Washington Administrative Code › Title 296 - Labor and Industries, Department of › Chapter 296-20 - Medical aid rules › Section 296-20-01002 - Definitions

Current through Register Vol. 24-14, July 15, 2024
Acceptance, accepted condition:
Determination by
				a qualified representative of the department or self-insurer that reimbursement
				for the diagnosis and curative or rehabilitative treatment of a claimant's
				medical condition is the responsibility of the department or self-insurer. The
				condition being accepted must be specified by one or more diagnosis codes from
				the current edition of the International Classification of Diseases, Clinically
				Modified (ICD-CM).
Appointing authority:
For the evidence-based
				prescription drug program, the appointing authority shall mean the following
				people acting jointly: The director of the health care authority and the
				director of the department of labor and industries.
Attendant care:
Those proper and necessary
				personal care services provided to maintain the worker in his or her residence.
				Refer to WAC
				296-23-246 for more
				information.
Attending provider:
For these rules, means a
				person licensed to independently practice one or more of the following
				professions: Medicine and surgery; osteopathic medicine and surgery;
				chiropractic; naturopathic physician; podiatry; dentistry; optometry; and
				advanced registered nurse practitioner. An attending provider actively treats
				an injured or ill worker.
Attending provider report:
This type of report may
				also be referred to as a "60 day" or "special" report. The following
				information must be included in this type of report. Also, additional
				information may be requested by the department as needed.
(1) The condition(s) diagnosed including the current federally
				adopted ICD-CM codes and the objective and subjective findings.
(2) Their relationship, if any, to the industrial injury or
				exposure.
(3) Outline of proposed treatment program, its length,
				components, and expected prognosis including an estimate of when treatment
				should be concluded and condition(s) stable.
An estimated return to work date should be included. The
				probability, if any, of permanent partial disability resulting from industrial
				conditions should be noted.
(4) If the worker has not returned to work, the attending
				doctor should indicate whether a vocational assessment will be necessary to
				evaluate the worker's ability to return to work and why.
(5) If the worker has not returned to work, a doctor's estimate
				of physical capacities should be included with the report. If further
				information regarding physical capacities is needed or required, a
				performance-based physical capacities evaluation can be requested.
				Performance-based physical capacities evaluations should be conducted by a
				licensed occupational therapist or a licensed physical therapist.
				Performance-based physical capacities evaluations may also be conducted by
				other qualified professionals who provided performance-based physical
				capacities evaluations to the department prior to May 20, 1987, and who have
				received written approval to continue supplying this service based on formal
				department review of their qualifications.
Authorization:
Notification by a qualified
				representative of the department or self-insurer that specific proper and
				necessary treatment, services, or equipment provided for the diagnosis and
				curative or rehabilitative treatment of an accepted condition will be
				reimbursed by the department or self-insurer.
Average wholesale price (AWP):
A pharmacy
				reimbursement formula by which the pharmacist is reimbursed for the cost of the
				product plus a mark-up. The AWP is an industry benchmark which is developed
				independently by companies that specifically monitor drug pricing.
Baseline price (BLP):
Is derived by calculating
				the mean average for all NDC's (National Drug Code) in a specific product
				group, determining the standard deviation, and calculating a new mean average
				using all prices within one standard deviation of the original mean average.
				"Baseline price" is a drug pricing mechanism developed and updated by First
				Data Bank.
Bundled codes:
When a bundled code is covered,
				payment for them is subsumed by the payment for the codes or services to which
				they are incident. (An example is a telephone call from a hospital nurse
				regarding care of a patient. This service is not separately payable because it
				is included in the payment for other services such as hospital visits.) Bundled
				codes and services are identified in the fee schedules.
By report:
BR (by report) in the value column of
				the fee schedules indicates that the value of this service is to be determined
				by report (BR) because the service is too unusual, variable or new to be
				assigned a unit value. The report shall provide an adequate definition or
				description of the services or procedures that explain why the services or
				procedures (e.g., operative, medical, radiological, laboratory, pathology, or
				other similar service report) are too unusual, variable, or complex to be
				assigned a relative value unit, using any of the following as indicated:
(1) Diagnosis;
(2) Size, location and number of lesion(s) or proce-dure(s)
				where appropriate;
(3) Surgical procedure(s) and supplementary
				proce-dure(s);
(4) Whenever possible, list the nearest similar procedure by
				number according to the fee schedules;
(5) Estimated follow-up;
(6) Operative time;
(7) Describe in detail any service rendered and billed using an
				"unlisted" procedure code.
The department or self-insurer may adjust BR procedures when
				such action is indicated.
Chart notes:
This type of documentation may also
				be referred to as "office" or "progress" notes. Providers must maintain charts
				and records in order to support and justify the services provided. "Chart"
				means a compendium of medical records on an individual patient. "Record" means
				dated reports supporting bills submitted to the department or self-insurer for
				medical services provided in an office, nursing facility, hospital, outpatient,
				emergency room, or other place of service. Records of service shall be entered
				in a chronological order by the practitioner who rendered the service. For
				reimbursement purposes, such records shall be legible, and shall include, but
				are not limited to:
(1) Date(s) of service;
(2) Patient's name and date of birth;
(3) Claim number;
(4) Name and title of the person performing the service;
(5) Chief complaint or reason for each visit;
(6) Pertinent medical history;
(7) Pertinent findings on examination;
(8) Medications and/or equipment/supplies prescribed or
				provided;
(9) Description of treatment (when applicable);
(10) Recommendations for additional treatments, procedures, or
				consultations;
(11) X rays, tests, and results; and
(12) Plan of treatment/care/outcome.
Consultation examination report:
The following
				information must be included in this type of report. Additional information may
				be requested by the department as needed.
(1) A detailed history to establish:
(a) The type and severity of the industrial injury or
				occupational disease.
(b) The patient's previous physical and mental health.
(c) Any social and emotional factors which may effect
				recovery.
(2) A comparison history between history provided by attending
				doctor and injured worker, must be provided with exam.
(3) A detailed physical examination concerning all systems
				affected by the industrial accident.
(4) A general physical examination sufficient to demonstrate
				any preexisting impairments of function or concurrent condition.
(5) A complete diagnosis of all pathological conditions
				including the current federally adopted ICD-CM codes found to be listed:
(a) Due solely to injury.
(b) Preexisting condition aggravated by the injury and the
				extent of aggravation.
(c) Other medical conditions neither related to nor aggravated
				by the injury but which may retard recovery.
(d) Coexisting disease (arthritis, congenital deformities,
				heart disease, etc.).
(6) Conclusions must include:
(a) Type of treatment recommended for each pathological
				condition and the probable duration of treatment.
(b) Expected degree of recovery from the industrial
				condition.
(c) Probability, if any, of permanent disability resulting from
				the industrial condition.
(d) Probability of returning to work.
(7) Reports of necessary, reasonable X-ray and laboratory
				studies to establish or confirm the diagnosis when indicated.
Doctor or attending doctor:
For these rules, means
				a person licensed to independently practice one or more of the following
				professions: Medicine and surgery; osteopathic medicine and surgery;
				chiropractic; naturopathic physician; podiatry; dentistry; optometry. An
				attending doctor is a treating doctor.
Only those persons so licensed may sign report of accident
				forms, the provider's initial report, and certify time loss compensation;
				however, physician assistants (PAs) also may sign these forms pursuant to WAC
				296-20-01501 (PAs may be
				"treating providers" pursuant to the definition contained in WAC
				296-20-01002); and ARNPs may
				also sign these forms pursuant to WAC
				296-23-241 (ARNPs may be
				"attending providers" consistent with the definition contained in WAC
				296-20-01002).
Emergent hospital admission:
Placement of the
				worker in an acute care hospital for treatment of a work related medical
				condition of an unforeseen or rapidly progressing nature which if not treated
				in an inpatient setting, is likely to jeopardize the workers health or
				treatment outcome.
Endorsing practitioner:
A practitioner who has
				notified the health care authority that he or she agrees to allow therapeutic
				interchange.
Fatal:
When the attending doctor has reason to
				believe a worker has died as a result of an industrial injury or exposure, the
				doctor should notify the nearest department service location or the
				self-insurer immediately. Often an autopsy is required by the department or
				self-insurer. If so, it will be authorized by the service location manager or
				the self-insurer. Benefits payable include burial stipend and monthly payments
				to the surviving spouse and/or dependents.
Fee schedules or maximum fee schedule(s):
The fee
				schedules consist of, but are not limited to, the following:
(1) Health Care Common Procedure Coding System Level I and II
				Codes, descriptions and modifiers that describe medical and other services,
				supplies and materials.
(2) Codes, descriptions and modifiers developed by the
				department.
(3) Relative value units (RVUs), calculated or assigned dollar
				values, percent-of-allowed-charges (POACs), or diagnostic related groups
				(DRGs), that set the maximum allowable fee for services rendered.
(4) Billing instructions or policies relating to the submission
				of bills by providers and the payment of bills by the department or
				self-insurer.
(5) Average wholesale price (AWP), baseline price (BLP), and
				policies related to the purchase of medications.
Health services provider or provider:
For these
				rules means any person, firm, corporation, partnership, association, agency,
				institution, or other legal entity providing any kind of services related to
				the treatment of an industrially injured worker. It includes, but is not
				limited to, hospitals, medical doctors, dentists, chiropractors, vocational
				rehabilitation counselors, osteopathic physicians, pharmacists, podiatrists,
				physical therapists, occupational therapists, massage therapists,
				psychologists, naturopathic physicians, and durable medical equipment
				dealers.
Home nursing:
Those nursing services that are
				proper and necessary to maintain the worker in his or her residence. These
				services must be provided through an agency licensed, certified or registered
				to provide home care, home health or hospice services. Refer to WAC
				296-20-091 for more
				information.
Independent or separate procedure:
Certain of the
				fee schedule's listed procedures are commonly carried out as an integral part
				of a total service, and as such do not warrant a separate charge. When such a
				procedure is carried out as a separate entity, not immediately related to other
				services, the indicated value for "independent procedure" is applicable.
Initial prescription drugs:
Any drug prescribed
				for an alleged industrial injury or occupational disease during the initial
				visit.
Initial visit:
The first visit to a health care
				provider during which the
Report of Industrial Injury or Occupational
				Disease
is completed and the worker files a claim for workers
				compensation.
Medical aid rules:
The Washington Administrative
				Codes (WACs) that contain the administrative rules for medical and other
				services rendered to workers.
Modified work status:
The worker is not able to
				return to their previous work, but is physically capable of carrying out work
				of a lighter nature. Workers should be urged to return to modified work as soon
				as reasonable as such work is frequently beneficial for body conditioning and
				regaining self confidence.
Under
				RCW
				 51.32.090, when the employer has modified
				work available for the worker, the employer must furnish the doctor and the
				worker with a statement describing the available work in terms that will enable
				the doctor to relate the physical activities of the job to the worker's
				physical limitations and capabilities. The doctor shall then determine whether
				the worker is physically able to perform the work described. The employer may
				not increase the physical requirements of the job without requesting the
				opinion of the doctor as to the worker's ability to perform such additional
				work. If after a trial period of reemployment the worker is unable to continue
				with such work, the worker's time loss compensation will be resumed upon
				certification by the attending doctor.
If the employer has no modified work available, the department
				should be notified immediately, so vocational assessment can be conducted to
				determine whether the worker will require assistance in returning to
				work.
Nonemergent (elective) hospital admission:
Placement of the worker in an acute care hospital for medical treatment of an
				accepted condition which may be safely scheduled in advance without
				jeopardizing the worker's health or treatment outcome.
Physician or attending physician (AP):
For these
				rules, means any person licensed to perform one or more of the following
				professions: Medicine and surgery; or osteopathic medicine and surgery. An AP
				is a treating physician.
Practitioner or licensed health care provider:
For
				these rules, means any person defined as a "doctor" under these rules, or
				licensed to practice one or more of the following professions: Audiology;
				physical therapy; occupational therapy; pharmacy; prosthetics; orthotics;
				psychology; nursing; advanced registered nurse practitioners (ARNPs); certified
				medical physician assistants or osteopathic physician assistants; and massage
				therapy.
Preferred drug:
A drug selected by the appointing
				authority for inclusion in the Washington preferred drug list and designated
				for coverage by applicable state agencies or a drug selected for coverage by
				applicable state agencies.
Preferred drug list:
Washington preferred drug
				list or "WPDL" is the list of drugs selected by the appointing authority to be
				used by applicable state agencies as the basis for the purchase of drugs in
				state purchased health care programs.
Proper and necessary:
(1) The department or self-insurer pays for proper and
				necessary health care services that are related to the diagnosis and treatment
				of an accepted condition.
(2) Under the Industrial Insurance Act, "proper and necessary"
				refers to those health care services which are:
(a) Reflective of accepted standards of good practice, within
				the scope of practice of the provider's license or certification;
(b) Curative or rehabilitative. Care must be of a type to cure
				the effects of a work-related injury or illness, or it must be rehabilitative.
				Curative treatment produces permanent changes, which eliminate or lessen the
				clinical effects of an accepted condition. Rehabilitative treatment allows an
				injured or ill worker to regain functional activity in the presence of an
				interfering accepted condition. Curative and rehabilitative care produce
				long-term changes;
(c) Not delivered primarily for the convenience of the
				claimant, the claimant's attending doctor, or any other provider; and
(d) Provided at the least cost and in the least intensive
				setting of care consistent with the other provisions of this definition.
(3) The department or self-insurer stops payment for health
				care services once a worker reaches a state of maximum medical improvement.
				Maximum medical improvement occurs when no fundamental or marked change in an
				accepted condition can be expected, with or without treatment. Maximum medical
				improvement may be present though there may be fluctuations in levels of pain
				and function. A worker's condition may have reached maximum medical improvement
				though it might be expected to improve or deteriorate with the passage of time.
				Once a worker's condition has reached maximum medical improvement, treatment
				that results only in temporary or transient changes is not proper and
				necessary. "Maximum medical improvement" is equivalent to "fixed and
				stable."
(4) In no case shall services which are inappropriate to the
				accepted condition or which present hazards in excess of the expected medical
				benefits be considered proper and necessary. Services that are controversial,
				obsolete, investiga-tional or experimental are presumed not to be proper and
				necessary, and shall be authorized only as provided in WAC
				296-20-03002(6)
				 and 296-20-02850.
Refill:
The continuation of therapy with the same
				drug, including the renewal of a previous prescription or adjustments in
				dosage.
Regular work status:
The injured worker is
				physically capable of returning to his/her regular work. It is the duty of the
				attending doctor to notify the worker and the department or self-insurer, as
				the case may be, of the specific date of release to return to regular work.
				Compensation will be terminated on the release date. Further treatment can be
				allowed as requested by the attending doctor if the condition is not stationary
				and such treatment is needed and otherwise in order.
Temporary partial disability:
Partial time loss
				compensation may be paid when the worker can return to work on a limited basis
				or return to a lesser paying job is necessitated by the accepted injury or
				condition. The worker must have a reduction in wages of more than five percent
				before consideration of partial time loss can be made. No partial time loss
				compensation can be paid after the worker's condition is stationary.
All
				time loss compensation must be certified by the attending doctor based on
				objective findings.
Termination of treatment:
When treatment is no
				longer required and/or the industrial condition is stabilized, a report
				indicating the date of stabilization should be submitted to the department or
				self-insurer. This is necessary to initiate closure of the industrial claim.
				The patient may require continued treatment for conditions not related to the
				industrial condition; however, financial responsibility for such care must be
				the patient's.
Therapeutic interchange:
To dispense a preferred
				drug in place of a prescribed nonpre-ferred drug within the same therapeutic
				class listed on the Washington preferred drug list.
Total permanent disability:
Loss of both legs or
				arms, or one leg and one arm, total loss of eyesight, paralysis or other
				condition permanently incapacitating the worker from performing any work at any
				gainful employment. When the attending doctor feels a worker may be totally and
				permanently disabled, the attending doctor should communicate this information
				immediately to the department or self-insurer. A vocational evaluation and an
				independent rating of disability may be arranged by the department prior to a
				determination as to total permanent disability. Coverage for treatment does not
				usually continue after the date an injured worker is placed on pension.
Total temporary disability:
Full-time loss
				compensation will be paid when the worker is unable to return to any type of
				reasonably continuous gainful employment as a direct result of an accepted
				industrial injury or exposure.
Treating provider:
For these rules, means a person
				licensed to practice one or more of the following professions: Medicine and
				surgery; osteopathic medicine and surgery; chiropractic; naturopathic
				physician; podiatry; dentistry; optometry; advanced registered nurse
				practitioner (ARNP); and certified medical physician assistants or osteopathic
				physician assistants. A treating provider actively treats an injured or ill
				worker.
Unusual or unlisted procedure:
Value of unlisted
				services or procedures should be substantiated "by report" (BR).
Utilization review:
The assessment of a claimant's
				medical care to assure that it is proper and necessary and of good quality.
				This assessment typically considers the appropriateness of the place of care,
				level of care, and the duration, frequency or quantity of services provided in
				relation to the accepted condition being treated.
Statutory Authority:
				  RCW
				   51.04.020,
				  51.04.030, and
				  Title
				  51 RCW. 08-24-047, §
				  296-20-01002, filed 11/25/08, effective 12/26/08. Statutory Authority: 2007 c
				  263, RCW
				   51.04.020 and
				  51.04.030. 08-04-095, §
				  296-20-01002, filed 2/5/08, effective 2/22/08. Statutory Authority:
				  RCW
				   51.04.020,
				  51.04.030 and 2007 c 134.
				  08-02-021, § 296-20-01002, filed 12/21/07, effective 1/21/08. Statutory
				  Authority:
				  RCW
				   51.04.020,
				  51.04.030. 07-17-167, §
				  296-20-01002, filed 8/22/07, effective 9/22/07. Statutory Authority: 2004 c 65
				  and 2004 c 163. 04-22-085, § 296-20-01002, filed 11/2/04, effective
				  12/15/04. Statutory Authority:
				  RCW
				   51.04.020,
				  70.14.050. 04-08-040, §
				  296-20-01002, filed 3/30/04, effective 5/1/04. Statutory Authority:
				  RCW
				   51.04.020. 03-21-069, § 296-20-01002,
				  filed 10/14/03, effective 12/1/03. Statutory Authority:
				  RCW
				   51.04.010,
				  51.04.020,
				  51.04.030,
				  51.32.080,
				  51.32.110,
				  51.32.112,
				  51.36.060. 02-21-105, §
				  296-20-01002, filed 10/22/02, effective 12/1/02. Statutory Authority:
				  RCW
				   51.04.020,
				  51.04.030,
				  51.32.060,
				  51.32.072, and
				  7.68.070. 01-18-041, §
				  296-20-01002, filed 8/29/01, effective 10/1/01. Statutory Authority:
				  RCW
				   51.04.020 and
				  51.04.030. 00-01-039, §
				  296-20-01002, filed 12/7/99, effective 1/8/00. Statutory Authority:
				  RCW
				   51.04.030,
				  70.14.050 and
				  51.04.020(4).
				  95-16-031, § 296-20-01002, filed 7/21/95, effective 8/22/95. Statutory
				  Authority:
				  RCW
				   51.04.020,
				  51.04.030 and 1993 c 159.
				  93-16-072, § 296-20-01002, filed 8/1/93, effective 9/1/93. Statutory
				  Authority:
				  RCW
				   51.04.020(4) and
				  51.04.030. 92-24-066, §
				  296-20-01002, filed 12/1/92, effective 1/1/93; 92-05-041, § 296-20-01002,
				  filed 2/13/92, effective 3/15/92. Statutory Authority:
				  RCW
				   51.04.020. 90-14-009, § 296-20-01002,
				  filed 6/25/90, effective 8/1/90. Statutory Authority:
				  RCW
				   51.04.020(4) and
				  51.04.030. 90-04-057, §
				  296-20-01002, filed 2/2/90, effective 3/5/90; 87-24-050 (Order 87-23), §
				  296-20-01002, filed 11/30/87, effective 1/1/88; 86-20-074 (Order 86-36), §
				  296-20-01002, filed 10/1/86, effective 11/1/86; 83-24-016 (Order 83-35), §
				  296-20-01002, filed 11/30/83, effective 1/1/84; 83-16-066 (Order 83-23), §
				  296-20-01002, filed 8/2/83. Statutory Authority:
				  RCW
				   51.04.020(4),
				  51.04.030, and
				  51.16.120(3).
				  81-24-041 (Order 81-28), § 296-20-01002, filed 11/30/81, effective 1/1/82;
				  81-01-100 (Order 80-29), § 296-20-01002, filed 12/23/80, effective
				  3/1/81.