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1/65 Official Disability Guidelines - Treatment in Workers Comp ODG Work Loss Data Institute (WLDI) 169 Saxony Road, Suite 101 Encinitas, CA 92024 Phone:

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Presentation on theme: "1/65 Official Disability Guidelines - Treatment in Workers Comp ODG Work Loss Data Institute (WLDI) 169 Saxony Road, Suite 101 Encinitas, CA 92024 Phone:"— Presentation transcript:

1 1/65 Official Disability Guidelines - Treatment in Workers Comp ODG Work Loss Data Institute (WLDI) 169 Saxony Road, Suite 101 Encinitas, CA Phone: WELCOME! This is a self-paced training module for the ODG website. Click on the button at the lower right-hand corner to begin. NOTE: To ensure success, right click and select Full Screen.

2 Instructions Before You Begin… This training module is designed to be interactive. Opportunities for you to practice your new skills have been built into the training. When the instructions appear on the screen, use your mouse to participate in the activity. Use your mouse clicker for rewinding or advancing slides or text boxes if you miss something. DO NOT USE THE SCROLL WHEEL on your mouse. Similar to a VCR, use the two blue buttons at the bottom of the screen to rewind or to play forward You can advance pop-up buttons by using the left-click on your mouse to speed the process The average run-time for the module is minutes

3 Training Objectives Understand when, why & how to use ODG Learn how to access the ODG website Learn how to use the navigation options to find the information youre looking for Learn about the different components of the guidelines Understand which guidelines you will use the most to do your job REMINDER: Click on button when youre ready to go.

4 4/65 ODG The Evidence-Based Authority on Utilization Review and Disability Duration

5 Reasons for Using ODG Prospective Case Management Setting Reserves / Claims Adjusting Retrospective Benchmarking Utilization Review / Management Clinical Practice

6 6/65 How to Get Into the Website ODG Access Information

7 Logging into the Site from Web Begin by opening your Web browser (i.e. Internet Explorer): Type in the address for the website You will get a pop-up box, like the one below, for your log-in information:

8 ODG Main Menu Your Toolbar is located at the top of the page. After logging in, click on the picture of the books to enter the site. This will open the Contents Page The Contents Page is Home Base. From here, first decide if you want treatment or duration guidelines, then enter Section A or B appropriately. (Section D has important background info, including the Preface and Users Guide).

9 From the Contents Page… The Contents Page contains 3 types of guidelines. Section A contains the ODG Treatment Guidelines (most useful for UR / UM, nurses and doctors). Section B contains the ODG Disability Duration Guidelines (useful for all users). In Section C, you will find Impairment Guides from IAIABC (not ODG).

10 10/65 How to Find What Youre Looking For ODG Indexing Functions

11 From the Contents Page Starting with an example in Section B, there are 3 ways you can search for duration guidelines. Index options for duration guidelines are listed under Section B. We will begin by going over the ICD9 Index option. Click anywhere on this page to proceed. You can look up by ICD9 diagnosis code, by keyword (i.e. name or body part) or by the CPT procedure code.

12 Using the ICD9 Index Starting from the Main Menu, use your mouse to click on ICD-9 Index to begin your search. Hint! In this example, say youd like to find disability duration guidelines for ICD9 code

13 Using the ICD9 Index By clicking on ICD9 Index, you will come to this list of the 18 major ICD9 categories. Note: You can use this Index even when you dont know the ICD9 code. For example, notice Chapter 5 covers Mental, Chapter 8 covers Respiratory, 17 has Injures, etc.

14 Using the ICD9 Index The ICD9 codes are listed in numerical order and in ranges. Using your mouse, click on the blue numerical range where the ICD9 code would fall. Hint ! With the ICD9 Index, lets open ICD9 code: 847.2

15 Using the ICD9 Index The categories are organized by types of conditions and similar conditions will be grouped together. Note fractures, then dislocations. Later come sprains & strains, contusions, etc. (many workers comp conditions are found in this chapter). Clicking on ( ) will take you to this page of sub-categories.

16 Using the ICD9 Index The diagnosis code of would fall within the range of Sprains and Strains. And under Sprains and Strains youll find 847 Sprains and Strains of the Back. Using your mouse, click on 847 to narrow your search down even more. Hint !

17 Using the ICD9 Index Now all conditions that start with 847 are listed, with those that are most common found in Bold Face. Select the diagnosis code from the list. Hint!

18 Using the ICD9 Index Now you have the RTW Guidelines for ICD9 code 847.2, Lumbar Sprains and Strains We will go over how to use each of these areas later in the module.

19 Another Index Method You may know the name of the condition, but not the ICD9 code. You can use the Keyword Index to locate the duration guidelines by name. Hint ! For example, your investigation reveals the claimant has a diagnosis of Lumbago. How will you find duration guidelines for this condition? Starting from the Contents Page, use your mouse to click on Keyword Index to begin your search.

20 Using the Keyword Index The Keyword Index is alphabetical by keyword. Lets look for the condition Lumbago. Using your mouse, click on the letter L from the list. Hint !

21 Using the Keyword Index Keywords are listed alphabetically. You will need to scroll down to the bottom of the list to find Lumbago.

22 Using the Keyword Index Heres the keyword Lumbago. Conditions matching the keyword are listed by ICD9 code. Clicking on the ICD9 code will take you to the duration guidelines for that condition. Using your mouse, click on ICD9 code for Lumbago. Hint !

23 Using the Keyword Index This page contains the duration guidelines for the diagnosis of Lumbago with the ICD9 code We will go over how to use each of these areas later in the module.

24 Another Index Method The last Index method for Section B is the CPT Index For example, Starting from the Main Menu, use your mouse to click on CPT Index. Hint ! Use the CPT Index when looking for benchmark procedure costs from the Medicare fee schedule (Note: these are not treatment recommendations).

25 Using the CPT Search Function By accepting the licensing agreement, you will come to this numerical list of procedural codes. Now, using your mouse, click on the 9 CPT Codes to proceed. NOTE: Only the most common procedural codes are listed in the system. If you are unable to find the code youre looking for, refer to a CPT reference book for more details. Hint ! Procedural code begins with the #9 and would fall within the range as listed (90788 to 99556).

26 Using the CPT Search Function All codes beginning with the number 9 will be listed in ascending numerical order. You will need to scroll down towards the bottom of the list to find procedural code

27 Using the CPT Search Function Below the CPT code 97110, there is a list of conditions. Note: these are not necessarily recommended – refer to ODG Treatment (later) for recommendations. Lumbago is the medical condition were interested in. Using your mouse, click on the ICD9 code for Lumbago to proceed. Hint ! The CPT code and the name of the procedure will be listed in bold text on the page, followed by a benchmark cost from the Medicare Fee Schedule.

28 Using the CPT Index By using the CPT Index to search, you arrived at the same guidelines page for the diagnosis of Lumbago. Now you will learn what all this information means and how you will use it.

29 29/65 How to Use the Information Understanding the ODG Content Now that you have found what you are looking for – How do you use this information? The ODG guidelines will provide plenty of useful information to help you manage your claims. Click below to find out how.

30 Duration Guidelines The key is to understand what everything means, or how it is defined. Depending on your position, ODG may be used differently. Well go over each of the highlighted areas in detail.

31 RTW Summary Guidelines The first section is the RTW Summary Guidelines, for those who just want to eyeball a target or range Notice the two Checkpoints, Midrange and At-Risk. This table indicates the time at which 50% and 90% of cases return-to-work, for two datasets: lost-time Claims (cases out more than 7 days), and All Absence data (everyone who missed work) Minimum=Always Zero Midrange Dates=Expected Range At-Risk Dates=Red Flag / Maximum

32 RTW Best Practice Guidelines The next section we will go over is the RTW Best Practice Guidelines This table is used when more job and medical details are available on a claim. This table provides expected duration based on factors such as: Severity Type of treatment or surgery Type of job Co-morbid conditions

33 Capabilities & Activity Modifications for Restricted Work Job factors in the Best Practice Guidelines may correspond to the Activity Modifications below For example: Note a severe lumbar sprain is ready for clerical/modified work at 0-3 days, and appropriate activity modifications follow. These remain in place until days when the case is ready for manual work

34 Other Valuable Features ODG provides a variety of other features that may help you: Links to the Procedure Summaries from ODG Treatment, where possible therapies are summarized with recommendations for use (if applicable), Direct link to ODG Treatment Index, Link to other sources such as Merck, State Guidelines, etc, Causality Likelihood (percent of claims that are work-related in nature), Average Hospital Costs and Length of Stay (for cases admitted to hospital), CM Triage (priority indicators: Level 1, 2 or 3), PT and Chiropractic Guidelines (frequency and duration of care), Workers Comp Costs (medical, indemnity and total costs at each quartile, with means – excellent for setting reserves)

35 Other Valuable Features Age Adjustment Factors (multipliers that can be used to adjust the Summary and Best Practice Guidelines) The Back-Up Data Follows: RTW Claims Data by decile (10% of claims back to work in 10 days, 20% in 12 days, etc). Both occupational and non-occupational are included. RTW Post-Surgery by decile. Integrated Disability Data (both occ. and non-occ.) distribution on all cases (not just claims). Strictly occupational data from OSHA NOTE: The back-up data is here to support your recommendations. But you dont need to worry about interpreting it. That has been done for you in the Summary and Best Practice Guidelines.

36 36/65 ODG Treatment in Workers Comp (Found Under Section A of the Contents Page)

37 From the Contents Page… Returning to the Contents Page, we will now review ODG Treatment. ODG Treatment is found under Section A and will be most useful to workers comp providers, reviewers and nurse case managers. Using your mouse, click on the link to access the ODG Treatment Guidelines. Hint !

38 ODG Treatment Index ODG Treatment covers conditions likely to be seen in workers comp – 99% of WC costs. Based on a comprehensive and ongoing medical literature review. Each Chapter includes the date of last update. Chapters are based on body part (plus Burns, CTS, Fitness for Duty, Hernia, Pain, Mental)

39 ODG Treatment Index (ODG/TWC) Scrolling down... Notice the Patient Information Index Using your mouse, click on Low Back to access the ODG-TWC.

40 Treatment Guidelines This is the Low Back chapter of ODG Treatment In each Chapter, there are three major sections The Treatment Protocols section goes over the pathways for ideal cases. Codes for Auto-Approval maps CPT codes to ICD9 codes for auto-approval The Procedure Summary is the most important feature. It lists every possible therapy and summarizes the medical evidence, with recommendations for use Lets begin with taking a look at Treatment Protocols. Click on the link to proceed. Hint !

41 Treatment Protocol The information provided in the Treatment Protocol is useful and well-supported by objective medical evidence. It is a visit-by-visit case plan for ideal cases, used primarily for clinical practice by the treating physician. This section integrates the RTW Best Practice Guidelines for disability duration We will now return to the top of the Low Back chapter and look at the next section Click on the forward button when ready.

42 ODG Treatment The next slide will go over the section on Codes for Automated Approval for the condition of Low Back. This section lists the number of CPT treatments that can be auto-approved for each ICD9. Using your mouse, click on the Codes for Auto-Approval. Hint !

43 Codes for Auto-Approval This section maps CPT procedure codes to the ICD9 diagnosis codes based on the ideal treatment plan. ALERT: Not all cases will fit this ideal protocol. Using the Procedure Summary is critical. Care should not be denied based on the Treatment Protocols or Codes for Auto-Approval. Only the Procedure Summary can be used to deny care. These procedures can be auto- approved until this point.

44 ODG Treatment The last section we will go over is the Procedure Summary for Low Back. The Procedure Summary lists every possible therapy and summarizes the medical evidence and provides VERY IMPORTANT details for Utilization Management. Using your mouse, click on the Procedure Summary section. Hint !

45 Procedure Summary The Procedure Summary lists all possible therapies and diagnostic tests, then summarizes the medical evidence with recommendations for use Each entry is clear, beginning with either Recommended…, Not recommended… (or in some cases, Under Study). Recommendations are linked to the supporting medical evidence, provided in abstract form. To view the entire list, you will need to scroll down.

46 Procedure Summary In the Procedure Summary youll find summaries of the effectiveness of virtually every treatment, procedure, or imaging test. If you want learn more about the evidence behind each recommendation, you have the option of clicking on the reference links…

47 Procedure Summary For an example of the reference links, see below: Using your mouse, click on the reference link for Tulder- Cochrane, 2000 (in color). Clicking on a reference link will open up a summary & the evaluation of that reference. Hint !

48 Link from Procedure Summary The reference link will take you to the abstract and evaluation of the medical study. Take a look at the highlighted area supporting ODG. The abstract will tell you all about the study (where it was published, objective, results, conclusions, etc). Note: References are provided to back-up your recommendations, but you dont have to worry about them or use them if you dont need to.

49 Youre Done! This completes your self-paced training module. Thank you for participating. For additional assistance, please use the ODG Helpdesk: address: Or call:

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