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OhioBWC - Basics: (Policy library) - File

Policy Name:

Medical Evidence for Diagnosis Determinations (MEDD)

Policy #:

CP-13-02

Code/Rule Reference:

RC 4123.53; O.A.C. 4123-3-09

Effective Date:

05/26/2015

Approved:

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

Origin:

Operational Claims Policy

Supersedes:

All Injury Management policies, directives and memos regarding MEDD that predate the effective date of this policy.

History:

New

Review date:

05/26/2020

 

 

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 Disability Determination Guidelines (DDG) to improve the quality of referrals to the Medical Service Specialist or the physician reviewer/examiner.

 

II. APPLICABILITY

 

This policy applies to field 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, or could be the result (e.g., flow-through) of a previously allowed condition in the claim.

 

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.

 

Disability Determination Guidelines (DDG): Tool used by BWC to identify the appropriate medical information needed to support field staff’s processing 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.    It is the policy of BWC to:

1.    Use the DDG 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.

 

B.    BWC shall not use the DDG as the exclusive criteria to either allow or deny a claim or new condition.

 

C.   BWC staff will consider the causal relationship between the requested condition and the mode or method of injury.

1.    Causality shall be established in one of the following ways:

a.    Direct causation (i.e., proximately caused);

b.    Substantial aggravation/exacerbation of a pre-existing condition (i.e., a worsening);

c.    Acceleration (i.e., hastened progression); or,

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

2.    MCOs must make and document at least two efforts to contact the provider. The MCO must try to obtain causality information. The MCOs must submit causality indicators, as indicated below, to BWC and identify the documentation the MCO is relying upon to support the indicator. The MCOs must submit one of three values:

a.    “Y” – indicates yes; the provider indicates the injury is causally related to the IW’s employment;

b.    “N” – indicates no; the provider does not indicate that the injury is causally related to the IW’s employment;

c.    “U” – indicates that the causality is undetermined and that BWC must seek additional information. Examples include:

i.      Provider failed to respond to whether a causal connection existed.

ii.     The injured worker did not seek medical treatment and the injury is not a minor injury.

 

D.   Medical documentation, except as noted in Section IV.E, below, is required and must establish that the condition probably occurred as a result of the injury or as a flow-through to already allowed conditions.

 

E.    It is the policy of BWC to permit field staff to allow, without the submission of medical evidence, a claim or condition classified as a minor injury.

1.    Minor injuries include only the following:

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

b.    Superficial lacerations (e.g., cut, open wound)

c.    Superficial contusions (e.g., bruise, hematoma)

d.    Insect stings

e.    Minor animal or human bites

f.     Superficial foreign body in the eye

g.    Corneal abrasions

h.    Conjunctivitis (also known as pink eye)

i.      Dermatitis

j.      Blisters

k.    Superficial injury/abrasion

2.    Staff shall not delay the investigation and processing of a minor-injury claim because BWC has not received medical evidence

3.    Field staff shall consider whether a causal relationship between the minor injury and the mode or mechanism of injury is established by a preponderance of the evidence (i.e., more likely than not).

4.    Field staff will consider the description of the accident to determine if the circumstances of the accident could produce the injury the IW is requesting.

5.    Staff may identify and code the diagnosis consistent with the mechanism of injury for these types of injures if there is no medical evidence on file.

 

F.    For non-minor injuries, if field staff obtain the appropriate medical evidence in accordance with the DDG and determine that all other legal factors are met:

1.    Field staff will either:

a.    Code the condition using the ICD code provided by the treating physician; or,

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

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

2.    Field staff will verify the site/location of injury:

a.    If field staff cannot verify the site or location:

                                          i.    Field 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 will issue a corrected order.

b.    Field staff shall refer to the ICD Modification policy and procedure, if needed.

 

G.   If field staff cannot obtain appropriate or sufficient medical evidence in accordance with the DDG for initial allowance of the claim, staff may make a referral to the local nurse and/or request a physician review for an opinion.

1.    Field staff may allow the claim or condition for the diagnosis(es) the physician reviewer provides.

2.    If a physician reviewer recommends allowance of a diagnosis different than what the IW requested, BWC will notify the parties via an order that the requested condition will be considered when the IW submits supporting medical evidence for that particular condition.

3.    Example:

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

b.    Per the DDG, 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.

 

H.   For subsequent allowance requests, if field staff cannot obtain:

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

2.    Appropriate or sufficient medical evidence in accordance with the DDG, field staff shall seek a physician review and refer the issue to the IC.

 

I.      Signatures

1.    It is the policy of BWC to accept original or stamped signatures on physician reports.

2.    It is the policy of BWC to accept electronic data interface (EDI) transmissions of medical evidence to make medical determinations.  However, if a claim is contested, BWC must obtain the hard copy medical report with a provider’s signature from the MCO.

3.    It is the policy of BWC to accept a healthcare provider’s authorized representative’s signature on medical reports. The physician of record (POR) or treating physician’s authorized representative/designee will sign for the POR or treating physician and initial.

4.    It is the policy of BWC to accept the signature of a nurse practitioner or a physician assistant to diagnose conditions for claim allowance decisions, additional conditions, and medical treatment decisions within the scope of their practice.

5.    Please refer to the “Physician Signature on Medical Evidence” Chart, located on COR for BWC staff.

 

 

BWC staff may refer to the corresponding procedure for this policy entitled “Medical Evidence for Diagnosis Determinations (MEDD)” for further guidance.


 

Procedure Name:

MEDICAL EVIDENCE FOR DIAGNOSIS DETERMINATIONS (MEDD)

Procedure #:

CP-13-02.PR1

Policy # Reference:

CP-13-02

Effective Date:

05/26/15

Approved:

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

Supersedes:

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

History:

New

Review date:

05/26/2020

 

 

II.    BWC staff shall refer to the Standard Claim File Documentation policy and procedure for claim-note requirements, and BWC staff and Managed Care Organization (MCO) staff shall follow any other specific instructions included in this procedure.

 

III.   Staff shall ensure a claim is compensable for initial determination

 

A.    Staff shall refer to the following policies and procedures to evaluate a claim, in addition to using the Disability Determination Guidelines (DDG) detailed in this procedure and corresponding policy:

1.    Interstate Jurisdiction

2.    Jurisdiction

3.    Compensability and Coverage.

 

B.    Causality

1.    BWC 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.    Substantial aggravation/exacerbation of a pre-existing condition (i.e., the injury or employment worsened a condition the injured worker [IW] already had);

c.    Acceleration (i.e., the injury or employment hastened the progression of a condition);

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

e.    A non-work related injury or illness.

2.    Staff shall rely on medical documentation, except as noted in Section IV, below, to establish 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).

1.    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. Reasons the MCO submits a “U” causality factor include, but are not limited to, the following reasons:

i)      The provider would not provide an opinion as to whether or not 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 or not 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.

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

3.    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.   Field 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.

 

IV.  Staff Shall Use the DDG

A.    Field staff shall refer to the DDG to ensure that the appropriate medical evidence required for the requested diagnosis(es) is submitted, and if all required evidence is in the claim, field staff may issue a decision without sending the claim for Medical Service Specialist (MSS) or physician review.

 

B.    If supporting evidence is submitted and field staff determines the requested condition(s) is related to the employment/injury, field staff shall follow the process in the ICD Modification policy and procedure.

 

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

1.    Refer the claim to the MSS to clarify and verify the medical documentation and assist in determining if the information in the submitted medical evidence meets the requirements of the DDG.

2.    Then, 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, field staff shall send for a physician review, and:

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

2.    If the decision is subsequent to the initial determination period, field staff shall:

a.    Seek clarification of the request;

b.    Ask the IW to modify the request;

i)      If the IW agrees to modify, process the request; or

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

 

E.    If the supporting evidence is not submitted after attempts to secure it have been made (except for a minor injury, covered in Section IV below), field staff shall:

1.    Check to verify if a diagnostic test is planned, and if field staff does not yet have results, field staff may set a task in the claim to follow-up with the MCO to obtain the test results prior to sending the claim for physician review.

a.    For an initial determination:

i.      If the evidence is not obtained before the determination date arrives and the IW is requesting only one condition, field staff shall deny the claim;

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

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

2.      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,

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

 

V.    Minor Injuries

 

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

B.    Staff shall not require medical evidence to determine the compensability of minor injuries. Minor injuries only include:

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

2.    Superficial lacerations (e.g., cut, open wound)

3.    Superficial contusions (e.g., bruise, hematoma)

4.    Insect stings

5.    Minor animal or human bites

6.    Superficial foreign body in the eye

7.    Corneal abrasions

8.    Conjunctivitis (also known as pink eye)

9.    Dermatitis

10.  Blisters

11.  Superficial injury/abrasion.

 

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

 

D.   Field staff shall not allow a minor injury if there is contrary evidence on file, but shall:

1.    If it is an initial determination, issue an order based on the evidence; or,

2.    If it is a subsequent decision, refer the claim to the IC for hearing. Field staff may refer to the Notice of Referral policy and procedure.

 

VI.  How to Gather Medical Evidence or Additional Medical Evidence

A.    Field Staff shall work and coordinate with the MCO, who is primarily responsible, to gather medical evidence, as needed.

 

B.    Field 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, field staff shall coordinate efforts with the MCO and may contact the treating physician directly for information.

 

C.   Lost-time field 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 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.

 

 

VII. Physician Signature

A.    Field staff shall ensure that physician reports are signed.

 

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

 

D.   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.    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 with the scope of practice, but not for disability certification.

 

 

 


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