BWC Diagnosis Determination Guidelines Quick Reference

Transcription

1 BWC Diagnosis Determination Guidelines Quick Reference Overview BWC relies on Managed Care Organizations to gather pertinent medical documentation from all treating providers to suppt the allowance determination. To perfm this function efficiently, BWC, MCOs and providers need to know the guidelines and criteria f diagnosis determination essential to substantiate diagnoses in claims. The medical documentation contained in the claim file is critical as evidence f the claims determination especially when this evidence is presented f a hearing. The primary objective of the Diagnosis Determination Guidelines is implementation of consistent criteria f diagnosis determination/coding decisions between BWC and the MCOs. These documents are to be utilized as reference tools. The document BWC Diagnosis Determination Guidelines is the detailed expanded version to be utilized as a reference manual if a guideline is unclear in the abbreviated document. The document BWC Diagnosis Determination Quick Reference is the abbreviated version of the first document BWC Diagnosis Determination Guidelines. This lists the ICD-9 code with the diagnosis narrative description, subjective and objective exam findings, diagnostic tests and findings f diagnosis substantiation. The medical repts, documentation and diagnostic tests are submitted to the customer care team to assist in the claim determination. These documents are not intended to direct medical care to be utilized in authization of medical treatment. In determination of allowed diagnoses in a claim it is appropriate to perfm diagnostic studies to determine rule out those conditions which have specific diagnostic requirements.

2 Quick Reference Guidelines f Diagnosis Determination ICD-9 (Should have at least one Subjective and at least one Objective) Findings Carpal Tunnel Syndrome NOTE: This is a common and potentially overused diagnosis. May suggest perfming electrodignostics to suppt this condition. Please code condition under tenosynovitis of wrist hand, sprain/strain of wrist, if suppted by a physician s review and treat appropriately. (See medical evidence policy) numbness and tingling in the median sensy distribution aching pain volar hand and wrist at the carpal tunnel positive Phalen test and positive Tinel sign weakness of thenar muscles, an 'early sign' positive median nerve compression test atrophy of thenar muscles, a 'late sign' loss deviation in 2 point discrimination, greater than 5-6 mm Nerve Conduction Velocity (NCV) Positive test findings through examination of the sensy and mot conduction of the median nerve Herniated Cervical Disc with without radiculopathy Cervical Disc Displacement without myelopathy NOTE: With radiculopathy code in conjunction with neck pain referred pain: upper limb and posteri shoulder paresthesia in a dermatomal pattern decreased range of motion of neck, and positive Spurling Sign decreased absent upper limb muscle stretch reflexes muscle weakness muscle atrophy decreased sensation in a dermatomal pattern MRI CT Scan Myelo-gram/CT Scan EMG (suppts the claim allowance of radiculopathy) herniated, ruptured, prolapsed, sequestered, extruded cervical disc, identifying the disc number(s) positive f cervical radiculopathy H Reflex Latency (flex c.r.): C-7

3 (Should have at least one Subjective and at least one Objective) Findings Herniated Lumbar Disc with without Radiculopathy Lumbar Disc Displacement without Myelopathy NOTE: With radiculopathy code in conjunction with low back pain referred pain: buttock, thigh, calf/shin, heel ankle decreased absent muscle stretch reflexes muscle weakness in radicular pattern muscle atrophy decreased sensation in a dermatomal pattern positive straight leg raising (SLR) verified by an aggravating maneuver foot drop, weakness dsiflex muscles, L5 involvement MRI CT Scan Myelo-gram/CT Scan EMG (suppts the claim allowance of radiculopathy) herniated, ruptured, prolapsed, sequestered, extruded lumbar disc, identifying the disc number(s) positive f lumbar radiculopathy increased H Reflex latency: S Herniated Thacic Disc with without Radiculopathy Thacic Disc Displacement without Myelopathy thacic pain referred pain: rib area MRI CT Scan Myelo-gram/CT Scan herniated, ruptured, prolapsed, sequestered, extruded thacic disc, identifying the disc number(s) NOTE: With radiculopathy code in conjunction with EMG abnmal in intercostals EMG (suppts the claim allowance of radiculopathy) positive thacic radiculopathy intercostal abnmality

4 (Should have at least one Subjective and at least one Objective) Findings Disc Displacement NOS Bulging Disc Discogenic Syndrome NOTE: This diagnosis is not considered eligible f surgical intervention. pain consistent with level affected complaints of pain on palpation movement MRI CT Scan Myelo-gram/CT Scan bulging protruded disc without nerve root impingement, identifying the disc number Cervicalgia NOTE: This diagnosis/symptom is not eligible f BWC claim allowance. pain in neck complaints of pain on palpation movement Cervical Radiculopathy Cervical Radiculitis Cervical Neuritis NOTE: This diagnosis is a symptom and is not considered eligible f claim allowance absent the diagnosis suppting cresponding pathology. sclerotomal pain paresthesia in a dermatomal pattern muscle weakness muscle atrophy decreased sensation dermatomal pattern MRI CT Scan Myelo-gram/CT Scan EMG (suppts the claim allowance of radiculopathy) herniated, ruptured, prolapsed, sequestered, extruded cervical disc, identifying the disc number(s) positive f cervical radiculopathy H Reflex Latency (flex c.r.): C Lumbago NOTE: This diagnosis/symptom is not eligible f BWC claim allowance. complaints of low back pain without radicular symptoms usually greater than 3 months duration may have tenderness complaints of pain with palpation

5 (Should have at least one Subjective and at least one Objective) Findings Lumbosacral Radiculopathy Lumbosacral Radiculitis Lumbosacral Neuritis NOTE: This diagnosis is a symptom and is not considered eligible f claim allowance absent the diagnosis suppting cresponding pathology. sclerotomal pain pain exacerbated with Valsalva paresthesia in a dermatomal pattern decreased absent muscle stretch muscle atrophy impaired bowel and bladder function, Cauda Equina involvement foot drop, weakness of dsiflex muscles, L5 involvement MRI CT Scan Myelo-gram/CT Scan EMG (suppts the claim allowance of radiculopathy) positive f a herniated disc bulging disc with significant nerve root impingement at the level of the clinical findings, identifying the disc number(s) positive needle EMG lumbar radiculopathy consistent with disc lesion increased H reflex latency:s Rotat Cuff Syndrome shoulder pain generally described as upper lateral and anteri arm down to the deltoid insertion night pain interrupting sleep muscle atrophy defmity positive Neer impingment sign positive Hawkins impingement sign X-rays: AP view in internal rotation and Axillary and Scapular-Y view See DX. Test findings as defined in the determination guidelines Impingement Syndrome shoulder pain in the upper lateral and anteri arm night pain interrupting sleep tenderness about the shoulder usually centered around the greater tuberosity positive Neer impingement sign positive Hawkins impingement sign X-rays: AP view in internal rotation and Axillary and Scapular-Y view See DX. Test findings as defined in the determination guidelines.

6 Findings aching in the proximal volar fearm Medial Epicondylitis resisted wrist flexion and pronation often produce symptoms weakness proximal volar fearm Lateral Epicondylitis aching in proximal fearm tenderness directly over slightly distal to the lateral epicondyle pain on resisted wrist finger extension aching at the radial styloid in distal fearm Radial Styloid Tenosynovitis De Quervain's Tenosynovitis tenderness at radial styloid positive Finkelstein test crepitation over the sheath occasional "locking" similar to triggering that occurs with tenosynovitis of digital flex sheath pain on the ulnar side of the wrist Tenosynovitis of hand and wrist extens carpi ulnaris tenosynovitis tenderness where the tendon passes through its sheath at its insertion along its entire length pain with resisted ulnar deviation extens pollicis longus tenosynovitis pain which may be vague on dsum of wrist triggering may occur tenderness and swelling over the tendon just distal to Lister s tubercle

7 Findings flex carpi radialis tenosyn ovitis pain over the flex carpi radialis just proximal to the wrist flex crease. May extend distally in tunnel pain produced on resisted wrist flexion tenderness and swelling over the tendon at the wrist Tenosynoviti s of hand and wrist: flex carpi ulnaris tenosyn ovitis pain in region of pisifm proximal to pisifm over flex carpi ulnaris tendon tenderness of flex carpi ulnaris just proximal to the pisifm. Lateral X-Ray Rule out calcific deposit pisotriquetral arthritis flex tenosyn ovitis of the wrist stabbing burning pain proximal to carpal tunnel Tenderness and swelling just proximal to the wrist flex creases Median neuritis may be co-existent as evidenced by positive Phalen Test and Tinel sign

8 Findings Myalgia and Myositis, NOS Myofascial Pain Syndrome Fibromyalgia Fibromyositis Post Traumatic Fibromyalgia Muscle Strain, third degree painful muscles fatigue tenderness on palpation of a given muscle muscle group increased consistency of muscle on palpation definitive fibromyalgia with positive findings in 11/18 points of palpation Nonallopathic Lesions Intersegmental Dysfunction Subluxation Tear of Medial Cartilage Meniscus of knee pain and tenderness asymmetry of joint function restricted range of motion soft tissue changes, i.e. spasm, edema, tenderness painful popping in knee with motion positive McMurray test locking of knee MRI Arthroscopy NOTE: Arthroscopy iginally auth. f diagnostic reasons may result in nec. surgical repair which requires submission of op rept f additional claim allowance consideration "Bright signals" within the meniscus which should reach the surface of the meniscus rept of defmity amputation of meniscus tear medial meniscus

9 Findings Rotat Cuff Tear shoulder and upper arm elbow and fearm wrist hand hip and thigh knee and leg ankle foot sacroiliac region other and unspecified parts of back Other and ill-defined sprains and strains Establish causal relationship utilizing mechanism of injury, injured wker histy and complaints to substantiate sprain/strain diagnosis. Possible subjective/objective findings: Pain, tenderness, swelling, bruising, decreased ROM. NOTE: F Sprain and Strain there are usually no specific diagnostic tests though a plain x-ray may be appropriate. It may be appropriate to utilize these diagnoses to establish the wkers' compensation claim while treating and perfming other diagnostic studies to meet me definitive diagnostic criteria. shoulder pain over the insertion of the rotat muscles pain when resists elevation of the arm and shoulder muscle atrophy over the insertion of the rotat muscles, if chronic tenderness over the insertion of the rotat muscles MRI Arthrography Tear is present

10 Findings MRI disruption tear cruciate ligament Tear of Cruciate Ligament of knee knee instability knee pain Arthroscopy NOTE: Arthroscopy iginally auth. f diagnostic reasons may result in nec. surgical repair which requires submission of op rept f additional claim allowance consideration disruption tear cruciate ligament knee effusion instability of knee joint with positive Drawer sign positive Lachmans sign

11 (Should have at least one Subjective and at least one Objective) Findings No Specifi c Assign ed Repetitive Motion Syndrome Cumulative Trauma Disder Overuse Syndrome Conditions Can Include: Tendinitis and tenosynovitis Nerve compression syndromes localized pain swelling pain on resisted motion pain numbness tingling weakness Myofascia l Pain localized soft tissue pain

12 Findings 719.4_ (fifth digit identifies body part) Pain in Joint (Chronic) NOTE: This diagnosis is a secondary diagnosis of ongoing symptoms after completion of treatment. Pain in joint Possible Subjective/Objective Findings: Joint swelling, buckling, decreased motion, instability. Diagnostic studies show absence of other appropriate diagnoses, i.e., osteoarthritis, recurrent injury degenerative condition of cartilage _ (fifth digit identifies back level) Postlaminectomy Syndrome NOTE: This diagnosis is a secondary diagnosis of ongoing symptoms after completion of surgical treatment and rehabilitation. Pain in low back Possible Subjective/Objective Findings: Leg pain, weakness, decreased spinal movement Diagnostic studies show pri surgical procedure and absence of me specific diagnosis, i.e., recurrent herniated disc, etc.

13 Findings Chronic Lumbosacral Sprain/Strain NOTE: This diagnosis is a secondary diagnosis of ongoing symptoms after completion of treatment. Pain in low back Possible Subjective/Objective Findings: Leg pain, weakness, decreased spinal movement Diagnostic studies show absence of other appropriate diagnoses, i.e., other disc pathology, spondylosis, spondylolistheses, degenerative disc disease, and degenerative osteoarthritis Pain in hand and arm Pain, burning aching Pain is regional Tingling numbness of the distal limb Complex regional pain syndrome I of upper limb (CRPS I) Reflex Sympathetic Dystrophy (RSD) of upper limb Shoulder-hand syndrome Stage 1 (Few Weeks to 6 months) Skin pitting edema, redness and warmth Excessive sweating Decreased range of motion of joints Stage 2 (Lasts 3-6 months after Stage 1) Edema described as brawny spreading Skin temperature nmal cool Excessive sweating Decreased range of motion of joints Atrophy of muscles and subcutaneous tissues Stage 3 (additional months after Stage 2) Skin smooth, glossy, dry, cool Coarse limb hair, ridged nails Permanent atrophy of muscle, soft tissue Loss of motion of joints. Condition may be suppted by: Triple phase bone (within 3 to 6 months) X-rays of the involved limb Triple phase bone scan showing increased uptake X-rays showing osteoposis of the involved limb

14 Findings Pain in lower limb Pain, burning aching Pain is regional Tingling numbness of the distal limb Complex regional pain syndrome I of lower limb (CRPS I) Reflex Sympathetic Dystrophy (RSD) of lower limb Stage 1 (Few Weeks to 6 months) Skin pitting edema, redness and warmth Excessive sweating Decreased range of motion of joints Stage 2 (Lasts 3-6 months after Stage 1) Edema described as brawny spreading Skin temperature nmal cool Excessive sweating Decreased range of motion of joints Atrophy of muscles and subcutaneous tissues Stage 3 (additional months after Stage 2) Skin smooth, glossy, dry, cool Coarse limb hair, ridged nails Permanent atrophy of muscle, soft tissue Loss of motion of joints. Condition may be suppted by: Triple phase bone (within 3 to 6 months) X-rays of the involved limb Triple phase bone scan showing increased uptake X-rays showing osteoposis of the involved limb

15 Findings Pain, hand arm Pain, burning aching Pain follows specific nerve distribution Tingling numbness of the distal limb Complex regional pain syndrome II of upper limb (CRPS II) Causalgia of upper limb Vasomot changes: Skin col mottled, cyanotic Skin temperature cool Edema Sudomot changes: Skin dry, overly moist Trophic changes: Skin smooth, nonelastic Soft tissue atrophy Joint stiffness, decreased passive motion Nail changes, blemished, curved, talonlike Hair growth changes falls out, longer, finer Trophic bone changes Condition may be suppted by: Triple phase bone scan X-rays of the involved limb Triple phase bone scan showing increased uptake X-rays showing osteoposis of the involved limb

16 (Should have at least one Subjective and at least one Objective) Pain, distal lower limb Pain, burning aching Pain follows specific nerve distribution Tingling numbness of the distal limb Findings Complex regional pain syndrome II of lower limb (CRPS II) Causalgia of lower limb Vasomot changes: Skin col mottled, cyanotic Skin temperature cool Edema Sudomot changes: Skin dry and overly moist Trophic changes: Skin smooth, nonelastic Soft tissue atrophy Joint stiffness, decreased passive motion Nail changes - blemished, curved, talonlike Hair growth changes falls out, longer, fine Trophic bone changes. Condition may be suppted by: Triple phase bone X-rays of the involved limb Triple phase bone scan showing increased uptake X-rays showing osteoposis of the involved limb