Prior to treating an injured worker, a medical provider should be familiar with WSI's medical policies available under the Medical Policies section. WSI's medical policies are intended to guide care and documentation requirements for certain medical/surgical services.
WSI considers the following types of practitioners to be a primary treating provider: MD, DO, APRN, PA, DC, DPM, OD, DDS, DMD. An injured worker may only have one primary treating provider. The primary treating provider manages treatment, assesses functional capabilities, and identifies when maximum medical improvement has been achieved. These unique aspects of injured worker care are described in further detail below.
A primary treating provider may refer an injured worker for evaluation and/or treatment with another specialty without approval from WSI, with the exception of mental health. To obtain approval for a mental health referral, a provider should contact the injured worker's claim adjuster.
The assessment of an injured worker'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 injured worker can safely perform at home as well as at work. A capability assessment should be done at every office visit and naturally change over time with an anticipated gradual increase in activity.
To document an injured worker's capabilities, the primary treating provider may utilize a form unique to their facility or WSI's Capability Assessment Form (C3) form. At each visit, the primary treating provider should give a written capability assessment form to the injured worker. This documentation assists the injured worker and their employer to develop a return to work plan. The primary treating provider should complete the capability form in addition to, but not as a substitute for medical documentation.
The primary treating provider may refer to a physical or occupational therapist to conduct a workability assessment when an objective measurement of the injured worker's abilities is deemed necessary. This assessment includes physical performance testing or measurements to evaluate the injured worker's ability to perform specific tasks. The workability assessment should be completed prior to the injured worker's office visit. It is the treating provider's responsibility to review the therapist's recommendations in order to assess the injured worker's capabilities.
The primary treating provider has an important role in helping an injured worker 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 times with the injured worker. Research shows an injured worker 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 worker to remain as active as possible, stressing the maximal functional recovery depends on this.
Key messages regarding the benefits of early return to work include the following:
- Return to work as soon as possible is good medicine
- Return to work is good for health
- Recovery at work should be encouraged
The primary treating provider is responsible for notifying WSI when a injured worker reaches maximum medical improvement (MMI). MMI is the point at which an injured worker'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 the injured worker's 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 of injury to assess availability of a permanent, modified job placement
- Request work hardening/conditioning
- Request functional capacity evaluation
- Assign vocational rehabilitation
- Schedule a permanent partial impairment (PPI) rating
The treating provider should notify WSI as soon as possible of an injured worker's MMI status by documenting this information in one of the following:
Permanent Partial Impairment (PPI) is a significant impairment, loss of use, or loss of a body part or body function that arises from a work injury, which remains after an injured worker has reached maximum medical improvement (MMI). If the PPI is estimated to be greater than or equal to 14% of whole-body function, an injured worker is eligible for a formal PPI evaluation.
Below are significant aspects of the PPI process:
- An injured worker's treating provider(s) cannot perform the PPI evaluation
- All body parts included in a claim must reach MMI status before WSI will schedule a PPI evaluation
- When an injured worker is deemed 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 unique aspects of injured worker care specific to the following provider types:
Initial chiropractic treatment on a claim is reimbursable without 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 and E&M service medical necessary to:
- Complete an initial evaluation to establish a treatment plan
- Assess and establish an injured worker's functional capabilities (applicable when a chiropractor is the primary treating provider)
- Request prior authorization for additional visits
- Evaluate an injured worker whose condition is exacerbated or failing to improve
- Evaluate an injured worker who has a lapse in care
Palliative Care may be medically appropriate for an injured worker who has reached maximum medical improvement (MMI). All palliative care requires prior authorization.
A dental provider must submit legible medical documentation for each visit, which specifies the extent of the injury and 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 to a PT/OT 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 a condition
- Initiation of treatment for a new body part
- Lapse in care (longer than two weeks)
WSI requires a therapist a 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 worker 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 which evaluate an injured worker's ability to perform 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 schedule office visit
- Performed no more often than once every 2 weeks
- Does not exceed 3 units (>38 through 52 minutes)
Work Conditioning/Work Hardening
An injured worker 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.
Functional Capacity Evaluation (FCE)
A primary treating provider may refer an injured worker 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 worker'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 worker's claim adjuster.
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 assessment every sixth visit or 30 days, whichever comes first
- Examinations, evaluations, diagnosis, prognosis and outcomes are the sole responsibility of the PT/OT
WSI does not reimburse for treatment provided by a PT Aide/Technician.