Policy and Procedure Name:
Medical Evidence for Diagnosis Determinations (MEDD)
R.C. 4123.54; R.C. 4123.01; O.A.C. 4123-3-09
Kevin R. Abrams, Chief Operating Officer
CP-13-02, effective 05/26/2015 and CP-13-02.PR1. effective
Rev. 12/10/2018; 08/23/2018; New 05/26/2015
Rev. 05/06/2019; 12/10/2018; 08/23/2018; New 05/26/2015
MEDD Table of Contents
I. POLICY PURPOSE
Contrary Medical Evidence
MEDD Coding Reference Guide ICD 10
Preponderance of the Evidence
A. General Policy Statement
B. MEDD Coding Reference
Guide ICD 10 job aid
A. Standard Claim File
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.
This policy applies to BWC claims services staff and Managed
Care Organizations (MCO).
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.
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.
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.
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.
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.
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.
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
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.
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.
medical evidence in accordance with the MEDD Coding Reference Guide ICD 10 job
without the submission of medical evidence, a minor injury as listed in section
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
1. BWC staff
shall refer to the Standard Claim File Documentation
and Altered Documents policy and procedure for claim note
follow any other specific instructions for claim notes included in this
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:
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
iv. Coverage and
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:
causation (i.e., the injury or employment proximately caused the condition);
(i.e., a new condition that develops as a result of an allowed condition);
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);
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);
non-work-related injury or illness.
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.
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.
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
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:
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.
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.
MCO shall identify the documentation that supports the causality indicator.
iii. The MCOs
shall not submit the initial EDI 148 until the MCO has:
and provided the causality indicator; or
a failure to obtain the information after at least two attempts to contact the
provider and secure the causality information.
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.
shall use the MEDD Coding Reference Guide ICD 10 job aid as follows:
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.
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.
the supporting evidence is submitted but claims services staff is not sure the
diagnosis is related to the employment/injury, claims services staff shall:
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.
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.
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
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.
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
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:
clarification of the request from the IW/attorney of record (AOR) and/or the
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
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:
to verify if a diagnostic test is planned.
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
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
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,
and process the claim based on the physician reviewer’s diagnosis, if one is
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:
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
services staff shall verify the site/location of injury:
a) If claims
services staff cannot verify the site or location:
services staff will select a site/location.
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
services staff shall refer to the ICD Modification policy and procedure, if
services staff shall rely on the description of the accident to determine if
the mode or mechanism of injury could produce the requested condition.
services staff shall not delay the investigation and processing of a
minor-injury claim because BWC has not received medical evidence.
services may not require medical evidence to determine the compensability of
minor injuries. Minor injuries include only:
degree burns to less than 10% of the body;
lacerations (e.g., cut, open wound);
contusions (e.g., bruise, hematoma);
iv. Insect stings;
animal or human bites;
foreign body in the eye;
vii. Corneal abrasions;
viii. Conjunctivitis (also known as pink
services staff shall, if determining the claim is compensable, identify a
diagnosis code consistent with the mode/mechanism of injury.
services staff shall not allow a minor injury if there is contrary evidence on
file, but shall:
an initial determination, issue an order based on the evidence; or,
a subsequent decision, refer the claim to the IC for hearing. Claims services
staff may refer to the Notice of Referral policy and procedure.
medical evidence or additional medical evidence
services staff shall work and coordinate with the MCO, who is primarily
responsible to gather medical evidence as needed.
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.
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
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.
subsequent allowance requests, if claims services staff cannot obtain:
medical evidence, the subsequent allowance request will be dismissed;
or sufficient medical evidence in accordance with the MEDD Guidelines, claims
services staff shall seek a physician review.
services staff shall ensure that physician reports are signed with an original
or stamped signature.
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.
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.
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
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.
services staff shall review the “Provider Signature on Medical Evidence” chart
to determine what signatures are required for disability certification.