.
May have other symptoms such as but not limited to leg pain, weakness, decreased
spinal movement, etc.
Symptoms including pain should not involve multiple sites such as polyarthralgias,
fibromyalgia, or systemic connective tissue diseases.
Objective:
None specific. Diagnosis is for chronic symptom of pain.
Diagnostic Tests:
Diagnostic studies and medical records show absence of other appropriate diagnoses
to account for painful condition including but not limited to disc pathology,
spondylosis, spondylolisthesis, degenerative disc disease, and degenerative
osteoarthritis.
c. Postlaminectomy Syndrome (fifth digit identifies back level) ICD-9 Code: 722.8*
Definition:
Ongoing pain symptoms of at least 12 months duration post completion of definitive
surgical procedure such as discectomy, laminectomy, fusion, etc. (Surgical procedures
does not include epiduroscopy, epidural steroid injection, myelogram, or discograms.)
provided medical records indicate that pain is primary factor limiting performance of
activities and focus of medical care is toward controlling/relieving pain. Medical records
should document there has been ongoing medical care and attempts to identify and treat
the source of pain. Such attempts should include appropriate diagnostic studies and
consultations.
Note: This diagnosis is a secondary diagnosis of ongoing symptoms after completion of
surgical treatment and rehabilitation in an individual who has undergone a surgical
spinal procedure and is significantly limited due to pain. It requires a primary diagnosis
recognized as allowed such as lumbosacral sprain/strain and usually a secondary
diagnosis to allow for the surgical procedure and documentation of invasive surgical
intervention such as laminectomy, discectomy, or fusion. Many of these injured workers
may have completed or may be eligible for multidisciplinary pain treatment program.
Injured worker should be at maximum medical improvement in relation to the allowed
condition of the lumbar spine for which the individual underwent the procedure.
Subjective:
March 2016 Final
3-78
HPP-Medical and Return To Work Management
Symptoms of pain of varying nature, intensity, and character localized to spine region
with primary allowed condition having received surgical procedure, rehabilitation,
and evaluation for more specific cause of pain such as recurrent herniated disc, etc.
causing symptoms post-operatively.
Treatment must be shown to have been present at least 12 months following
completion of last surgical treatment.
May have other symptoms such as but not limited to leg pain, weakness, decreased
spinal movement, etc.
Symptoms including pain should not involve multiple sites such as polyarthralgias,
fibromyalgia, or systemic connective tissue diseases.
Objective:
None specific. Diagnosis is for chronic symptom of pain.
Diagnostic Tests:
Diagnostic studies and medical records show prior surgical procedure and absence of
more specific diagnosis to explain painful condition such as recurrent herniated disc,
etc. Medical records should document diagnostic procedures and/or consultations to
try to determine and treat the source of pain in the individual.
d. Chronic pain due to trauma ICD-9 Code: 338.21 “chronic pain due to
trauma”
(Note: BWC to indicate body part/region in narrative for code)
Definition:
Ongoing pain symptoms of at least 12 months duration post completion of conservative
treatment or last definitive surgical procedure provided medical records indicate the
mechanism of injury involved a significant traumatic event. Medical records must
document that there has been ongoing medical care and attempts to identify and treat the
source of pain. Such attempts should include appropriate diagnostic studies and
consultations as appropriate.
Note: This diagnosis is a secondary diagnosis of ongoing symptoms after completion of
treatment in an individual who sustained a significant traumatic injury and whose
activity is significantly limited due to pain. It should not be used when a more specific
and appropriate diagnosis is available to explain symptoms such as osteoarthritis, reflex
sympathetic dystrophy, or neuropathic pain. Injured worker should be at maximum
medical improvement in relation to the allowed condition(s) pertaining to the traumatic
event.
Subjective:
Symptoms of pain of varying nature, intensity, and character localized to body region
of primary allowed condition that has received completion of planned treatment.
Treatment must be shown to have been present at least 12 months following
completion of conservative or last surgical treatment.
May have other symptoms such as but not limited to joint swelling, buckling,
decreased motion, or instability. Symptoms including pain should not involve
multiple sites such as polyarthralgias, fibromyalgia, or systemic connective tissue
diseases.
March 2016 Final
3-79
HPP-Medical and Return To Work Management
Objective:
None
Diagnostic Tests:
Diagnostic studies and medical records show absence of other appropriate diagnoses
to account for painful condition such as osteoarthritis, reflex sympathetic dystrophy,
etc.
e. Chronic post-thoracotomy pain ICD-9 Code: 338.22
Definition:
Ongoing pain symptoms of at least 12 months duration post completion of thoracotomy
for a recognized allowed condition in the claim. Medical records must indicate that pain
is primary factor limiting performance of activities and focus of medical care is toward
controlling/relieving pain. Medical records should document there has been ongoing
medical care and attempts to identify and treat the source of pain. Such attempts should
include appropriate diagnostic studies and consultations.
Note: This diagnosis is a secondary diagnosis of ongoing symptoms after completion of a
thoracotomy for an allowed condition in an individual who is significantly limited due to
pain when the pain is believed to be the primary result of the thoracotomy.
Subjective:
Symptoms of pain of varying nature, intensity, and character localized to the region
of the thoracotomy despite the individual having received conservative treatment and
evaluation for more specific cause of pain.
Treatment must be shown to have been present for at least 12 months following
completion of conservative or last surgical treatment.
May have other symptoms.
Symptoms including pain should not involve multiple sites such as polyarthralgias,
fibromyalgia, or systemic connective tissue diseases.
Objective:
None specific. Diagnosis is for chronic symptom of pain.
Diagnostic Tests:
Diagnostic studies and medical records show absence of other appropriate diagnoses
to account for painful condition such as primary pulmonary or cardiac etiology.
f. Other chronic post-operative pain ICD-9 Code: 338.28
(Note: BWC to indicate body part/region in narrative for code)
Definition:
Ongoing pain symptoms of at least 12 months duration post completion of a definitive
surgical procedure other than thoracotomy (338.22) or lumbar discectomy, laminectomy
or fusion (722.8) for a recognized allowed condition in the claim. Medical records must
indicate that pain is primary factor limiting performance of activities and focus of
medical care is toward controlling/relieving pain. Medical records should document
March 2016 Final
3-80
HPP-Medical and Return To Work Management
there has been ongoing medical care and attempts to identify and treat the source of pain.
Such attempts should include appropriate diagnostic studies and consultations.
Note: This diagnosis is a secondary diagnosis of ongoing symptoms after completion of
surgical treatment in an individual who has undergone a surgical procedure and is
significantly limited due to pain believed to be the result of the procedure.
Subjective:
Symptoms of pain of varying nature, intensity, and character localized to the body
region of the primary allowed condition for which the surgical procedure was
performed.
Treatment must be shown to have been present at least 12 months following
completion of the last surgical treatment.
May have other symptoms such as but not limited to referred pain, weakness,
decreased movement, etc.
Symptoms including pain should not involve multiple sites such as polyarthralgias,
fibromyalgia, or systemic connective tissue diseases.
Objective:
None specific. Diagnosis is for chronic symptom of pain.
Diagnostic Tests:
Diagnostic studies and medical records show prior surgical procedure and absence of
more specific diagnosis to explain painful condition such as recurrent herniated disc,
RSD, osteoarthritis, etc.
g. Other chronic pain ICD-9 Code: 338.29
(Note: BWC to indicate body part/region in narrative for code)
(Note: Use this code only if documentation does not meet 338.21, 338.22, and 338.28
which are more specific codes.)
Definition:
Pain in body part/region requiring medical care for at least 12 months (no reactivation)
after completion of conservative treatment for the primary allowed condition. Medical
records must indicate that pain is primary factor limiting performance of activities and
focus of medical care is toward controlling/relieving pain. Medical records should
document there has been ongoing medical care and attempts to identify and treat the
source of pain. Such attempts should include appropriate diagnostic studies and
consultations.
Note: This diagnosis is a secondary diagnosis of ongoing symptoms after completion of
treatment in an individual who is significantly limited due to pain. It requires a primary
diagnosis recognized as allowed for the specific body part/region. It should not be used
when a more specific and appropriate diagnosis is available to explain symptoms such as
osteoarthritis, reflex sympathetic dystrophy, etc. or a more specific chronic pain
diagnosis such as chronic post-thoracotomy pain or postlaminectomy syndrome..
March 2016 Final
3-81
HPP-Medical and Return To Work Management
Subjective:
Symptoms of pain of varying nature, intensity, and character localized to body
part/region for the primary allowed condition that has received completion of
conservative treatment.
Treatment must be shown to have been present for at least 12 months following
completion of conservative treatment directed at the allowed condition in the claim.
Symptoms including pain should not involve multiple sites such as polyarthralgias,
fibromyalgia, or systemic connective tissue diseases.
Objective:
None
Diagnostic Tests:
Diagnostic studies and medical records show absence of other appropriate diagnoses
to account for painful condition including but not limited to osteoarthritis, reflex
sympathetic dystrophy, etc.
h. Neoplasm related pain (acute) (chronic) ICD-9 Code: 338.3
Definition:
Pain in body part/region as a direct result of a neoplasm which is a recognized allowed
condition in the claim. Pain must significantly impacts activity and requires ongoing
medical treatment directed toward relief of pain. Individual may or may not have had
surgery, chemotherapy, radiation therapy or other treatment of the neoplasm. No specific
difference in the claim allowance regarding acute versus chronic duration of pain.
Note: This diagnosis is a secondary diagnosis of ongoing pain symptoms attributed
directly to a recognized allowed condition of neoplasm of a body part/region/organ
system.
Subjective:
Symptoms of pain of varying nature, intensity, and character attributed to a neoplasm
that is recognized as an allowed condition in the claim.
Treatment does not have specific time duration but optimally individual should have
received some treatment focused to the neoplasm.
May have other symptoms such as but not limited to, weakness, fatigue, decreased
appetite, etc.
Symptoms including pain should not involve multiple sites such as polyarthralgias,
fibromyalgia, or systemic connective tissue diseases.
Objective:
None specific. Diagnosis is for chronic symptom of pain.
Diagnostic Tests:
Diagnostic studies and medical records support the diagnosis of the neoplasm.
i. Pain Disorder Associated with Both Psychological Factors and a General Medical
Condition
ICD-9 Code: 307.89
March 2016 Final
3-82
HPP-Medical and Return To Work Management
Definition:
Chronic pain condition in which both psychological factors and a general medical
condition are considered to be significant contributors to the disorder whether the
psychological contribution contributes to the onset, severity, exacerbation, or
maintenance of the pain. Evaluation and treatment in most cases will require evaluation
and treatment of the medical conditions believed to be causing pain and evaluation and
treatment of the psychological factors.
Note: This diagnosis is a secondary diagnosis or second diagnosis of an individual who
is already recognized as having a chronic pain condition recognized by BWC. This
condition may be combined with an allowance of a chronic pain disorder to provide the
equivalent of chronic pain syndrome. In lieu of this diagnostic code, more specific
psychiatric diagnostic codes (most commonly those of depression) may be appropriate
and more specific.
Note: BWC does not recognize ICD-9 Code “307.80 Psychogenic pain, site
unspecified” since this code is a primary mental health code and a medical condition
has no or very minimal role.
Subjective:
Symptoms of pain of whose onset, severity, or maintenance are believed to be
significantly affected by psychological factors and a chronic medical pain condition.
Individual must have a chronic pain allowance describing a general medical
condition.
Objective:
None specific.
Diagnostic Tests:
Since this condition is considered a mental disorder, a psychological/psychiatric
independent medical evaluation must be performed as in any other request for a
psychological/psychiatric allowance.
T. WHEELCHAIRS
In order to be covered by BWC, a wheelchair must be reasonable and necessary for the
treatment of the allowed claim condition or improve the functioning of the injured or affected
body part and meet all BWC regulatory requirements.
A wheelchair is covered if the injured worker’s condition is such that without the use of a
wheelchair he would otherwise be bed or chair confined.
An upgrade that is beneficial solely in allowing the injured worker to perform leisure or
recreational activities is generally non-covered.
Reimbursement for wheelchair codes includes all labor charges involved in the assembly
of the wheelchair. Reimbursement also includes support services such as emergency
services, delivery, set-up, education, and on-going assistance with the use of the
wheelchair for 90 days.
March 2016 Final
3-83
HPP-Medical and Return To Work Management
Payment is usually made for only one wheelchair at a time. Rental of a wheelchair is
covered if an injured worker-owned wheelchair is being repaired.
For an item to be considered for coverage and payment by BWC, the information
submitted by the supplier must be corroborated by documentation in the injured worker’s
medical records. The injured worker’s medical records supporting the medical necessity
of the wheelchair must be made available by the MCO upon request.
The physician of record or treating physician is responsible for writing the prescription for
the wheelchair and completing the C-9 requesting the wheelchair and submitting this request
to the MCO. The physician’s request should include the type of wheelchair requested,
current medical status of the injured worker and documentation supporting medical necessity
of the wheelchair.
The BWC medical service specialist is responsible for working with the MCO case manager
or delegated MCO staff and the DME supplier to insure the wheelchair under consideration
is the most appropriate to fit the injured worker’s specific medical needs. This includes
ordering the correct size wheelchair and necessary wheelchair modifications while
considering medical necessity and cost containment. The medical service specialist will work
with the MCO to be certain the injured worker can use this wheelchair in the home or facility
where the injured worker resides and that access to enter/exit is accounted for.
The BWC Catastrophic Nurses are responsible for working with the MCO case manager or
delegated MCO staff and the DME supplier to insure the wheelchair under consideration is
the most appropriate to fit the catastrophically injured worker’s specific medical needs. All
ramp and/or home modification requests are referred to the CAT nurse.
1. Power Operated Vehicles
For any power operated vehicle (POV) to be reimbursable by BWC/MCO, it must be
reasonable and necessary for the treatment of an allowed claim condition, illness or
injury. A power operated vehicle can be reimbursed when the following criteria are met:
The IW’s condition is such that without the use of the wheelchair, the IW
would not be able to move around in his/her residence; and
The IW is unable to operate a manual wheelchair; and
The injured worker is capable of safely operating the controls for the POV;
and
The IW can transfer safely in and out of the POV and has adequate trunk
stability to be able to safely ride in the POV; and
It is ordered by a physician who is one of the following specialties: Physical
Medicine, Orthopedic Surgery, Neurology, or Rheumatology. Exception:
When a specialist is not reasonably accessible (e.g. more than one day’s round
trip from the IW’s home or the IW’s condition precludes such travel), an order
from the IW’s physician of record may be acceptable.
A POV will usually be denied as not medically necessary when it is needed only for use
outside the home. If a POV is covered, an electric wheelchair provided at the same time
or subsequently will generally be denied as not medically necessary.
March 2016 Final
3-84
HPP-Medical and Return To Work Management
2. Specially sized wheelchairs
Payment may be made for a specially sized wheelchair even though it is more expensive
than a standard wheelchair. For example, a narrow wheelchair may be required because
of the narrow doorways of an injured worker’s home or because of the injured worker’s
slender build. Such difference in the size of the wheelchair from the standard model is not
considered a deluxe feature. A physician’s certification or prescription for a special size
is not required when it can be determined from documentation in the file that a specially
sized wheelchair (rather than a standard one) is needed.
U. WAGE LOSS COMPENSATION
1. Applicable Laws and Rules include:
R.C. 4123.56 Compensation for Wage Losses of Returning Employee
Rule 4125-1-01 Rule for Wage Loss Compensation
Wage loss is payable in claims with date of injury or diagnosis on or after August 22,
1986. Wage loss is available when an injured worker, as a direct result of the restrictions
caused by allowed conditions in the claim, suffers a reduction in earnings.
a. Working Wage Loss (WWL) may be paid when the injured worker returns to
employment other than his/her former position of employment.
b. Non-Working Wage Loss (NWWL) is payable when the injured worker is unable to
find employment within the restrictions which are a direct result of the allowed
conditions in the claim.
The injured worker applies for WL benefits by completing the Application for Wage
Loss Compensation (C-140) and submitting a Wage Loss Statement (C-141) which
documents job search activity. The C-140 application includes a medical report that
identifies any restrictions that are a result of the allowed conditions in the claim and
whether those restrictions are temporary or permanent. This information may be
documented by the attending physician on the back of the C-140 or any other format that
provides the necessary medical information.
The physician must identify:
any restrictions which are a direct result of the allowed conditions in the claim;
whether these restrictions are temporary or permanent;
any other restrictions;
physical capacities.
Subsequent medical reports are required every 90 days if the conditions are temporary
and every 180 days if they are permanent. The Claims Service Specialist (CSS) will
coordinate obtaining these subsequent medical reports with the MCO. The back of the C-
140 may also be used as the subsequent medical report or any other format which
provides the necessary medical information.
V.
TENS and NMES
The intent of this policy is to implement minimum standards for all vendors supplying
TENS/NMES units to Ohio’s injured workers and to establish standardized criteria for the
March 2016 Final
3-85
HPP-Medical and Return To Work Management
medical indications for the use of TENS/NMES. Refer to Chapter 3 of the BRM for
TENS/NMES directives to providers. Rule 4123-6-43 covers payment for transcutaneous
electrical nerve stimulators and neuromuscular electrical stimulators. This rule can be accessed
on BWC’s Web site at:
https://www.ohiobwc.com/basics/guidedtour/generalinfo/ORCandOAC.asp.
TENS: A device that utilizes electrical current delivered through electrodes placed on
the surface of the skin to decrease the patient’s perception of pain by inhibiting the
afferent pain nerve impulses and/or stimulating the release of endorphins.
NMES: A device which transmits an electrical stimulus to muscle groups and causes the
muscle to contract.
1. Required Criteria for TENS/NMES Units
These criteria apply to all vendors supplying TENS/NMES units to Ohio’s injured
workers.
a. BWC Minimum Technical and Educational Criteria
1) TENS and NMES units
Requirement: Device must produce constant current.
Rationale: Constant current maintains waveform as it is driven
through the skin. It allows the current to be delivered in a uniform
pattern, increasing the comfort for the patient. Breakdown of the
waveform may result in increased skin irritation and burning.
2) Electrodes
Requirements: a.) Impedance must be no greater than 75 ohms.
Ideal impedance is 30-60 ohms. b) Re-usable electrodes must be
able to be reused 10-15 times depending on skin condition.
Rationale: a.) Increased ohms cause the need for higher current
levels for maximum functioning; b.) Re-use of electrodes provides
for increased efficiency and decreased costs.
3) Instruction/Education
Requirement: TENS and NMES units must be personally
fitted and face to face instruction given by a direct
employee of the billing provider within 5 business days of
the request for the unit, payable 1 time per Injured Worker.
Rationale: Injured workers are more apt to use the TENS or
NMES unit correctly and to have fewer problems and increased
relief if given face to face instruction rather than if given
written or telephonic instruction.
4) Supplies
March 2016 Final
3-86
HPP-Medical and Return To Work Management
The MCO may authorize the use of a TENS unit and supplies
according to the current process (e.g. 6 month period); however,
the injured worker should not automatically receive supplies
throughout the authorization period without MCO verification that
supplies are needed. Also, the TENS provider must receive
authorization from the injured worker’s MCO prior to delivery of
supplies and/or equipment. The TENS provider will then deliver
the supplies and bill the MCO.
The rule requires the injured worker’s MCO to regularly determine
the specific TENS supplies needed by the injured worker
throughout the period of time authorized for TENS use. The MCO
shall implement a process to determine the specific type and
quantity of medically necessary supplies required by the injured
worker for use of the approved TENS unit. The MCO shall have
contact with the injured worker at regular intervals as often as
mutually established by the MCO and injured worker. However,
where TENS supplies are authorized for a period exceeding 45
days, MCO contacts to injured worker must occur at least one time
every 45 days.
The MCO shall maintain documentation of each contact and the
type and quantity of each supply requested by the injured worker.
The MCO shall verify and document the injured worker’s choice
of BWC-certified TENS supply provider. If the injured worker
requests assistance in selecting a TENS supply provider, the MCO
shall maintain documentation of the communication and the
selected vendor.
For each contact with the injured worker, the MCO shall ensure the
specific supplies requested are necessary for the effective use of
the authorized TENS unit. The MCO shall issue an authorization
communication (e.g. letter, email, phone call, etc.) to the TENS
supply provider selected by the injured worker. Where TENS
supplies are authorized for a period exceeding 45 days,
authorization communication shall be issued to the provider at
least one time every 45 days. The authorization communication
shall include the type and quantity of supplies approved and the
beginning and end dates of the approval. The MCO shall maintain
a copy or documentation of each authorization communication.
The TENS supply provider shall only distribute and bill for
authorized supplies. The MCO shall reimburse the TENS supply
provider only for distributed and authorized supplies.
b. BWC Medical Necessity Criteria
March 2016 Final
3-87
HPP-Medical and Return To Work Management
1) TENS for Chronic Pain
Prior authorization by BWC, MCO, or self-insured employer or
their agents is required for TENS rental or purchase. Payment for a
transcutaneous electrical nerve stimulator (TENS) is covered for
the treatment of patients with chronic, intractable pain who meet
the following criteria:
Documentation from the physician of chronic pain that has
been present for three months;
Documentation from the physician of the location of pain,
duration of time patient has had pain, and the presumed cause
of the pain;
Documentation from the physician of other modalities that
have been tried and failed;
Trial rental period of only one month to determine the
effectiveness of TENS unit.
For purchase of a TENS unit for chronic pain, the following
documentation must be present in the physician’s records at the
conclusion of the 30 day trial:
Frequency and duration of use of TENS;
Results of TENS units modulating pain
2) TENS for Acute Post-operative Pain
TENS rental is generally limited to 30 days beyond surgery. For
reimbursement beyond 30 days, the physician must provide
medical documentation for justification.
3) Neuromuscular Stimulators (NMES)
A NMES device provides an electrical stimulus directly to the
muscle or motor nerve of the muscle, causing the muscle to
contract. The goal is to stimulate denervated muscle to prevent
atrophy or degeneration and to strengthen/train healthy muscles
that are at risk of atrophy from immobilization or disuse due to
injury. Prior authorization by BWC, MCO, or self-insured
employer is required prior to NMES rental or purchase.
The MCO Medical Director or an MCO physician consultant is
required to review each request for home rental or purchase of
NMES based on medical necessity and BWC NMES criteria.
Reimbursement of NMES devices for home use for the
treatment/prevention of muscle atrophy requires the following
conditions be met:
March 2016 Final
3-88
HPP-Medical and Return To Work Management
The patient has suffered partial or complete loss of function in
one or more muscles because of an injury to a peripheral nerve
or nerve root, and
Denervation is substantiated by EMG confirming the nerve
injury. The EMG must demonstrate positive waves and/or
fibrillation in the affected muscles.
BWC/MCOs will reimburse NMES and also Functional Electrical
Stimulation (FES) to enhance walking of injured workers with
spinal cord injuries (SCI) who meet all the following criteria:
Diagnosis of paraplegia of both lower limbs (ICD-9 344.1);
Willingness to use the device on a long-term basis;
High motivation, commitment and cognitive ability to use the
device for walking;
Completion of a physical therapy training program of a
minimum of 30 sessions with the NMES unit over a 3 month
period;
Intact lower motor units (L1 and below) both muscle and
peripheral nerve;
Demonstration of brisk muscle contraction to NMES and
sensory perception of electrical stimulations sufficient for
muscle contraction;
Muscle and joint stability for weight bearing at upper and
lower extremities with demonstration of balance and control to
maintain an upright support posture independently;
Ability to transfer independently and demonstration of standing
independently for at least 3 minutes;
Demonstration of hand and finger function to manipulate
controls;
Minimum of 6-month post recovery spinal cord injury and
restorative surgery; and
Absence of hip and knee degenerative disease and no history of
long bone fracture secondary to osteoporosis
The appropriate Level I CPT® code to be billed to MCO/BWC for the required
physical therapy with the NMES unit is 97116-gait training.
NMES/FES for walking is contraindicated for SCI injured workers with any of
the following:
Cardiac pacemakers or cardiac defibrillators;
Severe scoliosis or severe osteoporosis;
Irreversible contracture;
Autonomic dysreflexia: or
Skin disease or cancer at the area of stimulation
March 2016 Final
3-89
HPP-Medical and Return To Work Management
3. Coding of TENS/NMES
TENS/NMES coding information can be found in Chapter 8 of this manual.
W. UTILIZATION OF PRESCRIPTION MEDICATION FOR INTRACTABLE PAIN
The purpose of this policy is to provide to Ohio physicians treating Ohio Injured
Workers, BWC personnel, MCOs, BWC’s Disability Evaluators Panel (DEP) drug file
reviewers and independent medical examiners, and injured workers, their employers and
their respective representatives:
the rules for prescribing narcotic medication in the treatment of intractable pain
according to The State Medical Board of Ohio Administrative Code Chapter
4731-21;
the expectations of the type of medical evaluation and documentation necessary
to support and facilitate using prescription medication for the treatment of
intractable pain in injured workers in the Ohio Workers’ Compensation System;
the key elements that may be necessary in the claim file to assist BWC personnel
and physicians performing reviews to determine whether the use of prescription
medications in the claim meet statutory requirements;
the rationale and process for BWC claims management personnel to use to obtain
when necessary the information needed to support or deny the use of prescription
medications for the treatment of intractable pain and to facilitate the use of
prescription medication when necessary and appropriate for treatment, obtain
necessary information when insufficient information is lacking in the claim file,
and to deter use of prescription medications when there is lack of proof of medical
necessity and appropriateness.
Issues important to Ohio Workers’ Compensation include:
Lack of use of prescription medication, particularly opioids, by physicians who
are treating chronic intractable (non-malignant, benign) pain in some of Ohio’s
injured workers has been identified.
Variance in interpretation and application of The State Medical Board of Ohio
Administrative Code Chapter 4731-21 by physicians performing claims
management services for BWC and BWC personnel which ultimately impacts
authorization/denial decisions regarding use of prescription medications.
Lack of strict claims management guidelines regarding criteria to support use or
to deny authorization of prescription medication in the treatment of intractable
pain.
Concern for overuse and excessive prescribing of prescription pain medication for
some injured workers has been identified by BWC personnel, pharmacists,
physicians, employers, and other parties as it impacts well being of the injured
worker, potential for inappropriate use and distribution, social implications, and
financial costs to the system.
March 2016 Final
3-90
HPP-Medical and Return To Work Management
Statutes regarding the use of prescription medication for the treatment of intractable pain
have changed considerably in the past ten years both nationally and in Ohio.
In October 1997 the Ohio General Assembly passed Sub. H.B. 187 which required the
State Medical Board of Ohio to establish standards and procedures for physicians
regarding the diagnosis and treatment of intractable pain. The State Medical Board of
Ohio’s pain management rules became effective in November 11, 1998. These rules are
contained in Chapter 4731-21 of the Ohio Administrative Code.
The State Medical Board of Ohio Rule 4731-21-02 pertains to “utilizing prescription
drugs for the treatment of intractable pain”.
Since these rules provide the legal authorization and criteria for use of the prescription
drugs for treatment of intractable pain, they must also be followed by physicians
providing opinions for authorization of payment of such medications in claims in either
file reviews or independent medical evaluations for BWC.
According to Rule 4731-21-01 “Definitions” of The State Medical Board of Ohio Rules:
“Intractable pain” means a state of pain that is determined, after reasonable
medical efforts have been made to relieve the pain or cure its cause, to have a
cause for which no treatment or cure is possible or for which none has been
found. “Intractable pain” does not include pain experienced by a patient with a
terminal condition. “Intractable pain” does not include the treatment of pain
associated with a progressive disease that, in the normal course of progression,
may reasonably be expected to result in a terminal condition.”
To comply with this definition, reasonable medical efforts should have been made to
relieve the pain or cure its cause and that the pain has a cause for which no treatment or
cure is possible or at least none has been found. Therefore, intractable pain would be
considered only after reasonable medical efforts have been made to diagnose the cause of
the pain and adequate and appropriate medical treatment has been provided to treat the
cause. Many medical conditions seen in workers’ compensation patients could be
considered “intractable pain” such as, but not limited to, complex regional pain syndrome
I or the chronic pain frequently associated with lumbar procedures such as
postlaminectomy syndrome. Due to wide variance of symptoms and treatment over the
clinical course of a condition, not all patients with these allowed conditions in the claim
meet the definition of “intractable pain”.
Rule 4731-21-02 provides the guidelines or expectations of physicians managing
intractable pain with prescription drugs. Paragraph (A) requires:
an initial evaluation that includes complete medical, pain, alcohol and substance
abuse histories;
assessment of the impact of pain on physical and psychological functions;
review of previous diagnostic studies and previously utilized therapies;
an assessment of coexisting illnesses, diseases or conditions; and
an appropriate physical examination
March 2016 Final
3-91
HPP-Medical and Return To Work Management
The medical diagnosis must be documented that indicates the intractable pain along with
the signs, symptoms, and causes of the pain. An individual treatment plan is required to
be documented specifying the medical justification of the treatment of intractable pain
with prescription drugs on a protracted basis, the intended role of prescription drug
therapy within the overall plan, and other medically reasonable treatment for relief of the
intractable pain that have been offered or attempted without adequate or reasonable
success. The response to the treatment must be documented along with modifications to
the treatment plan. Section (4)(a) of Paragraph (A) states that the diagnosis of intractable
pain can be made only after having the patient “evaluated by one or more other
practitioners who specialize in the treatment of the anatomic area, system, or organ of the
body perceived as the source of the pain.” The prescribing physician is to maintain a
copy of the report of the evaluation. The evaluation is not required if the patient has been
evaluated and treated within a “reasonable period of time” by one or more other
practitioners who specialize in the anatomic area, system, or organ perceived to be the
source of pain and the treating practitioner is satisfied that he or she can rely on the
evaluation to meet the requirements of the Rule. The practitioner is required to obtain
and maintain a copy of the records or report on which he/she relied to meet the
requirements of an evaluation by a specialist. Last, Paragraph (A) requires an informed
consent be present retained in the medical record informing the patient of the risk and
benefits of receiving prescription drug therapy and of available treatment alternatives.
Paragraph (B)(1) requires that the practitioner see the patients at “appropriate periodic
intervals to assess the efficacy of treatment, assure that prescription drug therapy remains
indicated, evaluate the patient’s progress toward treatment objectives, and note any
adverse drug effects”. Paragraph (B)(2) also requires ongoing assessment of functional
status, the pain intensity, and its interference with activities of daily living, quality of life,
and social activities. If there is evidence or behavioral indications of drug abuse, the
practitioner may obtain a drug screen. According to Paragraph (B)(3), “It is within the
practitioner’s discretion to decide the nature of the screen and which type of drug to be
screened.” Results of the screening should be documented in the patient’s medical
record.
Paragraph (C) requires immediate consultation with an addiction medicine or substance
abuse specialists if the practitioner believes or has reason to believe the patient is
suffering from addiction or drug abuse.
Based on the above statutory and regulatory documents described, the use of prescription
medication for the treatment of chronic intractable pain is acceptable in Ohio on a
protracted basis or in amounts or combinations that may not be appropriate when treating
other medical conditions so long as the treating physician complies with The State
Medical Board of Ohio Rules. Based on Ohio Supreme Court decision, it is also required
that the authorization of payment for services be reasonably related, reasonably necessary
for treatment of the allowed injury, and that the costs are medically reasonable. To
support the reasonably necessary requirement, practitioners can be expected to provide
medical documentation to support intractable pain and the need to use prescription
medication for the treatment of intractable pain when present. Medical records should
March 2016 Final
3-92
HPP-Medical and Return To Work Management
also reflect or explain how the intractable pain and its treatment are reasonably related to
the allowed injury in the claim.
Key elements expected to be present in the medical file include but are not limited to:
Reasonable medical efforts (diagnostic study, consultation, and treatment) have been
performed to relieve the pain, identify the source, and cure its cause.
No other treatment or cure is possible or none has been found.
The initial evaluation by the treating practitioner meets the requirements of Rule
4731-21-02. (Note: This is not intended to be point-by-point specific, but that the
medical records do document sufficient history, pain description, relatedness of the
pain to the allowed condition in the claim, alcohol and substance abuse history,
assessment of physical and psychological function, diagnostic studies and treatment
performed, and an appropriate physical examination.)
Appropriate consultation has been performed either by consultation or previous
treating specialist as defined by Rule 4731-21-02 within a reasonable period of time,
not to exceed six months from the beginning of such treatment.
Medical records provide appropriate documentation to support continued use of the
medication and consistent with Rule 4731-21-02. This includes adequate monitoring
of the patient on a periodic basis to determine the continued need for prescription
medication.
BWC expects as part of the treatment guidelines that MCOs will provide
authorization for the following services:
Periodic office visitation to monitor treatment compliance, results, physiologic
and psychological functioning.
In certain claims, it may be necessary to obtain periodic urine drug testing to
determine drug abuse based on evidence or behavioral indications of addiction as
described in Rule 4731-21-02 Paragraph (B)(3). This most likely would be no
more frequent than quarterly.
Referral to an addiction medicine specialist or substance abuse specialist for
consultation and evaluation (most likely each case would need to be evaluated for
treatment) if the practitioner believes or has reason to believe the patient is
suffering from addiction or drug abuse as described in Rule 4731-21-02
Paragraph (C).
Since there is no specific allowance of “chronic intractable pain”, BWC personnel involved
with claim management determinations and physicians performing file reviews or
Independent Medical Evaluations for BWC should consider the following criteria in regard to
the use of prescription medication to treat chronic intractable pain:
that the medical records meet the definition of “intractable pain” as defined by the
State Medical Board of Ohio particularly in relation to reasonable medical efforts
to determine the source and treat the cause of the pain have been documented;
that a second opinion from an appropriate specialist has been performed;
that the medical records provide a reasonable relationship of the symptoms to the
allowed conditions in the claim; and
March 2016 Final
3-93
HPP-Medical and Return To Work Management
That the use of such medication is reasonably necessary to help manage the
symptoms experienced by the injured worker.
Should the above criteria be met, even though there is no allowance for chronic intractable
pain on the claim, then the BWC may authorize reimbursement for prescription medication
used in the treatment of chronic intractable pain.
In claim management, many, if not most, cases would be a continuation of or “flow-through”
of treatment of a condition that is presumed to be the cause of pain and for which the injured
worker has received appropriate diagnostic testing, treatment, and evaluations. Many
individuals considered to have “chronic intractable pain” will have obvious limitation of
activity and difficulty controlling pain following treatment of the allowed condition. Other
claims will be more difficult to assess. There may be issues of (1) need for additional
diagnostic testing; (2) need for specialist consultation, (3) uncertainty of diagnosis or
relationship to the allowed conditions in the claim, or (4) medical records do not support the
apparent need for continued treatment. It can be anticipated that some employers may also
request an independent medical evaluation of injured workers for the purpose of justification
of ongoing treatment in many of these cases.
In questionable cases or those requested by the employer, independent medical evaluation
performed by a specialist appropriate for the body part or system considered to be the source
of “chronic intractable pain” would be appropriate to determine issues such as:
Recommendations for any additional testing to identify source of pain
Other treatment that should be considered
Specialty consultation that may be beneficial
Provide description of the pain and impact on daily living, functioning, etc.
Clarify relationship of symptoms (pain) to the allowed conditions or work injury
Determine the apparent need for continued treatment
Other issues as deemed necessary.
In most workers’ compensation cases, the presumed source of pain will be limited to the
musculoskeletal system. Appropriate independent medical evaluating specialists would, in
general, be limited to orthopedists, hand surgeons for the upper extremity, neurosurgeons,
physical medicine and rehabilitation specialists, and possibly occupational medicine and pain
specialists depending on the nature of the issue.
Treating physicians who consistently fail to provide appropriate medical records or follow
The State Medical Board of Ohio rules should be referred to DEP Central or Provider
Relations along with the specific claim numbers of injured workers being treated.
Note: For the complete BWC position paper including references, see the BWC website
www.ohiobwc.com under Medical Providers/ Services/Medical Position Papers.
X. NEW MEDICAL TECHNOLOGIES and PROCEDURES POLICY
BWC has developed a process for evaluating requests for the review of new medical
technology or procedures for coverage for the treatment of workers’ compensation
March 2016 Final
3-94
HPP-Medical and Return To Work Management
conditions. This process does not apply to new products or methods for the treatment of
conditions when a similar method or product for treatment is currently available. The
review will include the following steps.
BWC or MCO identifies the technology or procedure of concern in regard to
authorization.
BWC will gather information regarding the procedure, treatment or technology.
Sources may include manufacturer’s literature, submitted documentation from the
provider requesting authorization of the service, and information from the MCO
The BWC Medical Services Division will review the documentation and will research
other sources such as MEDLINE or other databases; The Cochrane Library,
established treatment guidelines and specialty organizations, such as the Centers for
Disease Control.
The BWC Medical Services Division will review the information and create a draft
position document focusing on indications, outcomes, adverse effects, safety and cost.
The draft position will be presented to the appropriate medical committee (i.e., MCO
Medical Directors Committee or BWC Health Care Quality Assurance Advisory
Committee).
The final position paper will be posted on BWC’s website.
Y. VERTEBRAL AXIAL DECOMPRESSION
The purpose of this policy is address the coverage and reimbursement of vertebral axial
decompression therapy by BWC. This modality has also been called lumbar
decompression or spinal decompression by some providers.
Decompression therapy is intended to create negative pressure on the spine, so that the
vertebrae are elongated, pressure is taken off the roots of the nerve, and a disk herniation
may be pulled back into place. Decompression therapy is generally performed using a
specially designed computerized mechanical table that separates in the middle. Although
the American Medical Association (AMA), FDA and Centers for Medicare and Medicaid
Services (CMS) all consider decompression therapy to be a form of traction, the
manufacturers of these devices consider them different from traction devices. (Sherry,
2001) (Gose, 1998) (Colorado, 2001) (Deen, 2003) (Humana, 2004)
While there are some limited promising studies, the evidence in support of vertebral axial
decompression is insufficient to support its use in low back injuries. This policy includes,
but is not limited to, mechanical traction provided by the following powered traction
devices:
VAX-D
DRS System
Spina System
DRX 2000, DRX 3000m, DRX 5000
Lordex Traction Unit
Per the CPT© Assistant November 2004/ Volume 14, Issue 11:
“CPT© code 97012, application of modality to one or more areas; traction, mechanical, is
intended to identify a procedure that creates a force to allow for separation between joint
March 2016 Final
3-95
HPP-Medical and Return To Work Management
surfaces. The degree of traction is controlled through the amount of force allowed,
duration (time), and angle of pull using mechanical means. Therefore, code 97012 would
be the most appropriate code to report for various types of mechanical traction devices
including vertebral axial decompression.”
BWC requires vertebral axial decompression (spinal decompression, decompression
therapy) to be billed with the CPT code for mechanical traction and will pay one unit of
service per visit, regardless of the length of time the traction is applied. The decision
regarding authorization of decompression therapy will remain with the individual MCO.
Z. INTERFERENTIAL THERAPY
Interferential or sympathetic therapy is a type of electrical stimulation of the peripheral
nerves that is designed to alleviate pain by inducing a systemic effect on sympathetically
induced pain. Interferential stimulation is customarily provided on an out-patient basis for
about 20 treatment sessions followed by purchase of a home unit for the patient to self-
administer the interferential therapy for an unlimited period of time. Following a review
of the literature and coverage policies of other third party insurers, BWC has determined
that insufficient evidence exists to determine the effectiveness of “self-administered”
sympathetic therapy/ interferential therapy. BWC and the MCO will not reimburse the
rental or purchase of a therapy unit used to self-administer interferential therapy.
AA. DURABLE MEDICAL EQUIPMENT
Durable medical equipment is defined as equipment which:
Can withstand repeated use; i.e., could normally be rented and used by successive
patients;
Is primarily and customarily used to serve a medical purpose;
Generally is not useful to a person in the absence of illness or injury; and
Is appropriate for use in a patient’s home.
The following reusable items are examples of DME:
hospital beds
mattresses for hospital beds
walkers
wheelchairs
breathing machines
crutches
bedside commodes
seat lift mechanism
BWC considers a seat lift mechanism to be medically necessary for an injured worker
who requires a mobility aid to stand from a seated position due to physical limitations
that are reasonably related to the industrial injury (disease). BWC reimburses the seat-lift
mechanism, (E0627, E0628 or E0629) when the MCO determines it is medically
March 2016 Final
3-96
HPP-Medical and Return To Work Management
necessary and appropriate to the industrial injury. BWC does not reimburse the chair
(furniture).
Equipment which is primarily and customarily used for a non-medical purpose does not
qualify as durable medical equipment and will not be reimbursed by BWC. Some
examples include:
Home furniture including, but not limited to: reclining chairs, non-hospital beds,
water beds, lounge beds (such as Adjust-A-Sleep Adjustable Bed, Craftmatic
Adjustable Bed, Electropedic Adjustable Bed, Simmons Beautyrest Adjustable
Bed)
Home exercise equipment, such as treadmills and exercise bikes, are not
considered to be durable medical equipment and shall not be authorized or paid by
for BWC/MCO, except when the criteria has been met for an IW who is
participating in a vocational rehab program.
Home whirlpools including built-in whirlpools and pumps, portable hydrotherapy
pools, Jacuzzi tubs, portable saunas and spas, and TheraSaunas as considered to be
not medically necessary. This includes non-portable hot tubs/whirlpools billed as
E1310. When a request is received for a built in hot tub/whirlpool, the MCO must
call the provider to advise that BWC covers the “over tub whirlpool” (E1300) if
determined to be medically necessary and appropriate to the industrial injury
BWC/MCO must determine that DME is necessary and reasonable. The Miller Case
addresses these criteria.
The requested medical services are reasonably related to the industrial injury;
The requested services are reasonably necessary and appropriate for treatment of
the industrial injury;
The costs of the services are medically reasonable.
Specific features of durable medical equipment that have been determined by the
MCO/BWC to be features that are not medically necessary or do not have a reasonable
relationship to the allowed conditions in the claim will not be reimbursed by
BWC/MCO. Examples include:
BWC will not reimburse a heavy duty/bariatric piece of equipment unless the IW
meets the weight requirements.
BWC limits reimbursement of a hospital bed mattress to a single size mattress, or
the size that is required by the injured worker determined by the IW’s weight,
height, and medical condition. BWC does not reimburse for a double, queen, or
king size mattress to accommodate two people.
BWC will not reimburse a mattress for a non-hospital bed.
BWC will not reimburse a “deluxe” model if the standard model provides the
features that are medically necessary for the IW.
BWC considers Durable Medical Equipment (DME) to be purchased when rental has
reached the BWC purchase fee. BWC does not accept a provider’s percentage reduction
from the rental fees already paid which result in BWC payment of additional monies for
the purchase of the equipment beyond the BWC purchase fee.
March 2016 Final
3-97
HPP-Medical and Return To Work Management
Note: Equipment used as part of a surgical procedure (i.e. implantable devices, surgical
hardware) must be billed by the facility where the procedure takes place (i.e. ASC,
hospital) or by the physician if done in the physician’s office. BWC or the MCO will not
reimburse the manufacturer or supplier of the equipment when the equipment is used as
part of a surgical procedure. Examples of equipment used as part of a surgical procedure
include, but are not limited to: implantable neurostimulator pulse generator, implantable
neurostimulator electrodes, implant hardware, implantable infusion pump and
implantable intraspinal catheter.
BWC follows HCPCS Level II to report Durable Medical Equipment E0100-E9999.
BB. IN-HOME PHYSICIAN VISITS and PHYSICIAN MOBILE OFFICE VISITS
In-home physician visits (services) shall require prior authorization after the first visit;
however, the first and following visits must meet the Miller Criteria.
In-home physician visits may be appropriate and should be approved only when the
injured worker is homebound and is unable to access outpatient facilities because of
sensory impairment, immobility or transportation problems due to physical limitations.
Examples might include injured workers with catastrophic conditions or those requiring
end of life care. Lack of transportation does not constitute a medical reason for approving
in-home physician visits.
Prior approval shall be granted by the MCO according to the plan of care and health care
needs for the specific injured worker. Reimbursement to physicians will be made using
Current Procedural Terminology (CPT) codes for Home Visits and the level of code must
reflect current coding documentation standards for the CPT level of service. Services
rendered must only be those services indicated by the circumstances that are medically
necessary.
Mobile van or trailer physician visits or services, when the injured worker walks to the
van or trailer, will be reimbursed as a normal office visit according to CPT levels of
service and will not be eligible for billing as a home visit. Mobile offices must bill
using the appropriate office or other outpatient services CPT evaluation and management
code, with place of service 15 (mobile unit) and will be reimbursed at BWC’s Non-
Facility Fee.
If a physician chooses to make a home visit to an injured worker who does not meet the
criteria for a home visit or when determined by the MCO/BWC not to be medically
necessary, the physician may not bill the services as a home visit. If the services are
considered medically appropriate and necessary if delivered in a customary office setting,
the physician must bill using the appropriate office or other outpatient services CPT
evaluation and management code, with place of service 12 (home) and will be reimbursed
at BWC’s Facility Fee.
CC. OFFICE BASED SURGERY
March 2016 Final
3-98
HPP-Medical and Return To Work Management
BWC currently follows state licensure requirements for enrollment of providers, as outlined
in BWC Rules. The following providers that would perform surgery in their offices are
Doctors of Medicine (M.D.), Doctors of Osteopathic Medicine (D.O.) and Podiatrists
(D.P.M.) and are licensed in Ohio by the Ohio State Medical Board. Physicians who perform
surgery in their office must follow the State Medical Board rules (Ohio Administrative Code
Chapter 4731-25 Office Based Surgery). BWC will not enroll physicians who perform
surgery in their office any differently than is the current practice.
The Ohio State Medical Board is obligated to investigate complaints or allegations of
possible violations that are received by the board and has the authority, by law, to act upon
the allegations; therefore BWC/MCOs who have knowledge of a physician who may not be
in compliance with his/her licensure requirements in regard to office based surgery or other
issues, are encouraged to report this information to the Ohio State Medical Board. Providers
of office surgery are reimbursed according to BWC’s provider fee schedule as place of
service code 11 (office) and are reimbursed at the Non-Facility Fee.
