Best practices, guidelines for medical providers

The worker's compensation law requires the employer/insurer to cover all reasonable and necessary treatment, items and services prescribed by the authorized treating physician.
Provider invoices/forms should be filed within a reasonable period from the date of services using the CPT coding guidelines, and proper ICD-9 diagnosis codes. Documentation of the service provided (office notes, operative notes, etc.) greatly enhances payment processing. No physician, hospital or medical supplier shall bill the employee for authorized medial treatment.
Fees of physicians and charges of hospitals and other services under the worker's compensation law shall be subject to the approval of the State Board of Workers' Compensation. No physician, hospital, or other provider of services shall be entitled to collect any fee unless reports required by the board have been made.
Reimbursement of services is done according to the Schedule of Fee for Physicians, Surgeons, Pharmaceutical Home Health Care and Hospitals for Services Rendered under the Georgia Workers' Compensation Law. Reimbursement to the provider must be done within 30 days according to state law. If not paid within 30 days, 349-203 imposes a penalty of I0% of charges. For payment of charges made between 61-90 days after the due date
the penalty will be 20%. From the 91 st day after the date charges were due the interest due will be 12% per annum.
RESOLUTION OF DIFFICULT CASES
Roles of the Independent Medical Examination In Georgia an injured worker, after an accepted compensable injury and within 120 days of receipt of any income benefits, shall have the right to one examination at a reasonable time and place, within this state or within 50 miles of the employee's residence, by a duly qualified physician or surgeon designated by the employee and to be paid for by the employer/insurer. This Independent

Medical Examination shall not repeat any diagnostic procedures which have been performed since the date of the employee's injury unless the costs of such diagnostic procedures which are in excess of $250 are paid by a party other than the employer or the insurer. The employer/insurer also has the right to ask the employee to submit to examination by a physician designated by the employer. Records of previous treatment should be reviewed and a thorough history and examination performed and documented, along with a summary of the assessment and recommendations. This evaluation does not create a physician-patient relationship and is separate from treatment.
Impairment vs. Disability At the point of medical stability after treatment of a work related injury, also known as Maximum Medical Improvement (MMI), the patient should be evaluate4 for any permanent partial impairment (PPI) due to that injury.
"Impairment" is a medical term and in Georgia is measured by the objective criteria outlined in the AMA Guide to the Evaluation of Permanent Impairment, 5th Edition. The Impairment rating is expressed as a percentage of the involved area. "Disability" is a legal term and may include more subjective factors, such as the type of work the patient does. Disability determinations are not done as a part of standard medical evaluation.
This brochure is a joint project of the State Board of Workers' Compensation and the Medical Association of Georgia.
July 2001

THE PATIENT-PHYSICIAN ENCOUNTER
History
A thorough history should be taken including: symptoms, duration, nature, aggravating activities, and date of injury:
Work Status
Obtain information regarding work status including: type of work, how-long on the job and any recent ch~nge. Communicate with employer, as needed, regarding patient's current job requirements.
Past Medical History
Inquire about prior problems, medical problems and medication allergies.
Treatment
Prior treatment modalities, surgery, therapy, including "alternative" methods should be determined.
Social
Obtain information about hobbies, household and recreational activities, family history, litigation and psychosocial factors.
Prior Records
Obtain and review prior records as relevant. Do not rely on verbal reports.
Examination
A thorough physical examinatiort of the area of symptoms should be performed including any reasonable and necessary testing. Note any loss of mobility, swelling or deformity.
Testing
Prior test results should be reviewed to avoid repeating diagnostic tests unnecessarily.
Diagnosis
A specific diagnosis should be made, if possible, but if the diagnosis is not clear, there are ICD-9 codes available for pain, swelling, etc.This is preferable to labeling nonspecific musculoskeletal symptoms as tendinitis, etc. Terms such as "cumulative trauma" imply causality and should be avoid-

ed.The relationship, or lack thereof, of the the complaint to the patient's job sho~ld be made as clear as possible. In Georgia, aggravation of a preexisting condition is compensable as long as the aggravation lasts.
It is important to be objective as possible and to assess each situation individually and impartially.
Treatment Recommendations
The plan should be spelled out in as much detail as possible, including the need for diagnostic testing, medications, therapy, surgery, activity modification, splinting, etc. Information about length of treatment, recovery and prognosis is very helpful to all parties. Return to work status should be specifically addressed. Describe activities to be avoided.Avoid vague references to "light" duty. It is wise to contact the employer or insurer to determine if modifications are available rather than relying completely on verbal reports from the patient Prescriptions for workers' compensation patients should be so indicated.
Documentation
The above information should be readable and available to all involved parties in a timely manner. Copies of the office notes should be made available to the employer/insurer. Also, document any phone calls regarding the patient and keep copies of all correspondence. Referrals to other providers should be controlled by the"authorized treating physician: The authorized treating physician may be determined in several ways:
I) Selected from a posted" Panel of Physicians" listing at least four physicians. Effective january I, 2002 the required number of physicians for a valid panel
increases from four to six, unless the board has granted an exception.
2) Selected from a list of at least ten physicians known as the"Conformed Panel of Physicians:
3) Member of a Workers' Compensation certified Managed Care Organization (MCO) contracted by employer.
4) The law also provides for either party to request an order from the Board designating and appointing an authorized treating physician.

COMMUNICATION
The law in Georgia specifies that the medical record in a worker's compensation claim, or when the employer has paid any medical expenses, is open to all parties to the claim.These records may include communications with psychiatrists or psychologists related to that workers' compensation claim. Parties to the claim consist of other providers, insurers, employers, their attorneys and the patient.Therefore, patient release forms are not necessary when communicating with these parties. However, many providers attempt to obtain a release of information from the patient to expedite communication. The medical records are available from the insurer at no cost to the parties, however; if the insurer fails to provide the injured worker or employer with copies, the provider may charge the insurer $.50 per page with a $1 0.00 minimum.
Communication can be greatly facilitated by the provider's willingness to write or call the insurer, employer or case manager (when authorized) to resolve problems such as return to work issues, delayed recovery, etc.They are entitled to this information, and a provider who is willing to become involved in the communication process can greatly expedite resolution of problem cases. In some cases the call from the doctor may be the first knowledge the employer or insurer has that the injury has occurred.
PAYMENT ISSUES
It is very important to verify coverage at or before the patient's initial visit, if possible. It is the responsibility of the provider's office to obtain this verification.This should be in writing via the patient or faxed to the provider's office.The law makes exceptions in emergency or urgent situations.