WAC 296-20-01002
Definitions. 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 of the participating agencies in the
state purchased health care programs, appointing authority
shall mean the following persons acting jointly: The
administrator of the health care authority, the secretary of
the department of social and health services, 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 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 ICD-9-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.
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.
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
procedure(s) where appropriate;
(3) Surgical procedure(s) and supplementary procedure(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 ICD-9-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 reviewed
the preferred drug list and has notified the health care
authority that he or she has agreed to allow therapeutic
interchange of a preferred drug for any nonpreferred drug in a
given therapeutic class.
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:
(a) Health Care Common Procedure Coding System Level I
and II Codes, descriptions and modifiers that describe medical
and other services, supplies and materials.
(b) Codes, descriptions and modifiers developed by the
department.
(c) Relative value units (RVUs), calculated or assigned
dollar values, percent-of-allowed-charges (POAC), or
diagnostic related groups (DRGs), that set the maximum
allowable fee for services rendered.
(d) Billing instructions or policies relating to the
submission of bills by providers and the payment of bills by
the department or self-insurer.
(e) 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 healthcare 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 list: 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,
investigational 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) when a prescription is for an
antipsychotic, antidepressant, chemotherapy, antiretroviral or
immunosuppressive drug, or for the refill of an
immunomodulator/antiviral treatment for hepatitis C for which
an established, fixed duration of therapy is prescribed for at
least twenty-four weeks but no more than forty-eight weeks.
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 alternative: Drug products of different
chemical structure within the same pharmacologic or
therapeutic class and that are expected to have similar
therapeutic effects and safety profiles when administered in
therapeutically equivalent doses.
Therapeutic interchange: To dispense with the endorsing
practitioner's authorization, a therapeutic alternative to the
prescribed drug.
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.]