New York Workers Compensation Critical Update: Part 1

US Chiropractic Directory

from the desk of:

Mark Studin DC, FASBE(C), DAAPM, DAAMLP

"NYS W/C Critical Update: Part 1"

Disclaimer: This opinion does not reflect any organization, including but not limited to the US Chiropractic Director or any state or national organization. It is the sole opinion of Dr. Mark Studin and is intended to be a tutorial for the new NYS W/C Guidelines, effective 12-1-2010. Each doctor has to base their utilization of the guidelines, codes and treatment plans based upon the clinical findings of their individual patients.
 

The first step in the new W/C Guidelines is to understand that this system is driven by a combination of clinical and test results along with functional ability and improvement. You must also understand that these are acute care guidelines and not chronic care guidelines. The chronic care guidelines are in the process of being created and we have been invited to the table to help create those.

For now, while there are no long-term guidelines for chronic care, we must work with the set of rules in our hands and make them work for our patients.

The first step is to go to: http://www.wcb.state.ny.us/content/main/hcpp/MedicalTreatmentGuidelines/Training/MTG_CCE.jsp

At that site, you will find both the training and the Neck and Mid-Low Back Guidelines that outlines what needs to be done and how long you get for each service.

You also need to secure the fee schedule from Ingenix at: https://www.shopingenix.com/SearchResults.aspx?SearchTerm=1986

These are the tools required to work within the system and I urge you not to infract copyright laws and purchase them.

The new rules now unbundle the services of a chiropractor and the "old" 99213 for everything we do is no longer valid as of 12-1-2010 and will be correctly denied form the carriers.

The first thing you have to learn is the rules and the new WC Fee Schedule has 4 sections and each have their own set of rules that does only is valid for the specific section.

For instance, in the physical medicine section it states in Rule 3 of the guidelines that reimbursement is limited to 8 RUV's or Relative Value Units per day no matter how many units or relative values are billed. As an example, if you are performing a 98941 that has a relative unit value of 6 units and a 97124 that has a value of 2.62, which equals 8.62 units, you will only be reimbursed 8 units in total for the day.

As simple as this sounds, many doctors have argued with me incorrectly that we can perform 8 individual items and each individual item is considered 1 unit. that is an incorrect assumption and will both get you denied for billing anything over the 8 relative value units and leave you open to overutilization inquires.

To get the dollar amount, simply multiply your region dollar conversion factor found on page 3 of the NYS W/C Fee Schedule in the section "Introduction and Guidelines." Also pay careful attention to the rules that allow you to bill services on the same day as the initial evaluation (13.5 RVU's) or on the re-evaluation (11 RVU's.)

In order to certify care you need a complete examination that covers everything we were all taught in school. If your evaluation is not complete, you can get one at: http://teachchiros.com/index.php/forms-a-templates or any other reliable source. I n addition, you need complete SOAP notes and travel cards are one of those things that we should all evolved away from decades ago because they will be the cause of retrospective audits. Should you need a SOAP template, go to: http://teachchiros.com/index.php/forms-a-templates or any other reliable source.

A critical requirement is to document improvement in the status of your patient and the easiest way to do so is through ranges of motion and muscle testing.

I also strongly recommend that you bring in an independent company, Professional Healthcare Services, (http://functionalevaluations.com/ or 800-381-3108) to do an independent functional evaluation of your patient at different intervals on care to document the ongoing necessity for continued care.

Co-morbidity is important. If your patient has a herniated disc, radiculopathy, diabetes or any other type of problem that will necessitate more care, than these tests need to be ordered and documented as to the reasons why care is important. If you need more education on any of these issues, go to: www.TeachDoctors.com and take online CE courses to increase your knowledge base.

These guidelines are applicable to patients in all 50 states that are covered by NYS Workers Compensation. It has been suggested that if a patient lives in Connecticut, New Jersey, Ohio or any other state that the guidelines do not apply and that is false.

The process of variances are quite simple; if you need to treat beyond the recommended guidelines, you have to file a variance and the carrier has 1`5 days to respond. The carrier may opt to do an IME and that gives them 30 days to schedule the IME and then respond to you. In my opinion, you should rarely need to file for a variance and give your patient the care they need.

In order to understand the process and make it work for you, you have to accept that a patient needs more care than adjusting/manipulation. Yes, I said manipulation because who gives a crap, other than us the language used because it is the SAME THING.

We were all taught in professional school that our goal is to diagnose, prognose, create a treatment plan and then deliver that treatment plan. In doing so, our treatment plan is to reduce the acute sequella of the causality of the subluxation and the effects thereof and then work to make the structural correction. Once that has been accomplished we are to strengthen the correction and the person is "good to go" unless they choose wellness care.

The Workers Compensation system is for the expressed purposes of brining the patient back to their pre-injury status and not to fix all of their problems, nor to render wellness care. Therefore our job is to attend to the acute phase with passive care and then transition the patient to active care in the form of exercise and neuromuscular re-education so that their spines are stabilized.

A pitfall of the "Acute Care Guidelines" that we have been forced to accept is that the manipulation/adjustment is limited, while other forms of treatment take precedent.

In the next "Critical Update" I will show you how to work within the system in order to accomplish that goal. I am doing this with the NYS W/C Board Legal Department to get a finite answer so that my recommendations do not put you in "harm's way" with what I think common sense, but a lawyer working for a regulatory agency disagrees with and will hold you liable. Please remember that the allegiance of the lawyers for the W/C Board is with the carrier and not the people of the State of New York and certainly not with the doctors who have to provide the services. Although they are supposed to simply interpret the law, their immediate reaction is that my questions are too difficult and have to be brought to the medical director's office of the Workers Compensation Board.

Factually, I ask for a legal opinion and they immediately move it to the political arena. You do the math!

Critical Update Part 2: Sample Treatment Plans; 2 weeks to 24 weeks depending upon clinical necessity