Outcome Assessments and Hydrotherapy

People swimming in a pool

Most of us have undergone Workmans’ Comp (WC) case file reviews over the last several years. Upon the receipt of the reviewer’s comments, we note that all that was recommended for approval was 6 visits. Many of us cannot understand the reasons why.

The patient had positive findings, i.e., MRI with 5-6mm protrusion, needle EMG/NCV was positive, a referral from the Orthopedic Surgeon/Neuro-surgeon/Pain Management/Family MD, etc. The file is impeccable with up-to-date exams and best of all – outcomes assessments (OA) had been utilized properly to substantiate your evidence-based case. That is, OAs are utilized with every re-examination/evaluation. What gives?

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What many do not realize is that most if not all “XYZ Guidelines” require evidence-based documentation to indicate the efficacy of your care/treatment and that the WC carriers require them as well. In addition, most likely than not, these files are being sent for review for determination of necessity and reasonableness. Therefore, how should we best show necessity, reasonableness, and most importantly efficacy? The answer is simply outcomes assessments.

I can hear it now from those that do OAs. “Hey Doc, I do them now!!” Agreed. Those that do use OA’s, are following what is expected, but are you doing them when you should?

Before I continue, let me provide you with some of my current backgrounds. I am currently on the Medical Advisory Board of the Work Comp Research Institute, where we monitor WC in 16 states that includes Illinois. I have had numerous conversations with the advisors from the WC carriers and Industry. One thing that does come up is that they are not anti-Chiropractic. If anything, they have much respect for our profession. Their problems exist with the “rogues” of the profession, as all other professions have.

Resulting from these conversations comes the following:

  • Submission of the initial narrative report with outcomes assessments.
  • Submission of progress reports with outcomes assessment.
  • Submission of office/SOAP notes with outcomes assessment.
  • Performance of the OA’s every 6 visits. 1st visit, 6th visit, 12th visit, 18th visit, etc.

One Industry advisor stated that it was imperative that they receive outcomes every 6 visits for proper payment. If that facility did not provide these submissions, payment will be denied, and if that facility continues with this pattern, they would be removed from their list of approved facilities.

So, there you have it. Follow through or don’t follow through with outcomes assessments, it’s up to you.

Use of Hydrotherapy

Additionally, I have received various phone calls from docs around the state regarding the usage of hydrotherapy. Up until recent, payment was allowed on cryotherapy, as well as hot moist packs. It appears now that these are being denied or not allowed to some degree. The following was found on the IWCC website.

“Q: Is 97010 (Hot/cold packs) reimbursable if no physical medicine procedure is provided?

A: In certain limited circumstances, CPT® code 97010 may be separately reimbursable, provided that it is not billed in conjunction with any physical therapy or chiropractic modality or evaluation. It may be necessary, however, to provide supporting clinical documentation to support that bundling should not apply.”

In addition, the following was found on an IWCC presentation: “Payment Guide: CPT® 97010 (Hot/Cold Packs) – NCCI publisher has clarified that 97010 is included in other physical medicine procedures and should not be unbundled”

Therefore, if the facility utilizes CPT® 97010 during the care of the WC patients, please note the above regarding payment for these services. One must note the following, “It may be necessary, however, to provide supporting clinical documentation to support that bundling should not apply.” So, document, document, document.

“CPT Copyright 2017 American Medical Association. All rights reserved.
CPT® is a registered trademark of the American Medical Association.”

About Author

Carlos Boileve, DC, MCS-P

After completing his schooling in Chicago, Dr. Boileve entered the National College of Chiropractic (NCC) now the National University of Health Sciences (NUHS) in 1976, graduating in 1980, and licensed in Illinois as a Chiropractic Physician.He is a Certified Medical Compliance Specialist, and on the Medical Advisory Board of the Workers' Compensation Research Institute (WCRI). Dr. Boileve is also is a Certified Insurance Consultant /Reviewer and has been on staff at the National College of Naprapathic Medicine since 2007 as an instructor in Histology, Anatomy, Embryology, Physiology, and Symptomology and Lab Interpretation.

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