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Work
Loss Data Institute __________________________________ San Diego, CA Corpus Christi, TX |
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Utilizing
ODG in Texas: A Short Instructional on Implementation
of the Division Treatment Guidelines Under
the new disability management rules (Section 137.100) non-network healthcare
provided on or after May 1, 2007 to workers injured on the job in Texas is to be
in accordance with Official Disability Guidelines – Treatment in Workers’
Comp (ODG, ODG Treatment). This
article will serve as a short instructional from the publisher of ODG, Work Loss
Data Institute, on how it is best implemented under §137.100
First
of all, it is important to note that ODG in its entirety is a vast and
far-reaching database of return-to-work guidelines, disability duration
normative data, statistics on medical and indemnity costs in worker’
compensation, incidence and prevalence figures, and finally, treatment
guidelines for work-related conditions. The
complete ODG product line is delivered in a three-volume textbook set recording
over 4,100 pages, or on the Internet in a subscriber Web version representing
over 200 megabytes of content. Of
course, one needn’t be overwhelmed. As
logic would have it, ODG is broken into three distinct sections – guidelines
for Treatment, Duration and Impairment. Each
section is then further divided by diagnosis or body part, and so forth.
With respect to §137.100, it is one
section in particular – ODG Treatment – that is now pegged to be applied by
rule. ODG
Treatment is broken into 16 core chapters (Ankle/Foot, Burns, Carpal Tunnel
Syndrome, Elbow, Eye, Fitness for Duty, Forearm/Wrist/Hand, Head, Hernia,
Hip/Pelvis, Knee/Leg, Low Back, Neck/Upper Back, Pain, Shoulder, Stress/Mental).
Each chapter is broken into three sections, Treatment Planning, Codes for
Automated-Approval, and Procedure Summary.
In addition, the ODG Treatment UR Advisor is available to users of the
Web version. These sections are
dissected below in order of relevance. ODG
Treatment UR Advisor
Description Because
it is organized by ICD9 diagnosis code, this section is linked into Section B of
the site. The link opens a mapping of CPT codes to the ICD9 based on
recommendations from ODG Treatment and actual workers’ compensation claims
data representing about 2 million claims and almost 50 million paid invoices
covering about 10 billion dollars in actual incurred medical costs.
Data is provided on frequency, incidence, number of visits and cost, plus
the ODG treatment Bill Review Payment Flag.
Significance Most
significant is the Bill Review Payment Flag, labeled Green, Yellow, Red or
Black, meaning the following: Green
= OK to auto-pay up to ODG CAA max number of visits.
Yellow = OK to auto-pay up to 25th
percentile (or 50th percentile for more liberal policy) number
of visits. Red = Need to review.
Black or Not listed = Need to review.
The ODG Treatment UR Advisor is designed to streamline the UR process.
Further manual review should be done using Procedure Summaries.
The primary purpose of the ODG Treatment UR Advisor is to
facilitate early access to the right treatment for injured workers.
There are many treatments, diagnostic tests, and provider visits where
the best thing the insurance reviewer can do is get out of the way and let the
doctors treat. The UR Advisor lets them do that, and also frees up the
reviewers’ time to handle the more complex situations where their education
and experience can be used to best advantage.
Within the list of procedure codes in the UR Advisor, there are many
medical codes that are lacking the support of quality medical studies, but based
on actual claims data, these codes are very common for the diagnosis being
reviewed, their outcomes are good, and the total costs are not excessive.
Examples may include additional office visits for other specialist opinions,
relatively minor laboratory tests when the treating doctor suspects another
diagnosis, simple repairs of superficial wounds when the diagnosis is an open
wound, etc. These are cases where
there should be no delay in treatment just because a reviewer cannot find a
specific entry in the Procedure Summary.
These codes are typically Yellow in the UR Advisor, which indicates to
auto-pay up to the 25th percentile in number of visits. Procedure Summary
Description This
is the most important section of ODG. Listed
here alphabetically are all possible therapies, including surgeries, physical
medicine modalities, diagnostic and imaging tests, and virtually any other
treatment or procedure that might be considered for each condition or body part.
Beside each is a recommendation for appropriate use, if any, along with a
summary of the supporting medical evidence.
Links are also provided to abstracts of the cited references, which are
ranked and weighted alphanumerically.
Significance
This is where the
“teeth” of the rule lie. The
Procedure Summary is generally where an insurance carrier or a medical provider
will look to determine if a given intervention is supported by adequate medical
evidence and therefore recommended as an option.
Each entry will begin with one of the following three terms:
“Recommended…”, “Not Recommended…” or in some cases, “Under
Study”. It will then specify
patient selection criteria, clinical criteria, or other treatment plan that
should be applied or considered. Treatment
Planning
Description This
is presented as an ideal case plan, indicating selected interventions
recommended for each visit, along with timing for these visits.
The Treatment Planning section is only a recommendation.
It is NOT to be used as a rigid protocol applied in all cases.
Significance Healthcare
providers may choose to follow the Treatment Planning section at their own
discretion. They may also consider interventions outside of the Treatment
Planning section. When doing this,
they should verify these interventions are recommended as options in the
Procedure Summary. An insurance
carrier should not use the absence of a particular therapy from the Treatment
Planning section as a basis to deny care. Codes for Automated Approval
Description This
is presented as an optional tool to streamline the UR process.
Codes for Automated Approval maps procedure codes to diagnosis codes with
a field indicator for maximum occurrences for auto-approval. This is does not constitute a recommendation.
Significance Insurance
carriers and utilization review companies may choose to streamline their
processes by automatically approving procedures in the Codes for Automated
Approval section. However, this is
at their discretion. The
interventions here may have specific patient selection criteria – found in the
Procedure Summary – that may also be applied.
The “maximum occurrences” listed here are for the purpose of
auto-approval only. Additional
therapy may be recommended / allowed for in the Procedure Summary. Each
of the above sections is presented distinctly in the chapters of ODG
Treatment in Workers’ Comp. These
are the focus of §137.100, particularly the
Procedure Summaries. Complimentary
with ODG Treatment in Workers’ Comp comes the standard version of Official
Disability Guidelines. Official
Disability Guidelines provides disability duration or return-to-work
guidelines for every reportable condition based on severity, treatment and type
of job, organized by ICD-9 diagnosis code.
Within this section there are lists of every possible treatment for each
condition, hyper-linked to the listing in the Procedure Summary of the
appropriate chapter of ODG Treatment, so this section can facilitate access to
the treatment guidelines adopted
under §137.100 by ICD-9 code. Also
included are workers’ comp cost tables (medical, indemnity and total),
recommendations for activity modification, causality likelihood, age adjustment
factors, average hospital costs and length of stay, ICD-10 translations, and
normative data on time away from work in tabular or graphical form representing
over 10 million cases. While not
directly related to §137.100, users may find
significant value in this information as well. In summary, with respect to §137.100, the most important sections of Official Disability Guidelines – Treatment in Workers’ Comp are the Procedure Summaries within ODG Treatment. This is where treatment and utilization review decisions based on ODG should be considered. That said, while guidelines can assist clinicians in making treatment decisions and help insurance carriers make reimbursement determinations, they cannot take into account the uniqueness of each patient's clinical circumstances. As such, they should not be used as the sole evidence for an absolute standard of care. Given that they are evidence-based and sufficiently current, however, they should carry significant weight, and in the form of ODG Treatment they do under §137.100. Official Disability Guidelines – Treatment in Workers’ Comp is available in textbook and Web-based format from Work Loss Data Institute. The Web version is the official "current" edition of ODG at any point in time according to TDI DWC. Questions? Contact ODG Helpdesk at ODG@worklossdata.com |
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