Prior to treating an injured employee, a medical provider should become familiar with WSI's medical policies. These policies serve to guide care and outline documentation requirements for certain medical and surgical services.
WSI considers the following types of practitioners eligible to be a primary treating provider: MD, DO, APRN, PA, DC, DPM, OD, DDS, DMD. An injured employee may only have one primary treating provider, who will manage treatment, assess functional capabilities, and identify when the injured employee achieves maximum medical improvement. The sections below describe in further detail the unique aspects of caring for an injured employee.
A primary treating provider may refer an injured employee for evaluation and/or treatment with another specialty, except for mental health, without approval from WSI. To obtain approval for a mental health referral, a provider should contact the injured employee's claims adjuster.
The assessment of an injured employee's physical capabilities is an essential part of the treatment plan. In this assessment, the primary treating provider evaluates which activities related to the work injury the employee can safely perform at home as well as at work. A capability assessment should occur at every office visit with the expectation that capabilities naturally change over time with a gradual increase in activity.
To document an injured employee's capabilities, the primary treating provider may utilize WSI's Capability Assessment Form (C3) form or a form unique to their facility. The injured employee should receive a copy of the form at every visit as this documentation assists their employer in developing a return to work plan. The treating provider must complete the capability form in addition to, but not as a substitute for, medical documentation.
The primary treating provider may refer an injured employee to a physical or occupational therapist to conduct a workability assessment when a more objective measurement of abilities is necessary. This assessment includes physical performance testing to evaluate the injured employee's ability to complete specific tasks. The workability assessment should occur prior to the injured employee's office visit as it is the treating provider's responsibility to review the therapist's recommendations in order to assess the injured employee's capabilities.
The primary treating provider has an important role in helping an injured employee stay at work or return to work as soon as medically reasonable and safe. Early in the course of treatment, the treating provider should discuss the healing process and expected recovery time with the injured employee. Research shows an injured employee who returns to activity (including light duty work) has a speedier recovery and a reduced risk of becoming disabled from most work injuries. The treating provider should emphasize the positive role of activity on physical and psychological healing. This includes advising the injured employee to remain as active as possible, stressing maximal functional recovery depends on it.
The primary treating provider is responsible for notifying WSI when an injured employee reaches maximum medical improvement (MMI). MMI is the point at which an injured employee's medical condition is stable and further improvement is unlikely regardless of additional medical treatment.
WSI relies on the primary treating provider's accurate and timely designation of MMI to help guide claim management decisions. Depending on the extent of injury, the designation of MMI status may prompt WSI to initiate one or more of the following actions:
- Review for future medical treatment needs
- Confirm return to work without restrictions
- Coordinate with the employer to assess availability of a permanent, modified job placement
- Request work hardening/conditioning
- Request a functional capacity evaluation
- Assign vocational rehabilitation
- Schedule a permanent partial impairment (PPI) rating
The treating provider should notify WSI of an injured employee's MMI status as soon as possible by documenting the information in one of the following as appropriate:
Permanent Partial Impairment (PPI) is a significant loss of, or loss of the use of, a body part or function arising from a work injury, which remains after an injured employee has reached maximum medical improvement (MMI). If the PPI estimate is greater than or equal to 14% of whole-body function, an injured employee is eligible for a formal PPI evaluation.
Below are the significant aspects of the PPI process:
- An injured employee's treating provider(s) cannot perform the PPI evaluation.
- All body parts included in a claim must reach MMI before WSI will schedule a PPI evaluation.
- When an injured employee is eligible, WSI will schedule a PPI evaluation with a third-party examiner.
- A PPI examiner must calculate the PPI rating in accordance with the 6th Edition of the American Medical Association (AMA) Guides to Permanent Partial Impairment.
- For a PPI rating exceeding 14% whole body, WSI issues a one-time monetary award. See North Dakota Century Code (N.D.C.C.) § 65-05-12.
- An impairment award for amputation, loss of vision, or loss of an eye is exempt from the PPI rating process and is separately payable. See N.D.C.C. § 65-05-12.
Outlined below are the unique aspects of injured employee care specific to the following provider types:
Initial chiropractic treatment on a claim does not require prior authorization for the first 10 visits or 60 days of care, whichever comes first. WSI refers to this as a window period. Treatment occurring outside of a window period requires prior authorization. For additional information, visit the Prior Authorization section.
Evaluation and Management Services
An evaluation and management (E&M) service is separately reimbursable in addition to a chiropractic manipulation when medically necessary to treat a work injury. WSI considers an E&M service medical necessary to:
- Complete an initial evaluation to establish a treatment plan
- Assess an injured employee's functional capabilities (only applicable when a chiropractor is the primary treating provider)
- Request prior authorization for additional visits
- Evaluate an injured employee with an exacerbated condition or a condition failing to improve
- Evaluate an injured employee who has a lapse in care
Palliative Care may be medically appropriate for an injured employee who has reached maximum medical improvement (MMI). All palliative care requires prior authorization.
WSI requires legible medical documentation accompany each dental bill. Documentation must specify the extent of injury and the treatment provided. WSI also requests a dental provider complete the Dentist's Report of Injury (C31) form for each of the following:
- Initial evaluation
- Major change in the condition or treatment plan
- Discharge from care
WSI's policy for reimbursement of dental treatment may significantly differ from a traditional dental insurance plan. A dental provider should review the Dental Fee Schedule Guideline for complete information.
WSI requires a referral from a primary treating provider for therapy treatment. Initial therapy treatment on a claim does not require prior authorization for the first 10 visits or 60 days of care, whichever comes first. WSI refers to this as an initial window period. A therapist may also provide treatment without prior authorization during a post-operative window period of 10 visits or 60 days of care, whichever comes first. All therapy occurring outside of a window period requires prior authorization. For additional information on window periods and authorization procedures, visit the Prior Authorization section.
Initial Evaluation and Re-evaluation
WSI reimburses for an initial evaluation to establish a diagnosis and prognosis prior to intervention. Transfer of care to a new therapist of the same discipline within a practice does not require a new evaluation and is not reimbursable.
During any given episode of care, a treating therapist may perform a re-evaluation for the follow circumstances:
- Unanticipated improvement, exacerbation, or change of condition
- Initiation of treatment for a new body part
- Lapse in care (longer than two weeks)
WSI requires a therapist document time-based services in accordance with the Physical Medicine and Rehabilitation Time-Based Services Medical Policy.
A primary treating provider may refer an injured employee to a PT/OT for a workability assessment to obtain an objective measurement of functional capabilities. This assessment should include physical performance testing or measurements to evaluate an injured employee's ability to complete specific tasks. WSI does not require prior authorization for a workability assessment meeting the following criteria:
- Ordered by the primary treating provider
- Performed within 2 days of a scheduled office visit
- Performed no more often than once every 2 weeks
- Does not exceed 3 units (>38 through 52 minutes)
WSI requires the use of CPT® 97750 when billing for a workability assessment.
Work Conditioning/Work Hardening
An injured employee who reaches MMI but exhibits functional deficits or deconditioning may require additional therapeutic intervention to maximize their physical ability to return to work. In such circumstances, a primary treating provider may recommend work conditioning (WC) or work hardening (WH). WSI does not differentiate between WC/WH. If WSI authorizes these services, a provider should bill using CPT® 97545 for the initial 2 hours and CPT® 97546 for each additional hour.
Functional Capacity Evaluation (FCE)
A primary treating provider may refer an injured employee who has reached MMI to a PT/OT for a functional capacity evaluation (FCE) to address whether permanent restrictions apply. An FCE is an evaluation which provides objective, directly observed measurements of an injured employee's ability to perform a variety of physical tasks commonly encountered in a work environment. Only a PT/OT who is FCE certified may perform the evaluation. An FCE requires prior approval from the injured employee's claims adjuster. If approved, a provider should bill this service using WSI-specific code W0540.
PTA, COTA, ATC
Treatment provided by a PTA, COTA, or ATC is allowable when performed under the direction of a PT/OT. A PTA, COTA, or ATC should be aware of the following parameters:
- Treatment must follow the plan of care established by the PT/OT
- PT/OT must perform an assessment every sixth visit or 30 days, whichever comes first
- Examinations, evaluations, diagnoses, prognoses and outcomes are the sole responsibility of the PT/OT
WSI does not reimburse for treatment provided by a PT Aide/Technician.