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OhioBWC - Basics: (Policy library) - File

Policy and Procedure Name:

Cause of Loss Codes (Also known as “E-codes”)

Policy #:

CP-05-03

Code/Rule Reference:

None

Effective Date:

11/14/16

Approved:

Rick Percy, Chief of Operational Policy, Analytics & Compliance (Signature on File)

Origin:

Claims Policy

Supersedes:

Policy and procedure #CP-05-03, effective 07/31/15

History:

New: 07/31/15

 

 

I. POLICY PURPOSE

 

The purpose of this policy is to ensure BWC staff properly assigns a code in the claims management system which identifies the cause of an injury or occupational disease (OD) incurred by an injured worker (IW).

 

II. APPLICABILITY

 

This policy applies to BWC Field Operations staff.

 

III. DEFINITIONS

 

Cause of loss codes: Specific codes available in the BWC claims management system, (originating from the International Classification of Disease (ICD) code sets), which are assigned to a claim and used to capture how an injury or occupational disease occurred.

 

IV. POLICY

 

It is the policy of BWC to identify a cause of loss code in a claim for the purpose of BWC tracking and reporting.

 

V. Procedure

 

A.    For every new claim, field staff shall select and enter into the claims management system a cause of loss code, which reflects the illness or injury that caused the initial diagnosis or condition.

 

B.    If a managed care organization (MCO) or provider has identified a cause of loss code, field staff shall verify the code for appropriateness based on the accident description.

1.    If the cause of loss category and cause of loss are not populated and are provided by the MCO via the interface, the data will be systematically updated. If a revised entry is received from the MCO or provider and is appropriate, field staff shall enter it into the claims management system.

2.    If the cause of loss code is not appropriate, field staff shall determine the appropriate code and enter it into the claims management system.

 

C.   In existing claims in which a cause of loss code has not been entered, field staff shall determine and enter the code when a subsequent action is taken on the claim.

 

D.   If multiple events occurred simultaneously resulting in a claim, field staff shall code the event that caused the most serious diagnosis.

 

E.    Field staff shall not enter cause of loss codes for any intervening causes of an additional condition subsequent to the initial claim allowance.

 

F.    If field staff is unsure of the appropriate cause of loss code, the claim shall be staffed with the medical service specialist (MSS) or supervisor.

 

G.   If staffing does not result in a decision on the appropriate cause of loss code, field staff shall email the claim information to the “BWC Causation Questions” mailbox for direction.

 

 


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