STATE OF TENNESSEE
DIVISION OF WORKERS’ COMPENSATION
DEPARTMENT OF LABOR AND WORKFORCE DEVELOPMENT
220 FRENCH LANDING DRIVE
NASHVILLE, TENNESSEE 37243-1002
Present and Future
Changes including the 2013 Reform
1 July, 2014
Permanent Impairment Ratings
Aggravation of Pre-existing Condition
MMI and Pain Management
1 January, 2016
practitioners, other providers, companies, attorneys, injured workers, adjusters, case managers, therapists, etc.
we will all have to live in two worlds, just like the transition from the 5 th edition to the 6 th edition
The meaning and interpretation of these statutes and rules will be determined by the Judges, ultimately a legal and judicial decision.
This presentation is the guidance from the Medical
Director’s Office as of this time.
Now: in favor of the employee
“it happened at work, now I need treatment, therefore my employer should pay.”
designed as “no fault” temporary disability payments off work light duty job protection
“fair and impartial” removed from county courts
Judges appointed by the Administrator of the Division
8 regional courts, when fully implemented administrative procedures
Now: “in the course and scope of employment”
Except cumulative trauma disorders: rules for these changed in 2011
“primarily within the course and scope”
New: “primarily out of…and in the course and scope of employment…”
“…was it possibly caused by…?”
New: the employee must show…that the subsequent…
need for treatment
is “more likely than not” (greater than 50%), due to this injury,
“considering all causes, as opposed to speculation or possibility
Use of the physician’s opinion:
1. First visit-ER, Occupational Medicine.
2. First Referral: do not assume that the carrier has accepted the claim, even though they made the appointment.
3. Subsequent request for an opinion.
New: The opinion of the treating physician selected from the employer’s panel is presumed to be correct (causation).
The employer may present the employee with a panel of three physicians…
The employer has three days to object to a referral from one of the panel physicians and present the employee a different panel.
No particular requirements for subspecialty panels.
“An ‘injury’…means an injury by ‘accident’ that…arises primarily out of and in the course and scope of employment that causes death, disablement, or the need for treatment, provided that it is…caused by an incident, or series of incidents...identifiable by time and place of occurrence…”
“…and shall not include the aggravation of a pre-existing disease, condition or ailment, unless it can be shown to a reasonable degree of medical certainty that the aggravation arose primarily out of and in the course and scope of employment.”
Aggravation: a permanent worsening (a condition made permanently worse) with documentable anatomic change.
Exacerbation: temporary with no anatomic change.
Treating physician’s opinion is “…presumed to be correct…” if it is based upon a reasonable degree of medical certainty that the “injury” contributed “…more than 50%in causing...the need for medical treatment…more likely than not, considering all causes, as opposed to speculation or possibility
“J ust because your knee hurt after your covered
‘injury’ does not necessarily make it under Workers’ Compensation.”
Significant implications concerning: disability payments restricted duty off work time ability to “fire”
No permanent anatomic change.
Temporary decrease in function: limitations (cannot), restrictions (should not).
Implications: limitations restrictions pain temporary disability
Timing of causation appeal.
to the provider: treatment payment.
to the employee: job.
More requirements for initial evaluation concerning likelihood of causation and relationship to work.
Not likely that a PA or NP can see a patient for the first visit if there is a causation question.
More information is going to be needed to satisfy the new questions about causation.
More careful questioning.
More careful documentation.
Document verbal communications.
New: Released from disclosure form (C-31).
Communications (all pertinent) to employer/carrier/adjuster/case manager will not be restricted.
Now: ‘should’ complete and “scheduled member”
New: The treating physician is required to give
MMI “..conclusively presumed to be at MMI when the treating physician ends all active medical treatment…” except “…treatment of pain …”
New: The permanent impairment rating “shall be assigned by the treating physician…” and is to be converted to “body as a whole.”
a point in time…when further medical or surgical intervention cannot be expected to improve the underlying impairment
…not predicated on the elimination of symptoms and/or subjective complaints…stable…or can be managed with palliative measures. MMI does not preclude the deterioration…that is expected to occur with the passage of time…or normal aging process…”
AMA Guides, 6 th edition
“…it does not preclude allowance for ongoing follow-up for optimal maintenance of the medical condition in question.”
AMA guides, 6 th edition
“…patient may decline recommended treatment…or choose not to comply with recommended life style changes (weight reduction, smoking cessation)…physician may explain…and comment…”
AMA Guides Newsletter: Brooks, 2014.
“…shall not consider complaints of pain in calculating the degree of impairment, notwithstanding allowances for pain provided by the applicable edition of the AMA guides…”
“…is not entitled to a second opinion on…pain management.”
U/R after 90 days of any schedule II, III, IV.
referral to “pain specialist”
This is not a causation statute. It is designed to remove some subjectivity from the rating process.
1. Do not use Chapter 3 or PDQ.
Very few circumstances.
2. In nerve injury, use sensory deficit as opposed to pain assessment.
There are three grade modifiers: a. Physical Examination b. Clinical Studies c. Functional History
No change in first two.
3. In the Functional History Grade Modifier:
Do not consider complaints of “pain” in using this modifier.
Use concepts such as limited motion or weakness in assessing functional abilities and limitations.
In the Upper Extremity and in the Spine Chapters:
4. If the diagnosis is non-specific chronic pain, such as wrist pain or neck pain, by definition there are no physical examination or clinical studies modifiers that apply.
Do not use the functional history modifier.
Use only the default value.
Effective January 1, 2016
“The Administrator shall develop…”
“…for the most commonly occurring…”
“…shall presumed to be medically necessary…and not subject to utilization review.”
“…statements that include recommendations intended to optimize patient care that are informed by a systematic review of the evidence and an assessment of the benefit and harms of alternative care options.”
Easily Accessible, user friendly
Reasonable acquisition and use cost
1) Most numbers of procedures
2) High cost-length of disability
(indemnity and medical)
3) Payment under “open medical”
(in consultation with the
Medical Advisory Committee)
Adjustments made by CMS to conversion factors and RVUs January 1, 2014.
No change in the (combined) Tennessee conversion factor (GPCI, facility, etc) to calculate the RVUs, remains at 33.764. even though CMS raised the (combined)
Tennessee conversion factor but lowered some of the RVUs.
The conversion factor and the calculations were written into the rules (0800-02-18-.02(4)), so that if CMS reduced their conversion factors (SGR) below that level, the practitioners would not be affected without a hearing.
Effect of 2014 CMS RVU changes: orthopaedic impact (99204): -$10.00)
Tennessee-specific service (specialty) percentages unchanged
(Ortho-Neuro = 275%)
Since the Medical Fee Schedule follows CMS,
Watch for NCCI edits: new: shoulder bundles for 2014
The Division does not pay bills
It collects data and uses it for:
1. Case Management
2. Utilization Review
3. Benefits review and awards
1. The Division of Workers’ Compensation is considering accepting the use of ICD-10 codes on all submissions for Date of Service (DOS) on of after 1
2. It will not be necessary to convert codes from ICD-9 to ICD-10.
3. For the special circumstance where DOS includes before and after 1 October, 2014(5), such as an inpatient admission, the Division will accept either or both codes, in accordance with CMS guidelines.
4. As this issue in in flux, the Division has not made a determination yet. We are still gathering information.
Watch for further information on the web site.
Function: independent review when an appeal is made by any party to a dispute about an impairment rating.
Stipulated before a hearing.
Requirements: certification and review.
Workers’ Compensation Law: http://www.lexisnexis.com/hottopics/tncode/
Department of Health: http://health.tn.gov/Downloads/ChronicPain