What is an ICD code?
International Classification of Diseases (ICD) coding is a statistical classification system that arranges diseases and injuries into groups according to established criteria. ICD codes are alphanumeric and consist of three to seven alphanumeric characters and a description.
How does BWC use ICD codes?
Since ICD codes identify the type, episode of care and nature of the injury, we use them to determine appropriate medical treatment. For example, for a torn medial meniscus, a serious knee injury, surgery would likely be an appropriate type of treatment. However, if the allowed condition in the claim is a sprained knee, surgery would not be appropriate, nor approved.
In addition, when medical providers bill BWC for services, they list the ICD code on the billing forms. BWC and the managed care organizations review all bills to make sure medical providers treat only allowed conditions in the claim. If bills are submitted for injuries that are allowed within the claim, we will pay. If bills are submitted for injuries that are not allowed within the claim, we will not pay.
ICD codes are classified into various statuses. The status of the ICD code will determine whether we have allowed, denied or are still investigating the claim. Here are the various ICD statuses.
- New claim - The claim has been filed with BWC and is in the initial investigation stage to determine whether it meets BWC criteria and is valid. At this time, we have not yet been coded the claim with any ICD codes for injuries.
- Pending - Claim is under investigation but we have coded it with ICD codes for specific injuries.
- Allowed/appeal - We have completed the investigation, it appears the ICD code meets BWC criteria for allowance. We have issued an order granting the ICD code allowance; however, the claim is still within the appeal period. Any party to the claim can file and appeal during the appeal period.
- Allowed - We have issued an order granting the allowance of the ICD code. The appeal period has expired with no appeal filed, or the ICD code has been allowed via hearing order.
- Disallowed/appeal - We have finished the investigation, and it appears the ICD code does not meet the BWC guidelines for allowance. BWC has issued an order denying the claim, but the claim is still within the appeal period. At this time any party to the claim can file an appeal to the claim denial.
- Disallowed - BWC has written an order denying the allowance of the ICD code. The appeal period has expired with no appeal field, or the ICD code has been denied via hearing order.
- Hearing - An appeal has been filed to the BWC order which allowed/disallowed the ICD code. We have referred the claim to BWC's sister agency, The Industrial Commission of Ohio (IC) for a formal hearing.
- Hearing district hearing officer - The IC has allowed the claim, but the claim is still within the appeal period. We can pay compensation; however, the injured worker cannot receive medical benefits until the appeal period has ended or the claim goes to the next hearing level.
What is an invalid ICD code?
BWC has defined the following information as an invalid ICD-9 code.
- A code for an injury/condition that is not causally related to an industrial injury or occupational disease
- The proper application of coding principles (Code assignment requires the highest level of specificity, i.e., must assign the maximum number of digits for a code.) BWC has identified all three and four digit codes that require a fourth and fifth digits respectively
- An unspecified injury/condition or site code therefore a more specific code exists
- A symptom code
- A multiple injury/site code. Reported injury/condition with more than one injury/site are assigned individual codes for each.
What is substantial aggravation?
If a condition that existed before the workplace injury is aggravated by the injury, and objective diagnostic or clinical findings or test results document that substantial aggravation, the condition may be allowed in the claim. Once the pre-existing condition has returned to a level without the workplace injury, no compensation or benefits are payable.
Note: This applies to claims with dates of injury on or after Oct. 11, 2006.
Initial or subsequent allowance status definitions
- Pending - Substantial aggravation of a pre-existing condition is being considered for allowance in the claim.
- Pending payable - Substantial aggravation of a pre-existing condition is allowed pending a final decision.
This status applies only when an initial or subsequent allowance decision is in the appeal period or has been referred to the IC.
- Payable - The injured worker is eligible for compensation and medical benefits for the substantially aggravated pre-existing condition.
- Pending not payable - Substantial aggravation of a pre-existing condition is disallowed pending a final decision.
This status applies only when an initial or subsequent denial decision is in the appeal period or has been referred to the IC.
- Not payable - The injured worker is not eligible to receive compensation or medical benefits for the substantially aggravated pre-existing condition.
This status applies when the condition is allowed or disallowed; however, compensation and medical benefits can not be paid.
Note: For subsequent decisions of the substantially aggravated condition, only payable and not payable statuses apply.