Skip Navigation Links.
Online Support available
Monday through Friday
7:30 a.m. - 5:30 p.m.
Click here to get help!
OhioBWC - Basics: (Policy library) - File

Policy Name:

ICD MODIFICATION

Policy #:

CP-09-02

Code/Rule Reference:

R.C. 4121.32, 4121.39

Effective Date:

05/06/16

Approved:

Rick Percy, Chief of Operational Policy, Analytics and Compliance (signature on file)

Origin:

Claims Policy

Supersedes:

All Injury Management policies, directives or memos regarding ICD Modification that predate the effective date of this policy.

History:

Rev. 01/07/2016; New 08/11/2015

Review date:

05/06/19

 

 

I. POLICY PURPOSE

 

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.

 

 

II. APPLICABILITY

 

This policy applies to BWC Field Operations staff, Medical Services staff and managed care organizations (MCOs).

 

III. DEFINITIONS

 

Encoder:  Web-based software that converts a narrative medical description into a numeric ICD description, or vice versa.

 

ICD:  International 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.

 

IV. POLICY

 

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 claim; or 

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 or denied.

 

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.

 

Procedure Name:

PROCEDURES FOR ICD MODIFICATION

Procedure #:

CP-09-02.PR1

Policy # Reference:

CP-09-02

Effective Date:

05/06/16

Approved:

Rick Percy, Chief of Operational Policy, Analytics and Compliance

Supersedes:

All Injury Management procedures, directives and memos regarding ICD Modification that predate the effective date of this procedure.

History:

Rev. 01/07/2016; New 08/11/2015

Review date:

05/06/2019

 

      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 procedure.

 

    II.        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 (COR) to:

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.

 

I.      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 attorney.

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 jurisdiction.

 

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 coded.

 

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 site:

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 clarification, or

c.    For assistance in validating a code the staff selected or requesting the appropriate code that best reflects the diagnosis description.

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:

a.    Before a BWC order is issued;

b.    Before a NOR to the IC is sent; or,

c.    When an allowance made by IC Order is unclear.

4.    Field staff shall:

a.    Have the 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;

ii.     The reason for the request, which will systematically assign the priority:

a)    Additional Allowance (C86);

b)    Additional Allowance (C9);

c)    Death;

d)    FROI;

e)    IC Order;

f)     MCO Request;

g)    Modification;

h)    New Claim (0-7 day);

i)      New Claim (28 day);

j)      New Claim (Surgery Pending);

k)    New Claim (CAT Claim);

l)      Question;

m)  Sprain/Strain; or

n)    Surgery pending (after claim determination).

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;

b.    Any 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:

a.    Send questions regarding system-mapped ICD codes;

b.    Request specific training topics (with ‘training topic’ or ‘training request’ in the subject line); and

c.    Ask general ICD-10 project-related questions.

 

   III.        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:

a.    Issuing an initial order; or

b.    Allowing a subsequent condition; or

c.    Referring 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:

a.    The ICD code is provided without description;

b.    The condition does not match a valid ICD code;

c.    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:

a.    The MCO;

b.    The physician of record/treating physician, when the MCO is unable to obtain the documentation.

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 requested condition(s):

a.    Additional Allowance; and/or

b.    Order, Waivers, Appeals and Hearings; and/or

c.    Notice of Referral.

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:

a.    Determine if the symptom requested is addressed by a condition already allowed in the claim.

b.    If 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/recommendation.

c.    If 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).

d.    Send the request to physician review asking what, if any, condition does the medical documentation support.

e.    Based on the result of the physician review, follow the:

i.      Additional Allowance; and/or

ii.     Orders, Waivers, Appeals and Hearings; and/or

iii.    Notice of Referral.

 

  IV.        Correcting/Modifying ICD Descriptions after Allowance

 

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 circumstances:

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.

 

    V.        Correcting/Modifying ICD Codes Never Formally Allowed by BWC or IC Order

 

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 complete.

 

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:

a.    Field staff shall include all the conditions to be deleted in the “BWC ICD Deletion” letter.

b.    Field 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.

a.    Field staff shall delete the condition(s) after 14 days if no C-86 or C-9 is filed.

b.    Field staff shall follow the Additional Allowance policy if a C-86 or C-9 is filed.

c.    Field staff shall not delete the ICD Code(s) until the additional allowance process is complete.

 

  VI.        Correcting/Modifying 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 made.

 

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.

 

 VII.        Correcting/Modifying 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 is made.

 

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.

a.    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.

b.    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. 

a.    If the 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 conditions;

b.    If the 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.

 

  IX.        How to Replace Expired ICD Codes

 

A.    Field staff shall request modification through the “BWC ICD Modification Request” SharePoint site when expired codes are identified.

 

B.    Field staff shall add current codes when expired codes are identified by the ICD Modification SharePoint site coordinator.

 

C.   BWC ICD Modification Request SharePoint site coordinator will modify the narrative to reflect the previously allowed condition(s).

 

D.   Field staff shall delete the expired code from the claims management system.    

 

 


Resources