IMC Guidelines and Reimbursement - Part 3

Saturday, August 3, 2002 | 0

In part 2 of this series we began looking at the guidelines published by the California Industrial Medical Council and how these can affect the payment of medical bills. We dealt with the primary assessment of low back issues. Now we will look at secondary assessment of low back problems.

Secondary assessment is defined by the IMC guidelines:

"The purpose of secondary assessment is to determine the reason for delayed recovery in a patient who has not symptomatically or functionally improved after one month of appropriate treatment"

Remember that the guidelines presume that the vast majority of patients will recover within the first month of treatment. Thus the scope of a secondary assessment goes beyond soft tissue and delves into more significant issues: Conditions involving the bony spinovertebral axis such as cancer, infection or fracture; intraspinal pathology involving the neuraxis; arthritic or inflammatory conditions; mechanical conditions; or referred low back pain due to viscerogenic and/or other causes.

Diagnostic considerations in a secondary assessment, again, are important, and dependent on assignment of the patient's condition into one of the five clinical categories above. Failure to do so may give rise to reimbursement of ordered diagnostics. The guidelines are specific as to what diagnostic test is appropriate for which clinical category the patient has been assigned. Depending on the clinical assignment, the guidelines permit the following studies: plain x-rays, specialized imaging (CT, MRI, myelography, or CT-myelography), bone scan, lab testing, EMG/NCS, functional capacity testing, ergonomic evaluation, somatosensory evoked potential and/or psychiatric evaluation.

Just as important as the list of diagnostic studies that have been declared appropriate on secondary assessments is the list of inappropriate studies: discography, surface EMG, diagnostic blocks and injections including facet joint injections and computerized strength and range of motion testing.

Secondary treatment obviously is based on the secondary assessment findings, and the guidelines approve of a course of treatment that may be up to two additional months beyond the primary first month. The list published in the guidelines starts with conservative measures, such as rehabilitative exercises, and continues through more aggressive measures including surgery and injection therapies. Notes on the specific characteristics of what is deemed appropriate should be read carefully, because even though, for example, acupuncture is deemed an appropriate treatment modality in a secondary course, the notes specifically state that "if significant subjective and objective improvement is not demonstrated, treatment is to be discontinued." Ignore the notes at the peril of your bill!

Again, the guidelines are specific as to what is inappropriate for secondary treatment: ligamentous injections (sclerotherapy/prolotherapy); laser discectomy; bed rest; chemonucleolysis and percutaneous discectomy.

Follow the guidelines, and your billing is more difficult to dispute. Remember that the biggest cost component, and growing, in workers' compensation is the medical. Physicians that want to get paid must be attentive to the requirements dictated by the governing bodies in workers' compensation.

We'll look at other areas that the IMC has guidelines for in coming articles.

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.