Evaluation & Management of a Workers' Compensation Musculoskeletal Injury
Injured workers require medical care and careful attention to factors that will help them recover their ability to work, but current medical practice guidelines focus on disease diagnosis and treatment of symptoms, not function. At present, there is no widely used system of coding guidelines for workers’ compensation clinical encounters that is specifically geared towards maximizing outcomes for both patient health and patient work function. Current coding rules ...read more
Attending to FUNCTION as a vital sign would increase the value of medical care in every clinical setting, but is critical to clinical encounters related to workers’ compensation injuries. Workers’ compensation related care requires attention to causation, functional impact and work capacity. The criteria used to code levels of care in primary care Evaluation and Management encounters do not serve patients or payers in the workers’ compensation system. Because the current coding system does not reimburse providers for documentation of the data elements that are critical for workers’ compensation, there is insufficient attention to these issues in encounters, with resultant preventable work disability. For this reason, the ACOEM Council on Occupational and Environmental Medicine Practice has developed alternative ground rules for Evaluation and Management encounters, which will promote attention to the clinical details that evidence has shown result in less lost work days and more successful recovery, by providing an appropriate and auditable alignment of reimbursement with documentation of necessary elements of history, examination, medical decision making and problem severity. This figure illustrates the proposed new model. The complete document containing the current version of the coding criteria may be downloaded here.
The clinical history in a workers’ compensation related encounter should document how the injury happened, work factors, risk factors for poor recovery, work support and functional impact. These elements can be captured with modest variations from the current data elements of a history using CMS criteria. We propose modifying the scoring criteria for level of history in comparison to CMS criteria by revising the review of systems to capture physical/emotional/mental symptoms most relevant to work disability risk while also asking about important social systems...read more
Neither the 1995 nor the 1997 CMS multi-organ system examination criteria serve the patient or payer well when the exam relates to a work injury. We have developed an Occupational Medicine specialty musculoskeletal examination similar to the other 1997 specialty specific exams, which will promote a careful examination of the injured area, the adjacent areas and comparison with the unaffected side when applicable. This examination follows a format and bulleted coding scheme similar to the other specialty-specific examinations; we are building exam modular templates to include required exam criteria depending on the injured part of the musculoskeletal system and plan to develop other templates to address workers’ compensation conditions affecting other parts of the body beyond the musculoskeletal system...read more
Medical Decision Making
The proposed criteria for medical decision making are very similar to the CMS criteria, with some important differences. Risk of chronic work disability is recognized as an equivalent risk to loss of life or limb, based on research showing significantly increased morbidity and mortality for those who are not working, as well as the importance of the return-to-work outcome to patients and workers’ compensation payers. Management strategies to mitigate this risk in appropriate cases are recognized as important options warranting high risk designation. We also recognize that data reviewed in workers’ compensation related care should include information other than clinical data, for example job demands or ergonomic evaluations of the workplace...read more
Tools for Implementation
We have developed templates to support implementation in practice, and we are working on templates for commonly used electronic health records. As we develop new templates or update current templates, you can find them here.
Tools for Auditing and Research
We have developed an auditing checklist and a template to use for chart review and outcomes research. These will be updated here as we develop further tools with research partners.
Coding Criteria for E&M Encounters
Coding new and established patient encounters in workers’ compensation would use the same requirements as CMS for type of encounter, except that in workers’ compensation related care, it is the date of injury/claim that establishes a patient as new or established (new patient if new injury/claim even if known to the practice/clinician.)...read more