IMC Guidelines and Reimbursement - Neck Part 2

Monday, September 2, 2002 | 0

As with back cases, the Industrial Medical Council (IMC) has broken down neck injuries into three time frames relative to treatment: first month, second through third months, and more than three months. Treatment outside of what is deemed appropriate by the IMC during those time frames won't be paid for by the insurance company, so familiarity with what is acceptable is key to getting paid.

The IMC guidelines are specific relative to the goals of treatment: "The purpose of the initial treatment of neck injuries is to relieve pain and suffering and to restore functional capacity. The goal is to allow the injured worker to resume necessary activities including return to modified or regular work. Injured workers with radicular neck problems and neurologic deficits may require more intensive management and closer monitoring for further neurologic deterioration that may require additional diagnostic testing with possible surgical treatment."

I don't need to go into the specific guideline options item by item - you can read them on the IMC web site at www.dir.ca.gov/IMC/neck.html. What is important to note is the order in which treatment options are delineated - there is an underlying clue in this order: conservative measures are most highly favored, especially those that utilize return to work strategies as much as possible, and avoid medication or other physical treatments as much as possible.

Especially during the first four weeks of treatment, the Guidelines emphasize a constant reevaluation of the injured workers' condition:

Management during the first four weeks of treatment will be determined by the clinician's evaluation of the injured worker's response to therapy. Generally, re-evaluation of the problem, determination of treatment effectiveness and work status should be performed every one-two weeks until return to modified or full work is achieved. At each visit, the initial diagnosis should be confirmed or modified and the treatment plan adjusted if necessary."

When the injured worker continues treatment past the first month post injury, then the Guidelines assume a more serious physical condition, and the clinician should reassess the patient with the goal of making a diagnosis into one of five clinical categories. Diagnostic studies effective for ruling out various maladies within each of these categories are discussed and will be deemed appropriate if clinical indications warrant. Avoid the temptation to use diagnostics to place the patient into one of the categories; rather diagnostics should be used to confirm such placement and direct appropriate treatment. The Guidelines provide specifically what is an appropriate assessment tool based on clinical indications. Your reporting needs follow these recommendations. Detail what the clinical indications are, and what is to be achieved using the proposed assessment method.

Again, the Guidelines provide ample detail on what is and isn't appropriate for treatment during a secondary phase plan, and state that reassessment should occur AT LEAST every two weeks, and that results of all studies should be reviewed and reported on within a week of the assessment.

The Guidelines assume that the vast majority of cases are going to resolve during a secondary treatment phase:

"If the injured worker has not resumed near normal work duties after eight weeks in the secondary treatment phase, including adherence to a graded exercise program, a referral to a physician or surgeon trained and experienced in the evaluation and treatment of occupational disorders is recommended. Consultation should include a complete evaluation and recommendations for treatment and return to appropriate work. If psychosocial issues are judged to contribute to delayed recovery or heightened disability, it may be appropriate to have a psychiatric evaluation. If the condition becomes chronic or disabling despite full conservative treatment including appropriate medical, rehabilitative, and ergonomic interventions (and surgery if indicated), the injured worker should be evaluated for permanent disability."

The Guidelines do not go into chronic neck problems, so use of good medical sense prevails. The probability is that if a neck injury does to into the tertiary phase of treatment the condition is extremely serious, warranting more serious treatment discussions with the claims examiner. These should be documented in detail, with a complete history of all assessment and treatment to date giving rise to the more radical treatment being considered.

The Guidelines are your billing resource, but when the Guidelines are silent, you need to speak to the claims examiner so that BOTH of you come to some agreement on a treatment plan.

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.