IMC Guidelines and Reimbursement - Part 2

Sunday, July 21, 2002 | 0

The first article in this series discussed generally the IMC Guidelines and their importance in the review and payment of medical bills. Now we will start looking at some of the specific guidelines and how they impact your practice in the treatment of injured workers and medical reporting. Remember that these guidelines can affect the payment of your bills.

Since orthopedic cases are by far and away the most common types of injuries reported in work comp, we'll start with a review of IMC guidelines for the most common orthopedic injuries, those to the low back. The full text of the guidelines for the low back are available on the Internet at the IMC web site at http://www.dir.ca.gov/IMC/lowback.html. It is suggested that you refer to these guidelines as we go through this discussion.

The IMC gives a substantial clue as to how the WCAB is going to look at treatment of the low back right up front in the Introduction:

In the majority of injured workers with low back problems, recovery occurs within the first month of symptoms. Those who have not improved at the end of one month of treatment may need further diagnostic evaluation and consideration of other treatment options.

Looking at this statement from a claims examiner's viewpoint, if the majority of YOUR low back cases aren't resolving in a month, then something is wrong, and your treatment and report billings are going to be red flagged.

The initial assessment is critical and will determine the course of the treatment as well as how the management of the case will be set up from the outset by the carrier. Note the guidelines state that you should assign a diagnosis from one of five clinical categories: Conditions involving the bony spinovertebral axis, intraspinal pathology involving the neuraxis, arthritic or inflammatory conditions, mechanical conditions or, referred low back pain due to viscerogenic and/or other causes.

The next issue the guidelines discuss is the history and physical. The requirement of taking a good, thorough, and accurate history cannot be over stated. Review the history with the patient several times, in different settings, and using different personnel. Changes, disparities, and/or inaccuracies in the medical history of a litigating injured worker is the single biggest defense the carriers and their defense counsel have. Seemingly small inaccuracies on the initial intake can turn into monster holes that are impossible to fill. Your job as a physician is part historian. The guidelines specifically state, "A thorough physical examination that is based upon the appropriate history and presentation of the patient is expected." Failure to do this well increases the risk that your services will not be compensated!

The guidelines tell you what is expected as part of a "thorough physical examination". While a check-list may be helpful to you so that you remember all of the various aspects discussed in the guidelines, avoid reliance on a standard that is incorporated in every medical report you are supposed to be examining each patient individually who presumably would have different assessment needs because of differences in pathology, history of injury, and physical/mental attributes.

The guidelines discuss what is expected in each of the five clinical categories for assessment and diagnosis. They are not repeated here. However, note that the guidelines are very specific about what is NOT acceptable for the initial visit:

All of the following assessment methods have been determined inappropriate during the initial phase of assessment. (All are Appropriateness level 1.)
Routine use of:
1.3.1 Laboratory studies
1.3.2 Lumbar x-rays
1.3.3 CT, MRI, myelography, CT-myelography, and bone scan
1.3.4 Discography
1.3.5 Electromyography (EMG)
1.3.6 Computerized strength and range of motion testing

Claims examiners are trained to keep an eye out for these anomalies, and you will not be reimbursed if you venture into these areas on the initial visit.

Finally, for purposes of this discussion, the guidelines are, again, very specific about what treatment is appropriate for the initial course:

Treatment may include: 1) education about back problems and theirprevention 2) activity and environmental modifications 3) exercise 4) medication and/or 5) physical treatments

The guidelines discuss each of these items in detail, especially medication.

The careful physician should also read the "Medical Management for Claims Examiners" series on this web site for further insight as to what those adjusting your bills will be looking for.

The next article in this series will review the guidelines on secondary assessment of low back problems.

Authored by Denyse Shaw of Comp Pro Insurance Services, matching vendors to the specific needs of administrators and carriers. She can be reached at 916-944-7870, or by e-mail at denysekshaw@earthlink.net.