Percy, Chief of Operational Policy, Analytics and Compliance (signature on
Injury Management policies, directives or memos regarding ICD Modification
that predate the effective date of this policy.
01/07/2016; New 08/11/2015
The purpose of this policy is to ensure that claims
are assigned the correct numeric ICD code(s) and/or injury description
(narrative condition) based on the supporting medical evidence, and that the
code is accurately reflected in the claims management system.
policy applies to BWC Field Operations staff, Medical Services staff and
managed care organizations (MCOs).
Encoder: Web-based software that converts a narrative medical
description into a numeric ICD description, or vice versa.
Classification of Diseases. ICDs are standardized
classifications of diseases, injuries, and causes of death, by etiology and
anatomic localization and codified into a multi-digit number, which allows
clinicians, statisticians, health planners and others to speak a common
language, both in the US and internationally.
A. It is the policy of BWC
to assign the most accurate and specific ICD code and narrative description for
each condition allowed and/or disallowed in a claim to ensure that the correct
allowed conditions are captured in the claims management system and that all
future correspondence, including requests for independent medical exams (IMEs),
will contain the correct allowed conditions.
B. It is the policy of BWC
to update or modify condition(s) that have been coded incorrectly when:
1. The description does
not exactly match the condition allowed by order in the claim; or
2. ICD codes and
descriptions in the claims management system encoder are not an exact match
with the conditions that need to be allowed or which have been allowed in the
3. ICD codes have expired
or been revised due to changes in the diagnosis code set.
C. It is the policy of BWC
that the narrative condition/description requested on a First Report of Injury
(FROI), Request for Authorization and/or Recommendation of Additional
Conditions (C-9), a Motion (C-86), or allowed by BWC or Industrial Commission
(IC) Order takes precedence over the actual numeric International
Classification of Diseases (ICD) code(s).
D. It is the policy of BWC
that a BWC or IC Order is required for conditions to be recognized as allowed
E. BWC shall provide
notice of correction, modification, or deletion to the parties in the claim via
BWC order or letter unless:
1. The ICD code is being
changed but the narrative description remains the same; or
2. The narrative
description is being modified to reflect an earlier BWC or IC order.
BWC staff may refer to
the corresponding procedure for this policy entitled “Procedure for ICD
Modification” for further guidance.
FOR ICD MODIFICATION
Percy, Chief of Operational Policy, Analytics and Compliance
Injury Management procedures, directives and memos regarding ICD Modification
that predate the effective date of this procedure.
01/07/2016; New 08/11/2015
I. BWC staff shall refer to the
Standard Claim File Documentation policy and procedure for claim-note
requirements and shall follow any other specific instructions included in this
General Guidelines for ICD Modifications
A. Field staff shall obtain allowed
conditions from the order which originally granted the condition(s). Field
staff shall not obtain the conditions from the “previously allowed” section of
an Industrial Commission (IC) order.
B. Field staff shall not delete or modify
narrative descriptions for conditions allowed outside BWC’s jurisdiction and
shall staff all requests for modifications to conditions allowed by the IC with
a BWC Field Attorney.
C. Field staff shall update the claims
management system with all conditions allowed by BWC or IC Order.
D. Field staff shall use the encoder, the
ICD coding manual, Medical Evidence for Diagnosis Determination (MEDD) policy
and procedure and/or the correct coding tool found on Claims On-Line Resources
1. Ensure conditions are assigned the
correct ICD code;
2. Ensure any requested condition has not
already been addressed by another ICD code; and
3. Map an ICD-9 to an ICD-10.
E. Field staff shall:
1. Ensure all ICD-9 codes in claims with a
Health Insurance Claim Number (HICN) have been converted to ICD-10 codes.
2. Convert all ICD-9 codes to ICD-10 codes
when in a claim for any reason.
3. Convert all ICD-9 to ICD-10 codes when
Alternative Dispute Resolution (ADR) issues are being processed.
F. Field staff shall identify the correct
site and location of all conditions when required.
G. Field staff shall utilize the site
drop-down box on the diagnosis/injury status maintenance window to clarify a
condition, when necessary. For example, a C-86 Motion is submitted requesting
the condition Disc Displacement. Field staff shall choose the correct disc
level(s) from the site drop-down box.
H. Field staff shall not request a
modification on a condition when the condition is complete as coded. For
example, a First Report of Injury (FROI) is submitted with the condition
“lumbar strain” and the accompanying ICD code is S39.012A. The code
S39.012A comes up “Strain of Muscle, Fascia and Tendon Thoracic thru Sacral
Reg”; this code/narrative includes the “lumbar” site; therefore field staff
shall not send the condition for modification.
Field staff shall seek
agreement from all parties in the claim when a need for an ICD code
modification is identified on a condition previously allowed by BWC order.
1. When all parties are in agreement:
a. Field staff shall vacate the original
BWC order and issue a new corrected order with the corrected
narrative/condition when modifying or adding a new condition;
b. Field staff may staff modifications that
require vacating an order and issuing a new order with a supervisor or BWC
2. When all parties are not in agreement,
or where the condition was previously allowed by IC order, field staff shall
staff with a BWC attorney to consider referral to the IC for continuing
J. Field staff shall request a description
be modified prior to issuing a BWC order or referring to the Industrial Commission
(IC) via the “Notice of Referral” (NOR) if a description cannot be accurately
K. Field staff may correct or modify ICD
codes without notice to the parties in the claim when the narrative description
does not change.
L. Field staff shall complete the
electronic referral form located on the “BWC ICD Modification Request”
SharePoint site when modifications, clarification or ICD coding assistance is
needed, following the requirements below.
M. General guidelines for requesting ICD
modifications from the “BWC ICD Modification Request” SharePoint site:
1. Staff shall follow these procedures for
all claims requiring modification, including Self Insured (SI) claims.
2. Field staff shall send requests for
clarifications/modifications to the “BWC ICD Modification Request” SharePoint
a. Whenever staff cannot, using the
available tools, assign a code with the correct description for an allowed
condition in the claim,
b. As a resource for coding assistance and
c. For assistance in validating a code the
staff selected or requesting the appropriate code that best reflects the
3. Field staff shall review all medical
documentation in the claim prior to sending the request to the ICD modification
SharePoint site to ensure the requested modifications are appropriate. When
appropriate, the requests for clarification/modification shall be sent through
the SharePoint site:
BWC order is issued;
NOR to the IC is sent; or,
allowance made by IC Order is unclear.
4. Field staff shall:
following information available in order to complete the electronic referral
form on the “BWC ICD Modification Request” SharePoint site:
i. IW’s name and claim number;
The reason for the request,
which will systematically assign the priority:
a) Additional Allowance (C86);
b) Additional Allowance (C9);
e) IC Order;
h) New Claim (0-7 day);
i) New Claim (28 day);
New Claim (Surgery
k) New Claim (CAT Claim);
m) Sprain/Strain; or
n) Surgery pending (after claim
iii. Whether the claim is Self Insured (SI),
and if the condition/ICD code was allowed by the SI employer, the date of the
correspondence and/or claims management note documenting this information;
iv. Whether the request is for a BWC order
or IC order, and if it is for an IC order, the date of the order and the exact
description of the condition as stated in the IC Order;
v. Dates of medical documentation,
applications or orders (e.g., MRI report dated, C-86 Motion (C-86), IC Order,
etc.) that impact or support the request;
vi. If supporting medical documentation was
not provided, the date and type of documentation that was requested;
request that fails to provide the required elements listed above shall be
returned specifying the missing elements that need to be included.
5. Field staff shall receive a confirmation
via the SharePoint site “BWC ICD Modification Request” SharePoint site
coordinator. The returned SharePoint electronic referral form shall contain the
correct ICD code to use or indicate that the ICD description has been corrected
in the claims management system.
6. The BWC ICD Modification Request
SharePoint site coordinator shall return urgent or rush requests made by field
staff the same day when requests are made prior to 1 p.m. Requests made by
field staff after 1 p.m. will be returned the next business day.
7. Field staff shall enter notes in the
claims management system explaining the need for any diagnosis modification and
shall identify the documentation used to support the decision.
8. If the field and the “BWC ICD
Modification Request” SharePoint site coordinator disagree with the recommended
modifications, the issue shall be staffed with the BWC Nursing Director or
designee for determination.
9. Field staff shall send any questions
regarding manual conversions (mapping ICD-9 to ICD-10) for existing claims to
the ICD-9 to ICD-10 Conversion Referrals SharePoint site.
10. Field staff shall use the BWC ICD-10
Project Inquiry mailbox to:
regarding system-mapped ICD codes;
specific training topics (with ‘training topic’ or ‘training request’ in the
subject line); and
general ICD-10 project-related questions.
Correcting/Modifying ICD Code/Description Before Issuing a BWC Decision
A. Field staff shall ensure ICD codes and
narrative descriptions correspond and are valid workers’ compensation
conditions on all requests/recommendations for allowances [i.e., First Report
of Injury (FROI), C-86 and C-9 Request for Medical Service Reimbursement or
Recommendation for Additional Conditions for Industrial Injury or Occupation
Disease (C-9)], as well as ensure conditions identified on the documentation,
are correct and valid workers’ compensation conditions.
B. Reviewing and Investigating the Request
1. Field staff shall issue the BWC order or
NOR to the IC, as appropriate, when the description provided can be accurately
coded or the ICD and supporting documentation match exactly.
2. Field staff shall review the FROI and/or
medical documentation to obtain the correct location and/or site when that
information is not identified on the request. For example: the FROI gives the
condition “crushing injury of hand”; field staff shall review the available
documentation to determine if the injury was to the right or left hand.
3. Field staff shall not review medical
documentation and diagnose a condition; all conditions other than minor
injuries must be diagnosed by a physician. For example: If an MRI report is
submitted but the POR has not formally accepted the findings, field staff
cannot use those findings to support adding a condition to a claim.
4. Field staff shall request the
narrative description be modified/corrected if the requested/recommended
description is correct based on the medical documentation in file but that
description cannot be accurately coded in the claims management system. Field
staff shall only do this when:
initial order; or
subsequent condition; or
to the IC with a NOR (if a subsequent condition should be denied). Field staff
shall clearly state BWC’s position on the request and outline the supporting
evidence following the Notice of Referral policy.
5. Field staff shall contact the requesting
party, MCO or physician of record/treating physician to clarify the code and/or
condition description when:
code is provided without description;
condition does not match a valid ICD code;
is correct but spinal levels are required but not documented.
6. Field staff shall request medical
documentation if clarification is not given and the documentation on file is
insufficient to determine the appropriate ICD code/condition. Prior to sending
to medical review, field staff shall request medical documentation from:
physician of record/treating physician, when the MCO is unable to obtain the
7. Field staff shall send the request to physician
review if the condition has not been clarified to request what, if any,
condition is supported by the medical evidence.
8. Based on the result of the physician
review, field staff shall adhere to the following policies to address the
Waivers, Appeals and Hearings; and/or
9. Field staff shall use the ICD code
A00.00 on claims for which there was no injury.
10. If requests or recommendations are made
for symptoms and/or generic conditions, field staff shall:
if the symptom requested is addressed by a condition already allowed in the
request is addressed by a condition already allowed in the claim, telephone the
requesting party and ask the filing party to withdraw the
request is not addressed by a condition already allowed in the claim, telephone
the requesting party and/or physician of record/treating physician to clarify
the request (i.e., determine what condition is causing this symptom).
request to physician review asking what, if any, condition does the medical
the result of the physician review, follow the:
i. Additional Allowance; and/or
Orders, Waivers, Appeals
and Hearings; and/or
iii. Notice of Referral.
Correcting/Modifying ICD Descriptions
A. Field staff shall not address ICD codes/conditions
in claims that fall outside an employer’s experience or were allowed more than
five years ago for employers who are experience-rated, except in the following
1. The condition in question is one that is
currently driving the claim cost (indemnity and/or medical).
2. Anticipated future medical or indemnity
costs may be incurred due to the condition in question (i.e., request for
treatment or compensation may be filed).
B. Field staff shall review retro-rated or
Public Employer State Agency (PES) employer claims for modifications at any
time when there are potential medical and/or indemnity impacts identified that
adversely affect the claim cost.
C. The field may staff with an Employer
Service Specialist (ESS) or the BWC attorney to determine if the incorrect
diagnosis is one that impacts claim costs.
Correcting/Modifying ICD Codes Never Formally Allowed by BWC or IC
A. Field staff shall not address conditions
which were never formally allowed by BWC or IC Order that fall outside an
employer’s experience or have been allowed more than five years ago unless
potential medical and/or indemnity impacts are identified that adversely affect
the claim cost.
B. When the claims management system has an
ICD code(s)/description listed that was never formally allowed by BWC or IC
Order, field staff shall determine if the condition should be allowed, denied,
or deleted, and staff shall follow the procedures in Section V. E-G below.
C. Field staff shall include medical bill
review in the investigation to determine if the condition(s) is supported by
medical evidence and a causal relationship can be established, but a BWC or IC
order recognizing the condition is still required.
D. The condition(s) remains in an allowed
status in the claims management system until the determination process is
E. Field staff shall follow the Additional
Allowance policy to allow the condition or to refer the condition to the IC.
F. If the condition was not previously
allowed by BWC or IC Order and should be denied, the issue of denial of the
condition cannot be sent to the IC unless there is a C-86 currently on file
requesting the condition.
1. If the condition should
be denied, and there is a C-86 on file, the C-86 is referred to the IC for
hearing via a NOR.
2. If there is no C-86 on
file, field staff shall follow the procedures to delete the condition.
G. If field staff determines a condition
should be deleted from the claim:
1. Field staff shall review all conditions not
formally addressed by a BWC or IC Order when there is no supporting medical
evidence to allow the condition, or the condition does not appear to be related
to the claim.
2. Field staff shall address the conditions by
issuing the “BWC ICD Deletion” letter found in
COR. The ICD code shall not be deleted in the claims management system without
issuing a “BWC ICD Deletion” letter to notify the parties in the claim.
3. If there are multiple ICD codes on the claims
management system that were never formally addressed by BWC or IC Order:
staff shall include all the conditions to be deleted in the “BWC ICD Deletion”
staff shall issue both a BWC order and the “BWC ICD Deletion” letter when some
conditions can be allowed through the Additional Allowance policy, and some
conditions have no supporting medical evidence and should be removed.
4. Field staff shall not remove the ICD codes
addressed by the “BWC ICD Deletion” letter from the claims management system
until 14 days after the “BWC ICD Deletion” letter has been sent, allowing
parties the time to request/recommend allowance of the conditions by filing a
C-86 or C-9 with supporting evidence.
staff shall delete the condition(s) after 14 days if no C-86 or C-9 is filed.
staff shall follow the Additional Allowance policy if a C-86 or C-9 is filed.
staff shall not delete the ICD Code(s) until the additional allowance process
ICD Description Allowed by Industrial Commission (IC) Order
A. If field staff discovers a condition
allowed by IC Order is not available through the encoder in the claims management
system, field staff shall follow the general guidelines in Section II of this
procedure to obtain the correct ICD code.
B. Field staff shall request modification
if the ICD code is correct but the condition description is not available through
the claims management system encoder.
C. Field staff shall manually generate the
“Notice of Injury Claim Status” letter through the claims management system to
notify the parties/provider of the corrected description once the correction is
D. Field staff shall update the claims
management system notes explaining that the ICD description has been modified
to reflect the diagnosis description stated in the IC Order.
Miscoded ICD description
A. When conditions were formally allowed by
BWC or IC Order, but were miscoded in the claims management system:
1. Field staff shall follow the general guidelines
in Section II of this procedure to obtain the correct ICD code.
2. Field staff shall determine if the ICD
description needs to be modified to match the allowance in the order.
3. Field staff shall request modification if the
ICD code is correct, but the ICD description is not available through the
claims management system.
4. Field staff shall update notes in the claims
management system explaining that the ICD code and/or description has been
modified to reflect the diagnosis description stated in the BWC or IC Order.
5. Field staff shall manually generate the “Notice
of Injury Claim Status” letter in the claims management system to notify the
parties/provider of the corrected code and/or description once the correction
B. When conditions were formally allowed by
BWC or IC Order, but modification was never requested, field staff shall:
1. Follow the general guidelines in Section II of
this procedure to obtain the correct ICD code;
2. Request the description be modified when the
ICD code is correct, but the ICD description does not reflect the narrative
description in the IC/BWC Order.
Example: BWC Order was issued
using the description modification functionality in the claims management
system and the ICD description on the diagnosis/injury screen was never updated
to reflect the narrative description published on the BWC Order.
Example: Field staff discovers
discrepancy between the ICD narrative description that was allowed by IC Order
and the ICD narrative description that is contained in the claims management
system. The ICD modification was never requested.
VIII. Adding Specific Levels
for Back Injury Claims
A. When the IC has allowed a back condition
(e.g., degenerative disc disease) without indicating a specific level:
1. Field staff shall staff with the BWC field
attorney to determine if the claim should be returned to the IC for
clarification if the IC Order is still within the appeal period.
2. Field staff shall not update the condition to
add specific levels without a formal order.
B. If treatment is requested in a claim
where the level is not indicated and the MCO contacts field staff to clarify
the allowed condition, field staff shall:
1. Review the medical documentation supporting the
allowance that is referenced in the “based on” section of the IC Order;
2. Determine what level(s) was supported by the
medical documentation if indicated;
3. Staff with the MCO to determine what level the
requested treatment addresses.
requested treatment is for the level that is found in the medical evidence,
document this in notes in the claims management system for future reference and
share the information with the MCO. No updates shall be made to the allowed
requested treatment is for levels that appear to be unrelated to the level as
indicated in the medical documentation cited in the IC Order; or, the level is
supported by medical documentation received after the IC Order, field staff
shall staff with the BWC attorney to consider filing a C-86 for continuing
jurisdiction to clarify the allowance in the claim.
How to Replace
Expired ICD Codes
A. Field staff shall request modification
through the “BWC ICD Modification Request” SharePoint site when expired codes
B. Field staff shall add current codes when
expired codes are identified by the ICD Modification SharePoint site
C. BWC ICD Modification Request SharePoint site
coordinator will modify the narrative to reflect the previously allowed
D. Field staff shall delete the expired
code from the claims management system.