OhioBWC - Basics: (Policy library) - File

Policy and Procedure Name:

Medical Evidence for Diagnosis Determinations (MEDD)

Policy #:

CP-13-02

Code/Rule Reference:

R.C. 4123.54; R.C. 4123.01; O.A.C. 4123-3-09

Effective Date:

05/06/2019

Approved:

Kevin R. Abrams, Chief Operating Officer

Origin:

Claims Policy

Supersedes:

CP-13-02, effective 05/26/2015 and CP-13-02.PR1. effective 12/10/2018

History:

CP-13-02           

Rev. 12/10/2018; 08/23/2018; New 05/26/2015

CP-13-02.PR1   

Rev. 05/06/2019; 12/10/2018; 08/23/2018; New 05/26/2015


 

MEDD Table of Contents

 

I.           POLICY PURPOSE

II.          APPLICABILITY

III.         DEFINITIONS

Causal Relationship

Contrary Medical Evidence

MEDD Coding Reference Guide ICD 10 job aid

Medical Evidence

Minor Injury

Preponderance of the Evidence

IV.        POLICY

A.         General Policy Statement

B.         MEDD Coding Reference Guide ICD 10 job aid

V. PROCEDURE

A.         Standard Claim File Documentation

B.         Determining Compensability

 

 


 

I.          POLICY PURPOSE

 

The purpose of this policy is to ensure that BWC considers and makes determinations based on the sufficiency of medical evidence required to support allowances in the claim, and that staff use the MEDD Coding Reference Guide ICD 10 job aid to improve the quality of referrals to the Medical Service Specialist or the physician reviewer/examiner.

 

II.          APPLICABILITY

 

This policy applies to BWC claims services staff and Managed Care Organizations (MCO).

 

III.          DEFINITIONS

 

Causal Relationship: For purposes of this policy and related procedure, a reasoned medical determination with legal implications that determines if the condition the injured worker (IW) is requesting is compatible with or could result from:

  • The mechanism or mode of injury (i.e., direct causation);
  • A previously allowed condition (e.g., flow-through);
  • An aggravation (claims with date of injury before August 25, 2006) / substantial aggravation (claims with date of injury on or after August 25, 2006) of a pre-existing condition (i.e., the injury or employment worsened a condition the injured worker already had.

 

Contrary Medical Evidence: For purposes of this policy and related procedure, medical evidence that does not support the allowance of a claim or condition, and may derive from the medical opinion of a BWC physician review/exam or from medical documentation that conflicts with the medical documentation submitted to support the allowance of the condition.

 

MEDD Coding Reference Guide ICD 10 job aid: Tool used by BWC to identify the appropriate medical information needed to support the processing of a requested condition in the claim without needing to seek additional medical input; also used to improve the quality of referrals to the Medical Service Specialist and the physician reviewer/examiner.

 

Medical Evidence: Relevant information that may prove or disprove whether a requested condition is medically supported in a claim; one criterion that BWC must consider when determining compensability of a claim or allowance of a condition.

 

Minor Injury: Injury type, as specifically identified by BWC, that requires no medical evidence for staff to allow the condition in the claim and permits staff to make a claim allowance or condition allowance decision based on the description of the accident.

 

Preponderance of the Evidence: A standard of proof which is met when a party’s evidence on a fact indicates that it is “more likely than not” that the fact is as the party alleges it to be.

 

 

IV.          POLICY

 

A.     General Policy Statement

It is the policy of BWC to:

1.     Use the MEDD Coding Reference Guide ICD 10 job aid as a tool to assess the sufficiency of medical evidence;

2.     Weigh the medical evidence as one criterion with other required legal factors such as jurisdiction, coverage, compensability and causality;

3.     Make claim and condition determinations based on the totality of the evidence.

4.     Require medical evidence that establishes that the condition probably occurred as a result of the injury, as a flow-through to already allowed conditions, or as an aggravation / substantial aggravation of a pre-existing condition.

5.     Require medical evidence in accordance with the MEDD Coding Reference Guide ICD 10 job aid.

6.     Allow, without the submission of medical evidence, a minor injury as listed in section V.B.3 below.

 

B.     MEDD Coding Reference Guide ICD 10 job aid

BWC shall not use the MEDD Coding Reference Guide ICD 10 job aid as the exclusive criteria to either allow or deny a claim or new condition.

 

V.          PROCEDURE

 

A.     Standard Claim File Documentation

1.     BWC staff shall refer to the Standard Claim File Documentation and Altered Documents policy and procedure for claim note requirements; and

2.     Shall follow any other specific instructions for claim notes included in this procedure.

 

B.     Determining Compensability

1.     Claims service staff shall refer to the following policies and procedures to evaluate a claim, in addition to using the MEDD Coding Reference Guide ICD 10 job aid detailed in this procedure and corresponding policy:

a.     Claims services staff shall refer to the following policies and procedures to evaluate a claim, in addition to using the MEDD Coding Reference Guide ICD 10 job aid detailed in this procedure and corresponding policy:

i.       Interstate Jurisdiction;

ii.      Jurisdiction;

iii.     Compensable Injuries; and

iv.    Coverage and Employer/Employee Status.

b.     Causality

i.       Claims services staff shall consider the relationship between the requested condition and the mode or method of injury to determine the specific theory of causation, which is one of the following:

a)     Direct causation (i.e., the injury or employment proximately caused the condition);

b)     Flow-through (i.e., a new condition that develops as a result of an allowed condition);

c)     Aggravation of a pre-existing condition for claims with date of injury before August 25, 2006 (i.e., the injury or employment worsened a condition the IW already had);

d)     Substantial aggravation of a pre-existing condition for claims with date of injury on or after August 25, 2006 (i.e., the injury or employment worsened a condition the IW already had);

e)     A non-work-related injury or illness.

ii.      Claims services staff shall rely on medical documentation, except as noted in Section V.C. below, to establish whether the condition probably resulted from the injury or employment.

c.      The MCO is primarily responsible for gathering the documentation that establishes causality and shall submit the causality indicators to BWC via the Electronic Data Interchange (EDI) 148 for initial determinations. For subsequent decision requests, the MCO shall include this information in a detailed note. MCOs must make and document at least two efforts to contact the provider.

i.       The MCOs shall choose one of the following indicator values:

a)     “Y” – Yes, the provider has indicated that the injury is causally related to the IW’s injury or employment;

b)     “N” – No, the provider has indicated that the injury is not causally related to the IW’s injury or employment;

c)     “U” – Undetermined and BWC must seek additional information. Reasons the MCO submits a “U” causality factor include, but are not limited to, the following:

i)       The provider would not provide an opinion as to whether the injury was causally related to the IW’s employment. The MCO shall enter a note indicating the provider declined to establish a causal connection.

ii)      The provider did not provide an opinion as to whether the injury was causally related to the IW’s employment and the MCO has documented at least two attempts to obtain the information.

iii)    The injured worker did not seek medical treatment.

ii.      The MCO shall identify the documentation that supports the causality indicator.

iii.     The MCOs shall not submit the initial EDI 148 until the MCO has:

a)     Obtained and provided the causality indicator; or

b)     Documented a failure to obtain the information after at least two attempts to contact the provider and secure the causality information.

d.     Claims services staff shall determine if the medical evidence the MCO gathered, including consideration of the causality factor, supports the subjective/objective exam findings for the diagnosis(es) being requested.

2.     Staff shall use the MEDD Coding Reference Guide ICD 10 job aid as follows:

a.     Claims services staff shall refer to the MEDD Coding Reference Guide ICD 10 job aid to ensure that the appropriate medical evidence required for the requested diagnosis(es) is submitted.  

b.     If supporting evidence is submitted and claims services staff determines the requested condition(s) is related to the employment/injury, claims services staff may issue a decision without sending the claim for Medical Service Specialist (MSS) or physician review.

c.      If the supporting evidence is submitted but claims services staff is not sure the diagnosis is related to the employment/injury, claims services staff shall:

i.       Refer the claim to the MSS to verify the medical documentation and assist in determining if the submitted medical evidence meets the requirements of the MEDD Coding Reference Guide ICD 10 job aid.

ii.      The MSS may request a physician review to opine on a diagnosis.

d.     If the IW’s request for a condition is not supported by the medical evidence, claims services staff shall send for a physician review.

i.       If the decision is an initial determination and the physician reviewer recommends allowance of a diagnosis different from the requested condition(s), claims services staff shall allow the claim for the physician reviewer’s recommended allowed condition(s) and include in the order the following statement: “The specific condition requested will be considered upon submission of appropriate medical evidence.”

ii.      Example:

a)     Treating physician diagnoses rotator cuff syndrome but no MRI was performed.

b)     Per the MEDD Coding Reference Guide ICD 10 job aid, staff cannot allow the condition without a physician review.

c)     The physician reviewer recommends allowance of sprain/strain of the shoulder based on the medical evidence in the file.

d)     Staff will issue an order allowing the sprain/strain of the shoulder and noting that the rotator cuff syndrome will be considered when the IW submits supporting medical evidence.

e.     If the decision is subsequent to the initial determination period, and the physician reviewer recommends allowance of a diagnosis different from the requested condition(s), claims services staff shall:

i.       Seek clarification of the request from the IW/attorney of record (AOR) and/or the requesting provider;

ii.      Ask the IW/AOR to modify the request;

a)     If the IW/AOR agrees to modify, process the request; or

b)     If the IW/AOR will not agree to modify, refer the claim to the Industrial Commission (IC).

f.       If the supporting evidence is not submitted after attempts to secure it have been made (except for a minor injury, covered in Section V.B.3 below), claims services staff shall:

i.       Check to verify if a diagnostic test is planned.

ii.      If diagnostic test(s) are planned, claims services staff may set a work item in the claim to follow-up with the MCO to obtain the test results prior to sending the claim for physician review.

iii.     For an initial determination:

a)     If the evidence is not obtained before the determination date arrives and the IW is requesting only one condition, claims services staff shall deny the claim;

b)     If the IW is requesting more than one condition and evidence is obtained on some but not all the conditions, claims services staff shall indicate that the condition for which no evidence was obtained is neither allowed nor disallowed.

g.     For a subsequent determination, if the evidence is not obtained before the determination date arrives, staff shall process the claim with the evidence on file.

h.     If no diagnostics are received or planned, send the issue to the Virtual Medical group so that an MSS may request a physician review to opine on the appropriate diagnosis, if any, for the claim allowance; and,

i.       Code and process the claim based on the physician reviewer’s diagnosis, if one is supplied.

j.       If claims services staff obtain the appropriate medical evidence in accordance with the MEDD Coding Reference Guide ICD 10 job aid and determine that all other legal factors are met:

i.       Claims services staff shall:

a)     Code the diagnosis using the narrative diagnosis the treating physician has provided, whether the treating physician has provided an ICD code or not; or.

b)     If no narrative diagnosis was given, code the condition using the ICD code provided by the treating physician; or,

c)     If the physician has provided both an ICD code and a narrative diagnosis and the two do not match, claims services staff shall seek clarification from the BWC ICD Modification Unit.

ii.      Claims services staff shall verify the site/location of injury:

a)     If claims services staff cannot verify the site or location:

i)       Claims services staff will select a site/location.

ii)      If it is discovered, even after expiration of the appeal period, that the site/location is different, BWC will consider such a clerical error and issue a corrected order.

b)     Claims services staff shall refer to the ICD Modification policy and procedure, if needed.

3.     Minor injuries

a.     Claims services staff shall rely on the description of the accident to determine if the mode or mechanism of injury could produce the requested condition.

b.     Claims services staff shall not delay the investigation and processing of a minor-injury claim because BWC has not received medical evidence.

c.      Claims services may not require medical evidence to determine the compensability of minor injuries. Minor injuries include only:

i.       First degree burns to less than 10% of the body;

ii.      Superficial lacerations (e.g., cut, open wound);

iii.     Superficial contusions (e.g., bruise, hematoma);

iv.    Insect stings;

v.      Minor animal or human bites;

vi.    Superficial foreign body in the eye;

vii.   Corneal abrasions;

viii. Conjunctivitis (also known as pink eye);

ix.    Dermatitis;

x.      Blisters; and

xi.    Superficial injury/abrasion.

d.     Claims services staff shall, if determining the claim is compensable, identify a diagnosis code consistent with the mode/mechanism of injury.

e.     Claims services staff shall not allow a minor injury if there is contrary evidence on file, but shall:

i.       For an initial determination, issue an order based on the evidence; or,

ii.      For a subsequent decision, refer the claim to the IC for hearing. Claims services staff may refer to the Notice of Referral policy and procedure.

4.     Gathering medical evidence or additional medical evidence

a.     Claims services staff shall work and coordinate with the MCO, who is primarily responsible to gather medical evidence as needed.

b.     Claims services staff shall follow up with the MCO if the MCO does not send medical evidence within three (3) days of BWC’s receipt of the initial EDI 148. If the MCO does not submit the medical evidence within four (4) days of the BWC’s receipt of the initial EDI 148, claims services staff shall coordinate efforts with the MCO and may contact the treating physician directly for information.

c.      Lost-time claims services staff shall call the MCO or provider to obtain information, and if that is unsuccessful, may send the “Request for Additional Information” letter to the treating provider, as needed, to obtain additional or sufficient medical evidence.

d.     Medical claims services staff may call the MCO or provider to obtain information, and shall send the “Request for Additional Information” letter to the treating provider, as needed, to obtain additional or sufficient medical evidence.

e.     For subsequent allowance requests, if claims services staff cannot obtain:

i.       Any medical evidence, the subsequent allowance request will be dismissed;

ii.      Appropriate or sufficient medical evidence in accordance with the MEDD Guidelines, claims services staff shall seek a physician review.

5.     Physician signature

a.     Claims services staff shall ensure that physician reports are signed with an original or stamped signature.

b.     Claims services staff may accept electronic data interface (EDI) transmissions as medical evidence in making claim determinations.  However, if a claim is contested, BWC must obtain the hard copy medical report with a provider’s signature from the MCO.

c.      Claims services staff shall ensure that the person signing the report has authority to do so. Claims services staff shall refer to chart entitled “Physician Signature on Medical Evidence” for details on signatory authorization.

d.     Claims services staff shall accept a healthcare provider’s authorized representative’s signature, pursuant to IC Resolution R97-1-06. The POR or treating physician’s authorized representative (designee) will sign for the POR or treating physician and initial.

e.     Claims services staff shall accept the signature of a nurse practitioner and/or physician assistant as valid medical evidence for claim allowance decisions and medical treatment decisions within the scope of practice.

f.       Claims services staff shall review the “Provider Signature on Medical Evidence” chart to determine what signatures are required for disability certification.