Value Statement Supporting a Function-Oriented Model
Every year in the United States, there are over a million workplace injuries or illnesses severe enough that days are lost from work. 1 The number of work-related illnesses and injuries in the American workforce requiring at least one day from work totals 1,157,410 cases annually, with a median of 9 days lost from work. The cost for total workers’ compensation benefits paid in 2013 was $63.6 billion, an increase of more than 8% since 2009. This accounts for at least 5% of payroll costs for the average workplace.
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 fail to incentivize the delivery of services that are critically important in the workers’ compensation arena or take into account occupational exposures, functional capacity, work disability risk or employment status. In addition to the usual medical care, workers’ compensation requires health care providers to address additional issues such as causation, functional impact, return-to-work planning, and other issues not represented in the most widely used payment systems.
The resulting misalignment between these current coding rules designed for other purposes and Occupational Medicine best practices has often negatively impacted medical outcomes for injured workers, and created barriers to improved health care quality and needlessly increased medical and disability costs. There is evidence, however, that even modest changes to compensate physicians for specific services within specific time frames produce tremendous benefits. The states of Washington and Colorado have instituted measures to include medical treatment guidelines and disability management. In the Washington state system, this new system has resulted in the reduction of disability days per claim by 4.1 days and in one area near Seattle, 4,800 days of disability were avoided per 1,000 workers treated by providers in the program. This program has demonstrated that a small investment of money to incentivize providers to follow a few best practices specific to workers’ compensation patients can produce very rewarding returns in the health and satisfaction of workers, and cost-savings for employers.
ACOEM supports the adoption of a different set of ground rules for using the Current Procedural Terminology (CPT®) Evaluation and Management (E&M) codes when the visits are for workers’ compensation clinical encounters. These new rules provide guidelines for documenting many of the services relevant in workers’ compensation encounters to align them with a functional-based evaluation. The proposed changes align with the CPT/CMS guidelines for Evaluation and Management codes, adding functionality and disability risk as components in documenting history, exam and medical decision-making elements, while decreasing emphasis on history and examination elements that are not as significant in workers’ compensation encounters. The Occupational Medicine musculoskeletal specialty exam would place emphasis on functional impact and comprehensive examination of the injured body part. Details of the proposed changes may be found at www.betterworkcompcare.org.
In addition to changes to documentation guidelines for outpatient visit Evaluation and Management services, ACOEM also proposes the continued use of consultation codes in workers’ compensation, and the use of case management codes with alternative ground rules (to be developed) appropriate for workers’ compensation care.
In those instances where there are no existing CPT codes for services critical to workers’ compensation care, ACOEM proposes the adoption of new codes with ground rules for their use.
The advantages of utilizing a properly focused payment system in workers’ compensation should be clear and the incentives are significant to the workers, the workers’ compensation carriers, the employers, as well as the providers.
1 Bureau of Labor Statistics http://www.bls.gov/iif/oshwc/osh/case/osch0055.pdf