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Clear documentation rules are needed for multiple types of clinical services critical or specific to workers' compensation care. This page details the current plans or draft documents related to each of these types of service.

Here is a one-page value statement to describe the project and plans.

Targeted Services

Evaluation and Management Codes

Evaluation and Management (E&M) Codes are the codes used to bill routine encounters (initial or follow-up care) with any kind of specialist. We have developed alternative documentation rules for using these routine care codes for workers' compensation encounters.

This document describes the proposed alternative criteria for clinical encounters, including History, Physical Exam, and Medical Decision Making, with tables comparing the proposed workers' compensation criteria with the Centers for Medicare and Medicaid Services (CMS) criteria used in other clinical settings: 


Draft OEM Workers' Compensation Coding Criteria

Similar to the 1997 CMS specialty-specific exam templates, we developed a template for an Occupational Medicine physical exam for musculoskeletal conditions, which includes examining the patient for functional deficits and indicators of possible psychosocial barriers to recovery. This examination could be used by other types of specialists and for purposes other than workers' compensation:

We developed a scoring sheet to assist in implementation, billing, auditing and research:

Consultation Codes

Although CMS does not recognize outpatient consultation code services, there is still a great need for these codes and rules for using them in workers' compensation. Draft rules for applying these codes and documenting care are in development. 

Case Management

We plan to develop specific rules for documentating physician case management services separate from the routine encounter, for workers' compensation purposes.

Disability Risk 
Factor Screening

We plan to develop specific rules for deploying formal risk factor screening in workers compensation care, and for documenting this service. 

Work Disability Prevention Counseling

When work disability risk factors, such as fear/avoidance or disability beliefs, are identified, there is a role for treating providers to provide targeted counseling, education and follow-up to mitigate the impact of these risk factors on recovery and return to work. This service will likely need new codes, with specific rules for documenting the need for such service, the counseling provided, and the outcomes.

We developed a new template for Review of Systems, capturing the critical physical, emotional, mental and social systems that can impact work disability risk. This should replace the generic review of systems that asks about random organ systems usually unrelated to the area of interest.

Review of Systems
Occupational Medicine Musculoskeletal Exam Template
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