PERMANENT RULES
LABOR AND INDUSTRIES
Date of Adoption: December 22, 1999.
Purpose: To rewrite WAC 296-20-06101, concerning health care provider reporting requirements, in clear rule writing format. The rewrite complies with Executive Order 97-02 on regulatory improvement.
Citation of Existing Rules Affected by this Order: Amending WAC 296-20-06101.
Statutory Authority for Adoption: RCW 51.04.020, 51.04.030, 51.36.060.
Adopted under notice filed as WSR 99-20-139 on October 6, 1999.
Number of Sections Adopted in Order to Comply with Federal Statute: New 0, Amended 0, Repealed 0; Federal Rules or Standards: New 0, Amended 0, Repealed 0; or Recently Enacted State Statutes: New 0, Amended 0, Repealed 0.
Number of Sections Adopted at Request of a Nongovernmental Entity: New 0, Amended 0, Repealed 0.
Number of Sections Adopted on the Agency's Own Initiative: New 0, Amended 1, Repealed 0.
Number of Sections Adopted in Order to Clarify, Streamline, or Reform Agency Procedures: New 0, Amended 1, Repealed 0.
Number of Sections Adopted Using Negotiated Rule Making: New 0, Amended 0, Repealed 0; Pilot Rule Making: New 0, Amended 0, Repealed 0; or Other Alternative Rule Making: New 0, Amended 1, Repealed 0. Effective Date of Rule: January 24, 2000.
December 22, 1999
Gary Moore
Director
OTS-3379.2
AMENDATORY SECTION(Amending WSR 93-16-072, filed 8/1/93,
effective 9/1/93)
WAC 296-20-06101
((Reporting requirements.)) What reports
are health care providers required to submit to the insurer?
((The department or self-insurer requires several kinds of
reports at various stages of the claim in order to authorize
treatment, time loss compensation, and treatment bills. For
additional information refer to the medical aid rules and fee
schedules.
Initial report of accident: The first report required is the report of accident. The report of accident qualifies as the office note or report of the initial visit for Level 1 or 2 office calls. In addition to the office call charge, the doctor may bill for the filing of the accident report. Reimbursement of these services will be paid if the claim is allowed by the department or self-insurer. If the initial visit is a transfer case, a report is required. Billing for a Level 3, 4, or 5 initial visit may require submission of additional reports as required by department policy.
Office notes: Legible copies of office or progress notes are required for all follow-up visits. Office notes are not acceptable in lieu of requested narrative reports.
Sixty-day narrative reports: When conservative treatment is to continue beyond sixty days, submission of a narrative report is required to substantiate the need for continued care. A narrative report must contain basic information contained in chapter 296-20 WAC, or as determined by department policy. For this narrative report, the department or self-insurer will pay at a rate determined by department policy for a routine report in addition to a routine office call if the call is needed to provide the information. If the doctor supplies additional comprehensive information in the report, payment of a charge submitted in excess of the allowed fee will be considered. In most cases, payment for a narrative report in addition to a Level 3, 4, or 5 office visit will not be considered as the fee for those services includes a comprehensive report. A narrative report should be described as a "sixty-day report."
Consultations reports: Following one hundred twenty days of conservative care (nonsurgical cases), a consultation with the doctor of the attending doctor's choice is required to substantiate further treatment authorization. No prior authorization is required for such consultations. The department or self-insurer should be notified via a consultation referral form (LI-210-299). The consultant is responsible for submitting a copy of the report as outlined in chapter 296-20 WAC, or as determined by department policy, along with the bill to the department or self-insurer.
Follow-up reports: Following the one-hundred twenty day consultation, narrative reports are required at sixty-day intervals as outlined in chapter 296-20 WAC. The department or self-insurer will request additional consultations and/or special exams as warranted by the individual case.
Hospital reports: When workers are hospitalized it is the responsibility of the doctor to submit the reports to the hospital for submission with the hospital billing. The doctor may bill for hospital visits without attaching copies of the reports. However, billing for operative procedures requires a copy of the operative report.
Reopening application: On claims closed over sixty days, the department or self-insurer will pay for completion of a reopening application, an office visit and diagnostic studies necessary to complete the application. (See chapter 296-20 WAC.) No other benefits will be paid until the adjudication decision is rendered.)) The department or self-insurer requires different kinds of information at various stages of a claim in order to approve treatment, time loss compensation, and treatment bills. The department or self-insurer may request the following reports at specified points in the claim. The information provided in these reports is needed to adequately manage industrial insurance claims.
| Report | Due/Needed by Insurer | What Information Should Be Included In the Report? | Special Notes |
| Report of Industrial Injury or Occupational Disease (form) | Immediately - within five days of first visit. | See form | Only MD, DO, DC, ND, DPM, DDS, and OD may sign and be paid for completion of this form. |
| Self-Insurance: Physician's Initial Report (form) | If additional space is needed, please attach the information to the application. The claim number should be at the top of the page. | ||
| Sixty Day (narrative)
|
Every sixty days when only conservative (nonsurgical) care has been provided. | (1) The conditions diagnosed, including ICD-9-CM codes and the subjective complaints and objective findings. | Providers may submit legible comprehensive chart notes in lieu of sixty day reports PROVIDED the chart notes include all the information required as noted in the "What Information Should Be Included?" column. |
| (2) The relationship
of diagnoses, if any,
to the industrial injury
or exposure.
|
However, office notes are not acceptable in lieu of requested narrative reports and providers may not bill for the report if chart notes are submitted in place of the report. | ||
| Please see WAC 296-20-03021 and 296-20-03022 for documentation requirements for those workers receiving opioids to treat chronic noncancer pain. | |||
| (4) Current medications, including dosage and amount prescribed. With repeated prescriptions, include the plan and need for continuing medication. | Providers must include their name, address and date on all chart notes submitted. | ||
| (5) If the worker has not returned to work, indicate whether a vocational assessment will be necessary to evaluate the worker's ability to return to work and why. | |||
| (6) If the worker has not returned to work, a doctor's estimate of physical capacities should be included. | |||
| (7) Response to any specific questions asked by the insurer or vocational counselor. | |||
| Special Reports/Follow-up Reports (narrative) | As soon as possible following request by the department/insurer. | Response to any specific questions asked by the insurer or vocational counselor. | "Special reports" are payable only when requested by the insurer. |
| Consultation Examination Reports (narrative) | At one hundred twenty days if only conservative (nonsurgical) care has been provided. | (1) Detailed history.
|
If the injured/ill
worker had been seen
by the consulting
doctor within the past
three years for the
same condition, the
consultation will be
considered a
follow-up office
visit, not
consultation. A copy of the consultation report must be submitted to both the attending doctor and the department/insurer. |
| Purpose: Obtain an objective evaluation of the need for ongoing conservative medical management of the worker. | |||
| The attending doctor may choose the consultant. | (4) Condition(s) diagnosed including ICD-9-CM codes, subjective complaints and objective findings. | ||
| (5) Outline of proposed treatment program: Its length, components, expected prognosis including when treatment should be concluded and condition(s) stable. | |||
| (6) Expected degree of recovery from the industrial condition. | |||
| (7) Probability of returning to regular work or modified work and an estimated return to work date. | |||
| (8) Probability, if any, of permanent partial disability resulting from the industrial condition. | |||
| (9) A doctor's estimate of physical capacities should be included if the worker has not returned to work. | |||
| (10) Reports of necessary, reasonable x-ray and laboratory studies to establish or confirm diagnosis when indicated. | |||
| Supplemental Medical Report (form) | As soon as possible following request by the department/insurer. | See form | Payable only to the attending doctor upon request of the department/insurer. |
| Attending Doctor Review of IME
Report (form) Purpose: Obtain the attending doctor's opinion about the accuracy of the diagnoses and information provided based on the IME. |
As soon as possible following request by the department/insurer. | Agreement or disagreement with IME findings. If you disagree, provide objective/subjective findings to support your opinion. | Payable only to the attending doctor upon request of the department/insurer. |
| Loss of Earning Power (form) | As soon as possible after receipt of the form. | See form | Payable only to the AP. |
| Purpose: Certify the loss of earning power is due to the industrial injury/occupational disease. | |||
| Application to Reopen Claim Due to Worsening of Condition (form) | Immediately following identification of worsening after a claim has been closed for sixty days. | See form | Only MD, DO, DC, ND, DPM, DDS, and OD may sign and be paid for completion of this form. |
| Purpose: Document worsening of the accepted condition and need to reopen claim for additional treatment. | Crime Victims: Following identification of worsening after a claim has been closed for ninety days. |
What documentation is required for initial and follow-up visits?
Legible copies of office or progress notes are required for the initial and all follow-up visits.
What documentation are ancillary providers required to submit to the insurer?
Ancillary providers are required to submit the following documentation to the department or self-insurer:
| Provider | Chart Notes | Reports |
| Audiology | X | X |
| Biofeedback | X | X |
| Dietician | X | |
| Drug Alcohol Treatment | X | X |
| Free Standing Surgery | X | X |
| Free Standing Emergency Room | X | X |
| Head Injury Program | X | X |
| Home Health Care | X | |
| Infusion Treatment, Professional Services | X | |
| Hospitals | X | X |
| Laboratories | X | |
| Licensed Massage Therapy | X | X |
| Medical Transportation | X | |
| Nurse Case Managers | X | |
| Nursing Home | X | X |
| Occupational Therapist | X | X |
| Optometrist | X | X |
| Pain Clinics | X | X |
| Panel Examinations | X | |
| Physical Therapist | X | X |
| Prosthetist/Orthotist | X | X |
| Radiology | X | |
| Skilled Nursing Facility | X | X |
| Speech Therapist | X | X |
[Statutory Authority: RCW 51.04.020, 51.04.030 and 1993 c 159. 93-16-072, § 296-20-06101, filed 8/1/93, effective 9/1/93. Statutory Authority: RCW 51.04.020(4) and 51.04.030. 86-06-032 (Order 86-19), § 296-20-06101, filed 2/28/86, effective 4/1/86. Statutory Authority: RCW 51.04.020(4), 51.04.030, and 51.16.120(3). 81-24-041 (Order 81-28), § 296-20-06101, filed 11/30/81, effective 1/1/82; 81-01-100 (Order 80-29), § 296-20-06101, filed 12/23/80, effective 3/1/81; Order 74-39, § 296-20-06101, filed 11/22/74, effective 1/1/75.]