As you may know, in order to receive reimbursement from Medicare, Medicaid, or private insurance companies, E&M coding, or evaluation and management coding, to support medical billing is required. Importantly, the current system was designed for use by primary care and group health plans, which often times fail to align with the needs of workers’ compensation providers. Due to the misalignment, many factors used in assessing a patient for purposes of workers’ compensation treatment do not fit squarely into the billing guidelines for E&M coding. The result is the inability of workers’ compensation physicians to properly bill for medical care in workers’ compensation patients. Though this misalignment of billing practices may seem like a small problem, given that national workers’ compensation medical benefits paid in 2015 amounted to over $31.5 billion[1], it is clear that an inadequacy or misalignment in billing practices may have a large effect across the country.

Another issue related to this is the belief physicians involved in workers’ compensation matters feel that they are not adequately compensated for the time and expertise involved in assessing problems of medical causation, minimizing disability, and assessing patient’s disability. While these metrics are of little importance in the general health care setting, they clearly provide the groundwork for the workers’ compensation system.  Therefore, ensuring compensation commensurate with high quality care has come to the forefront of discussions nationally. . As it stands, the current system of coding published by the Center for Medicaid and Medicare Services does not address the many of the tasks required of workers’ compensation providers, while requiring many procedures which have no place in a workers’ compensation setting.

The solution to this problem, as proposed by the American College of Occupational and Environmental Medicine in its 2016 Guidance Statement involves (1) the adoption of new ground rules for documenting E&M encounters, emphasizing those tasks vital to proper workers’ compensation care, (2) the recognition of codes for consultation in workers’ compensation care, (3) the use of management codes with alternative ground rules for workers’ compensation care, and (4) for the development of coding for services with no codes under the current system, but which have been determined to be vital to workers’ compensation care. In support of their proposed changes, ACOEM cites to Washington State’s program, Centers of Occupational Health and Education (COHE), which was designed to test the resultant effect on disabilities in the state under a system financially incentivizing health care providers to engage in one or more of four specific occupational medicine best practices: (1) prompt submission of the report of accident form, (2) calls from the health care provider to the employer in circumstances when an employee is to be taken off work, (3) the health care provider is required to see the injured worker every 2 weeks, filling out an activity prescription form for each visit, and (4) performing a disability assessment if an injured worker has not returned to work within 4 weeks. The results of the program showed a reduction in disability time as well as a reduction in overall claim costs, even after the increased cost of medical services was taken into account.[2] Though not specifically related to opioids, the ACOEM proposal envisions a substantial reduction in opioid use, which has become a national epidemic.

The changes proposed by the ACOEM have not gone into effect.  Nonetheless, the proposal points out the distinct differences between general health care services versus medical care in workers’ compensation. The model in Washington highlights what other states are doing to reduce disability and overall claims cost in the workers’ compensation arena in future.

[1] Sengupta I, Baldwin ML. Workers’ Compensation: Benefits, Coverage, and Costs, 2013. Washington, DC National Academy of Social Insurance; August 2015. Available at: 2015.pdf. Accessed December 14, 2016.

[2] Wickizer TM, Franklin G, Fulton-Kehoe D, et al. Improving quality, preventing disability and reducing costs in workers’ compensation healthcare: a population-based intervention study. Med Care. 2011;49:1105-1111.