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Policy and Procedure Name:
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ICD MODIFICATION
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Policy #:
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CP-09-02
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Code/Rule Reference:
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R.C. 4121.32, 4121.39
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Effective Date:
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03/06/20
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Approved:
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Ann Shannon, Chief of Claims Policy and Support
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Origin:
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Claims Policy
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Supersedes:
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Policy # CP-09-02, effective 05/06/16 and Procedure # CP-09-02.PR1,
effective 05/06/16
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History:
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CP-09-02
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Rev. 05/06/16; 01/07/16; New 08/11/15
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CP-09-02.PR1
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Rev. 05/06/16; 01/07/16; New 08/11/15
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ICD Modification Table of Contents
I. POLICY
PURPOSE
II.
APPLICABILITY
III.
DEFINITIONS
IV. POLICY
A. Code
Assignment
B. Notification
V. PROCEDURE
A. Standard
Claim File Documentation
B. General
Guidelines for ICD Modifications
C. Correcting/Modifying
ICD Code/Description Before Issuing a BWC Decision
D. Correcting
or Modifying ICD Descriptions after Allowance
E. Correcting
or Modifying ICD Codes Never Formally Allowed by BWC or IC Order
F. Correcting
or Modifying ICD Description Allowed by IC Order
G. Correcting
or Modifying Miscoded ICD description
H. Adding
Specific Levels for Back Injury Claims
I. How
to Replace Expired ICD Codes
The purpose of this policy is to ensure that
claims are assigned the correct numeric ICD code(s), injury description
(narrative condition) is based on the supporting medical evidence, and that the
code is accurately reflected in the claims management system.
This policy applies to BWC Claims Services Operations staff,
Medical Services staff and managed care organizations (MCOs).
Encoder: Web-based software that converts a narrative medical
description into a numeric ICD description, or vice versa.
ICD: International Classification of Diseases. ICDs
are standardized classifications of diseases,
injuries, and causes of death, by etiology and anatomic localization and
codified into an Alpha-numeric code, which allows clinicians, statisticians,
health planners and others to speak a common language, both in the US and
internationally.
1. It is the policy
of BWC to assign the most accurate and specific ICD code and narrative
description for each condition allowed and disallowed in a claim to ensure that
the correct conditions are captured in the claims management system and that
all future correspondence, including requests for independent medical exams
(IMEs), will contain the correct conditions.
2. It is the policy
of BWC to update or modify condition(s) that have been coded incorrectly when:
a. The description
does not exactly match the condition allowed by order in the claim; or
b. ICD codes and
descriptions in the claims management system encoder are not an exact match
with the conditions that need to be allowed or which have been allowed in the
claim; or
c. ICD codes
have expired or been revised due to changes in the diagnosis code set.
3. It is the policy
of BWC that the narrative description of the condition(s) requested on a First
Report of Injury (FROI), Request for Authorization and/or Recommendation of
Additional Conditions (C-9), a Motion (C-86), or allowed by BWC or Industrial
Commission (IC) Order takes precedence over the Alpha-numeric ICD code(s).
4. It is the policy
of BWC that a BWC or IC Order is required for conditions to be recognized as
allowed or denied.
: BWC shall provide notice of correction, modification, or
deletion to the parties in the claim unless:
1. The ICD code is
being changed but the narrative description remains the same; or
2. The narrative
description is being modified to reflect an earlier BWC or IC order.
1. BWC staff shall
refer to the Standard
Claim File Documentation and Altered Documents policy and
procedure for claim note requirements; and
2. Shall follow any
other specific instructions for claim notes included in this procedure.
1. Claims services staff
shall obtain allowed conditions from the order which originally granted the
condition(s). Claims services staff shall not obtain the conditions from the
“previously allowed” section of an Industrial Commission (IC) order.
2. Claims services
staff shall not delete or modify narrative descriptions for conditions allowed
outside BWC’s jurisdiction and shall staff all requests for modifications to
conditions allowed by the IC with a BWC attorney.
3. Claims services
staff shall update the claims management system with all conditions allowed by
BWC or IC Order.
4. Claims services
staff shall use the encoder, the ICD coding manual, Medical Evidence for
Diagnosis Determination (MEDD) policy and procedure and the correct coding
tool found on Claims On-Line Resources (COR) to:
a. Ensure
conditions are assigned the correct ICD code;
b. Ensure any
requested condition has not already been addressed by another ICD code; and
c. Map an
ICD-9 to an ICD-10.
5.
Claims services staff shall:
a. Ensure all ICD-9
codes in claims with a Health Insurance Claim Number (HICN) have been converted
to ICD-10 codes.
b. Convert all
ICD-9 codes to ICD-10 codes when in a claim for any reason.
c. Convert
all ICD-9 to ICD-10 codes when Alternative Dispute Resolution (ADR) issues are
being processed.
6. Claims services
staff shall identify the correct site and location of all conditions when
required.
7. Claims services
staff shall utilize the site drop-down box on the diagnosis/injury status
maintenance window to clarify a condition, when necessary. For example, a C-86
Motion is submitted requesting the condition Disc Displacement. Claims services
staff shall choose the correct disc level(s) from the site drop-down box.
8. Claims services
staff shall not request a modification on a condition when the condition is
complete as coded. For example, a First Report of Injury (FROI) is submitted
with the condition “lumbar strain” and the accompanying ICD code is S39.012A.
The code S39.012A comes up “Strain of Muscle, Fascia and Tendon of Lower Back”;
the narrative for this code includes the “lumbar” site; therefore, claims
services staff shall not send the condition for modification.
9. Claims services
staff shall seek agreement from all parties in the claim when a need for an ICD
code modification is identified on a condition previously allowed by BWC order.
a. When all parties
agree:
i. Claims
services staff shall vacate the original BWC order and issue a new corrected
order with the corrected narrative/condition when modifying or adding a new
condition;
ii. Claims
services staff may staff modifications that require vacating an order and
issuing a new order with a supervisor or BWC attorney.
b. When all parties
are not in agreement, or where the condition was previously allowed by IC
order, claims services staff shall staff with a BWC attorney to consider
referral to the IC for continuing jurisdiction.
10. Claims services staff shall
request a description be modified prior to issuing a BWC order or referring to
the Industrial Commission (IC) via the “Notice of Referral” (NOR) if a description
cannot be accurately coded.
11. Claims services staff may
correct or modify ICD codes without notice to the parties in the claim when the
narrative description does not change.
12. Claims services staff shall
complete the electronic referral form located on the “BWC ICD Modification
Request” SharePoint site when modifications, clarification or ICD coding
assistance is needed, following the requirements below.
13. General guidelines for
requesting ICD modifications from the “BWC ICD Modification Request” SharePoint
site:
a. Staff shall
follow these procedures for all claims requiring modification, including Self
Insured (SI) claims.
b. Claims services
staff shall send requests for clarifications or modifications to the “BWC ICD
Modification Request” SharePoint site:
i. Whenever
staff cannot, using the available tools, assign a code with the correct
description for an allowed condition in the claim,
ii. As a
resource for coding assistance and clarification, or
iii. For assistance
in validating a code the staff selected or requesting the appropriate code that
best reflects the diagnosis description.
c. Claims
services staff shall review all medical documentation in the claim prior to
sending the request to the ICD modification SharePoint site to ensure the
requested modifications are appropriate. When appropriate, the requests for
clarification or modification shall be sent through the SharePoint site:
i. Before
a BWC order is issued;
ii. Before a
NOR to the IC is sent; or,
iii. When an
allowance made by IC Order is unclear.
d. Claims services staff
shall:
i. Have
the following information available in order to complete the electronic
referral form on the “BWC ICD Modification Request” SharePoint site:
a) IW’s name and
claim number;
b) The reason for
the request, which will systematically assign the priority:
i) Additional
Allowance (C-86);
ii) Additional
Allowance (C9);
iii) Death;
iv) FROI;
v) IC Order;
vi) MCO Request;
vii) Modification;
viii) New Claim (0-7 day);
ix) New Claim (28 day);
x) New Claim
(Surgery Pending);
xi) New Claim (CAT Claim);
xii) Question;
xiii) Sprain/Strain; or
xiv) Surgery pending (after claim
determination).
c) Whether the
claim is Self Insured (SI), and if the condition/ICD code was allowed by the SI
employer, the date of the correspondence and claims management note documenting
this information;
d) Whether the
request is for a BWC order or IC order, and if it is for an IC order, the date
of the order and the exact description of the condition as stated in the IC
Order;
e) Dates of medical
documentation, applications or orders (e.g., MRI report dated, C-86 Motion
(C-86), IC Order, etc.) that impact or support the request;
f) If
supporting medical documentation was not provided, the date and type of
documentation that was requested;
ii. Any
request that fails to provide the required elements listed above shall be
returned specifying the missing elements that need to be included.
e. Claims services
staff shall receive a confirmation via the SharePoint site “BWC ICD
Modification Request” SharePoint site coordinator. The returned SharePoint
electronic referral form shall contain the correct ICD code to use or indicate
that the ICD description has been corrected in the claims management system.
f. The
BWC ICD Modification Request SharePoint site coordinator shall return urgent or
rush requests made by claims services staff the same day when requests are made
prior to 1 p.m. Requests made by claims services staff after 1 p.m. will be
returned the next business day.
g. Claims services
staff shall enter notes in the claims management system explaining the need for
any diagnosis modification and shall identify the documentation used to support
the decision.
h. If claims
services staff and the “BWC ICD Modification Request” SharePoint site
coordinator disagree with the recommended modifications, the issue shall be
staffed with the BWC Nursing Director or designee for determination.
i. Claims
services staff shall send any questions regarding manual conversions (mapping
ICD-9 to ICD-10) for existing claims to the BWC ICD Modification Request
SharePoint site.
j. Claims
services staff shall use the BWC ICD-10 Project Inquiry mailbox to:
i. Send
questions regarding system-mapped ICD codes;
ii. Request
specific training topics (with ‘training topic’ or ‘training request’ in the
subject line); and
iii. Ask general
ICD-10 project-related questions.
1. Claims services
staff shall ensure ICD codes and narrative descriptions correspond and are
valid workers’ compensation conditions on all requests or recommendations for
allowances [i.e., First Report of Injury (FROI), C-86 and C-9 Request for
Medical Service Reimbursement or Recommendation for Additional Conditions for
Industrial Injury or Occupation Disease (C-9)], as well as ensure conditions
identified on the documentation, are correct and valid workers’ compensation
conditions.
2. Reviewing and
Investigating the Request
a. Claims services
staff shall issue the BWC order or NOR to the IC, as appropriate, when the
description provided can be accurately coded or the ICD and supporting documentation
match exactly.
b. Claims services
staff shall review the FROI and medical documentation to obtain the correct
location and site when that information is not identified on the request. For
example: the FROI gives the condition “crushing injury of hand”; claims
services staff shall review the available documentation to determine if the
injury was to the right or left hand.
c. Claims
services staff shall not review medical documentation and diagnose a condition;
all conditions other than minor injuries must be diagnosed by a physician. For
example: If an MRI report is submitted but the POR has not formally accepted
the findings, claims services staff cannot use those findings to support adding
a condition to a claim.
d. Claims services
staff shall request the narrative description be modified or corrected if the
requested or recommended description is correct based on the medical
documentation in file, but that description cannot be accurately coded in the
claims management system. Claims services staff shall only do this when:
i. Issuing
an initial order; or
ii. Allowing a
subsequent condition; or
iii. Referring to the
IC with a NOR (if a subsequent condition should be denied). Claims services
staff shall clearly state BWC’s position on the request and outline the
supporting evidence following the Notice of Referral policy.
e. Claims services
staff shall contact the requesting party, MCO, physician of record or treating
physician to clarify the code and condition description when:
i. The
ICD code is provided without description;
ii. The
condition does not match a valid ICD code;
iii. ICD code is
correct but spinal levels are required but not documented.
f. Claims
services staff shall request medical documentation if clarification is not
given and the documentation on file is insufficient to determine the
appropriate ICD code/condition. Prior to sending to medical review, claims
services staff shall request medical documentation from:
i. The
MCO;
ii. The
physician of record or treating physician, when the MCO is unable to obtain the
documentation.
g. Claims services
staff shall send the request to physician review if the condition has not been
clarified to request what, if any, condition is supported by the medical
evidence.
h. Based on the
result of the physician review, claims services staff shall adhere to the
following policies to address the requested condition(s):
i. Additional
Allowance; and/or
ii. Order,
Waivers, Appeals and Hearings; and/or
iii. Notice of
Referral.
i. Claims
services staff shall use the ICD code A00.00 on claims for which there was no
injury.
j. If
requests or recommendations are made for symptoms or generic conditions, claims
services staff shall:
i. Determine
if the symptom requested is addressed by a condition already allowed in the
claim.
ii. If the
request is addressed by a condition already allowed in the claim, telephone the
requesting party and ask the filing party to withdraw the request or recommendation.
iii. If the request
is not addressed by a condition already allowed in the claim, telephone the
requesting party, physician of record, or treating physician to clarify the
request (i.e., determine what condition is causing this symptom).
iv. Send the request to
physician review asking what, if any, condition does the medical documentation
support.
v. Based on
the result of the physician review, follow the:
a) Additional
Allowance; and/or
b) Orders,
Waivers, Appeals and Hearings; and/or
c) Notice of
Referral.
1. Claims services
staff shall not address ICD codes and conditions in claims that fall outside an
employer’s experience or were allowed more than five years ago for employers
who are experience-rated, except in the following circumstances:
a. The condition in
question is one that is currently driving the claim cost (indemnity and
medical).
b. Anticipated
future medical or indemnity costs may be incurred due to the condition in
question (i.e., request for treatment or compensation may be filed).
2. Claims services
staff shall review retro-rated or Public Employer State Agency (PES) employer
claims for modifications at any time when there are potential medical and
indemnity impacts identified that adversely affect the claim cost.
3. Claims services staff
may staff with an Employer Service Specialist (ESS) or the BWC attorney to
determine if the incorrect diagnosis is one that impacts claim costs.
1. Claims services
staff shall not address conditions which were never formally allowed by BWC or
IC Order that fall outside an employer’s experience or have been allowed more
than five years ago unless potential medical and indemnity impacts are
identified that adversely affect the claim cost.
2. When the claims
management system has an ICD code(s) listed that was never formally allowed by
BWC or IC Order, claims services staff shall determine if the condition should
be allowed, denied, or deleted, and staff shall follow the procedures in Section
V.E.3-7 below.
3. Claims services
staff shall include medical bill review in the investigation to determine if
the condition(s) is supported by medical evidence and a causal relationship can
be established, but a BWC or IC order recognizing the condition is still
required.
4. The condition(s)
remains in an allowed status in the claims management system until the
determination process is complete.
5. Claims services
staff shall follow the Additional Allowance policy to allow the
condition or to refer the condition to the IC.
6. If the condition
was not previously allowed by BWC or IC Order and should be denied, the issue
of denial of the condition cannot be sent to the IC unless there is a C-86
currently on file requesting the condition.
a. If the condition
should be denied, and there is a C-86 on file, the C-86 is referred to the IC
for hearing via a NOR.
b. If there is no
C-86 on file, claims services staff shall follow the procedures to delete the
condition.
7. If claims
services staff determines a condition should be deleted from the claim:
a. Claims services
staff shall review all conditions not formally addressed by a BWC or IC Order
when there is no supporting medical evidence to allow the condition, or the
condition does not appear to be related to the claim.
b. Claims services
staff shall address the conditions by issuing the “BWC ICD Deletion” letter
found in COR. The ICD code shall not be deleted in the claims management system
without issuing a “BWC ICD Deletion” letter to notify the parties in the claim.
c. If there
are multiple ICD codes on the claims management system that were never formally
addressed by BWC or IC Order:
i. Claims
services staff shall include all the conditions to be deleted in the “BWC ICD
Deletion” letter.
ii. Claims
services staff shall issue both a BWC order and the “BWC ICD Deletion” letter
when some conditions can be allowed through the Additional Allowance
policy, and some conditions have no supporting medical evidence and should be
removed.
d. Claims services
staff shall not remove the ICD codes addressed by the “BWC ICD Deletion” letter
from the claims management system until 14 days after the “BWC ICD Deletion”
letter has been sent, allowing parties the time to request allowance of the
conditions by filing a C-86 or C-9 with supporting evidence.
i. Claims
services staff shall delete the condition(s) after 14 days if no C-86 or C-9 is
filed.
ii. Claims
services staff shall follow the Additional Allowance policy if a C-86 or
C-9 is filed.
iii. Claims services
staff shall not delete the ICD Code(s) until the additional allowance process
is complete.
1. If claims
services staff discovers a condition allowed by IC Order is not available
through the encoder in the claims management system, claims services staff
shall follow the general guidelines in Section V.B.1-13 of this procedure to
obtain the correct ICD code.
2. Claims services
staff shall request modification if the ICD code is correct but the condition
description is not available through the claims management system encoder.
3. Claims services
staff shall manually generate the “Notice of Injury Claim Status” letter
through the claims management system to notify the parties and provider of the
corrected description once the correction is made.
4. Claims services
staff shall update the claims management system notes explaining that the ICD
description has been modified to reflect the diagnosis description stated in
the IC Order.
1. When conditions
were formally allowed by BWC or IC Order, but were miscoded in the claims
management system:
a. Claims services
staff shall follow the general guidelines in Section V.B.1-13 of this procedure
to obtain the correct ICD code.
b. Claims services
staff shall determine if the ICD description needs to be modified to match the
allowance in the order.
c. Claims
services staff shall request modification if the ICD code is correct, but the
ICD description is not available through the claims management system.
d. Claims services
staff shall update notes in the claims management system explaining that the
ICD code or description has been modified to reflect the diagnosis description
stated in the BWC or IC Order.
e. Claims services
staff shall manually generate the “Notice of Injury Claim Status” letter in the
claims management system to notify the parties and provider of the corrected
code or description once the correction is made.
2. When conditions
were formally allowed by BWC or IC Order, but modification was never requested,
Claims services staff shall:
a. Follow the
general guidelines in Section V.B.1-13 of this procedure to obtain the correct
ICD code;
b. Request the
description be modified when the ICD code is correct, but the ICD description
does not reflect the narrative description in the IC or BWC Order.
i. Example:
BWC Order was issued using the description modification functionality in the
claims management system and the ICD description on the diagnosis/injury screen
was never updated to reflect the narrative description published on the BWC
Order.
ii. Example: Claims
services staff discovers discrepancy between the ICD narrative description that
was allowed by IC Order and the ICD narrative description that is contained in
the claims management system. The ICD modification was never requested.
1. When the IC has
allowed a back condition (e.g., degenerative disc disease) without indicating a
specific level:
a. Claims services
staff shall staff with the BWC attorney to determine if the claim should be
returned to the IC for clarification if the IC Order is still within the appeal
period.
b. Claims services
staff shall not update the condition to add specific levels without a formal
order.
2. If treatment is
requested in a claim where the level is not indicated and the MCO contacts claims
services staff to clarify the allowed condition, claims services staff shall:
a. Review the
medical documentation supporting the allowance that is referenced in the “based
on” section of the IC Order;
b. Determine what
level(s) was supported by the medical documentation if indicated;
c. Staff with
the MCO to determine what level the requested treatment addresses.
i. If
the requested treatment is for the level that is found in the medical evidence,
document this in notes in the claims management system for future reference and
share the information with the MCO. No updates shall be made to the allowed
conditions;
ii. If the
requested treatment is for levels that appear to be unrelated to the level as
indicated in the medical documentation cited in the IC Order, or the level is
supported by medical documentation received after the IC Order, claims services
staff shall staff with the BWC attorney to consider filing a C-86 for
continuing jurisdiction to clarify the allowance in the claim.
1. Claims services
staff shall request modification through the “BWC ICD Modification Request”
SharePoint site when expired codes are identified.
2. Claims services
staff shall add current codes when expired codes are identified by the BWC ICD Modification
Request SharePoint site coordinator.
3. BWC ICD
Modification Request SharePoint site coordinator will modify the narrative to
reflect the previously allowed condition(s).
4. Claims services
staff shall delete the expired code from the claims management system.