OhioBWC - Basics: (Policy library) - File

Policy and Procedure Name:

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

Policy #:

CP-05-03

Code/Rule Reference:

None

Effective Date:

12/14/2020

Approved:

Ann M. Shannon, Chief of Claims Policy and Support

Origin:

Claims Policy

Supersedes:

All Injury Management policies, procedures, directives and memos regarding cause of injury codes or E-codes that predate the effective date of this policy and procedure.

History:

Previous versions of this policy are available upon request

 

 

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 claims services staff.

 

III. DEFINITIONS

 

Cause of Injury 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 OD occurred.

 

IV. POLICY

 

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

 

V. Procedure

 

A.     General Claim Note and Documentation Requirements

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

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

 

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

 

C.      If a cause of injury code has been identified by a managed care organization (MCO) or provider, claims services staff shall verify the code for appropriateness based on the accident description.

1.      If the cause of injury code as provided by the MCO or provider is appropriate, claims services staff shall enter it into the claims management system.

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

3.      If the cause of injury category is not populated and is 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, claims services staff shall enter it into the claims management system.

 

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

 

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

 

F.      Claims services staff shall not enter cause of injury codes for any intervening causes of an additional condition subsequent to the initial claim allowance.

 

G.     If claims services staff is unsure of the appropriate cause of injury code, the claim shall be staffed with the medical service specialist (MSS) or supervisor.

 

H.     If staffing does not result in a decision on the appropriate cause of injury code, claims services staff shall email the claim information to the “BWC Claims Policy Field Techs” mailbox for direction.