Medical Fee Schedule: Section 12

In Accordance with the N.C. Industrial Commission’s
Medical Fee Schedule & Subsequent Updates, 1996-2010

Bernadine Singh
Chief Medical Fee Examiner
N.C. Industrial Commission
E-mail: Bernadine.Singh@ic.nc.gov

Industrial Rehabilitation Section 12

INDUSTRIAL REHABILITATION

• Because each of the programs or evaluations listed below varies in time depending on the injured employee, the Industrial Commission will not set fees.  The provider must obtain authorization from the Employer/Self-Insurers or Insurance Company before entering a patient into a program.  If they are in agreement with the program, the Self-Insurer or the Insurance Company may pay the bill and retain all bills and reports in their file.  The Commission requests that you deal directly with the Employer/Self-Insurer or Insurance Company for payment.  Once you have permission to enter a patient in a work conditioning or work hardening program, all charges from Day One until the patient has been released are all inclusive charges.  This includes physical therapy, psychiatric, psychological, neuropsychologist, and other treatment. When billing for these services, the Medical Provider must use the codes listed below:
   
1. Work Conditioning: WC100 or (97545-97546).
    
2. Work Hardening: WH100 or (97545-97546).
    
3. Evaluations—FC100, PC100 & other evaluations: EV100.
    
4. Rehabilitation with psychological services: PSY00.

These services are covered under the agreement between the Self-Insurer/Insurance Company and the Medical Provider. Each of these programs or evaluations listed above varies in time.  Pay per your agreement.  Do not submit the above bills to the Industrial Commission.

REHABILITATION NURSE’S CHARGES

• Effective January 1, 1993 bills for services of Rehabilitation Nurses and Rehabilitation Specialists are required to be submitted to the N.C. Industrial Commission for record purposes. Copies of rehabilitation notes are no longer required, but must be provided on request. Bills will be entered on our computer using a code RN100 to identify these charges. Bills will be approved in full and you will receive a “bill analysis.” You must pay them as you have in the past and it will not be necessary to wait for the bill analysis. Each bill must have the rehabilitation firm’s Federal Tax I.D. number and the I.C. file number and list the dates of service. Otherwise, no special form is required.

OTHER CHARGES

• The Industrial Commission has given the Self-Insurers and Insurance Companies permission to pay the following bills without submitting them to the Industrial Commission for approval. Please obtain a copy of the bill for your file. The North Carolina Industrial Commission does not process the following bills.
   

1. Travel Bills—$.445 per mile effective January 18, 2006. Patients must travel at least 10 miles one way in order to collect. Travel for job replacement is also covered.
    
2. Minor Medical ($2,000 or less)—Consult the Medical Fee Schedule.  To save time and the submission of a Form 19, if there is a “BY REPORT” item on the bill, you may pay this item in full if the item does not exceed $50. If item exceeds $50, file a Form 19.
    
3. Pharmacy Bills—Pay in full or per agreement.
    
4. Ambulance—Pay in full or per agreement.
    
5. Out-of-State Bills and Claims—Pay in full or per agreement or by your state's fee schedule.
    
6. Nursing bills (private duty and home health)—Pay in full or per agreement.
    
7. Nursing Homes—Pay in full or per your agreement with insurance carrier/self-insurer.
    
8. Pain Clinic—Pay per your agreement with insurance carrier/self-insurer.
    
9. Industrial Rehabilitation (“work hardening programs” and “psychological services”)—Pay per your agreement with the insurance carrier/self-insurer.
    
10. Rehabilitation Nurse Bill—pay in full or per agreement—new rule effective January 1, 1993/Charges must be reflected on Form 51.

Guidelines for Work Conditioning Programs

PREFACE

Injured workers benefit from physical therapy services from the onset of injury through return to work.  Early physical therapy management consists of traditional treatment for acute musculoskeletal problems.  Many clients are able to return to their previous employment without the need for additional services.

However, for the workers not able to return to work, other approaches have developed.  The programs that have evolved over the past 10-15 years have been collectively called work hardening.  These programs have addressed one or more of the physical, psychosocial, and vocational needs of injured works thus enabling them to return to gainful employment.  Physical therapists generally have provided individualized, graded conditioning and simulated work activities.  Given the growing sophistication, technological advances, and the services available for the injured worker, the American Physical Therapy Association now finds it prudent to define terminology in order to clarify the role of the physical therapist in the provision of these services.

In contemporary practice, work conditioning programs provided by licensed physical therapists have evolved for these injured workers who do not require vocational and psychosocial services in order to return to gainful employment.  These workers benefit from graded conditioning activities, education, and simulated work-relevant tasks following acute management.

Work hardening services are indicated for those clients with multivariate problems (physical, psychosocial, and vocational).  Work hardening is currently defined as an interdisciplinary program.  Physical therapists provide the physical component of these services.

This document identifies work conditioning and work hardening as distinct and independent components on the continuum of care for the injured worker.

Definitions

WORK CONDITIONING

Work conditioning is a work relevant, intensive, goal-oriented treatment program specifically designed to restore an individual’s systemic, neuro musculo-skeletal function (strength, endurance, movements flexibility and motor control).  The objective of the work conditioning program is to restore the client’s physical health and function so the client can return to work, or for the client to become physically reconditioned so vocational rehabilitation services can commence.

WORK HARDENING

Work hardening is a highly structured, goal-oriented, individualized treatment program designed to maximize the person’s ability to return to work.  Work hardening programs, which are interdisciplinary in nature, use conditioning tasks that are graded to progressively improve the biomechanical, neuromuscular, cardiovascular/metabolic and psychosocial functions of the person in conjunction with real or simulated work activities.  Work hardening focuses on the physical, psychosocial, and vocational needs of the client while addressing the issues of productivity, safety, physical tolerances, and worker behaviors.

DIRECT SUPERVISION

The remainder of this document addresses the elements of a work conditioning program.

CLIENT ELIGIBILITY

1.   To be eligible for work conditioning, a client must:

a.  Have stated or demonstrated willingness to participate.

b.  Have identified systemic neuro-musculo-skeletal deficits that interfere with work.

c.  Be at the point of resolution of the initial or principal injury that participation in the conditioning process would not be prohibited.

d.  Be seen by an appropriate professional if psychosocial problems are identified.

e.  Be seen by an appropriate professional if vocational problems are identified.

2.   Work conditioning generally follows acute medical care or may begin when the client meets the eligibility criteria.

3.   Work conditioning may not begin after 365 days have elapses following the injury without a comprehensive interdisciplinary evaluation to establish eligibility.

PROGRAM PROVIDER RESPONSIBILITY

1.   The employer and/or carriers shall be notified prior to initiation of the program.

2.   The need for a program shall be established by a work conditioning assessment performed by a work conditioning provider.

3.   The program shall be provided by or under the direct supervision of a work conditioning provider.

4.   The work conditioning provider shall document all evaluations, services provided, client progress, and discharge plans.  Information shall be available to the client/patient, employer, other professional providers, insurance carriers, and any referral source with appropriate authorization.

5.   The work conditioning provider shall develop and utilize a program evaluation system designed to assess, at a minimum, patient care outcomes, as well as program effectiveness and efficiency.

WORK CONDITIONING PROGRAM CONTENT

1.  Assessment of specific job requirements in relation to program goals.

2.  Development of strength, endurance, movement, flexibility, and motor control related to the performance of work tasks.

3.  Practice, modification, and instruction in simulated or work relevant activities.

4.  Education related to safe job performance and injury prevention.

5.  Promotion of client responsibility and self-management.

6.   Work conditioning programs are usually provided in multi-hour sessions available five days a week for a duration of two to eight weeks.

PROGRAM TERMINATION

1.   The client shall be discharged from work conditioning when the goals for the client have been met.

2.   Work conditioning shall be discontinued when any of the following occur:

a.  The client has or develops psychosocial or vocational problems, which are not being addressed.

b.  There are few medical contraindications.

c.  The client demonstrates a lack of willingness to participate.

d.  The client fails to comply with the requirements of participation.

e.  The client has plateaued prior to meeting goals and there is no further progress.

3.     When the client is discharged or discontinued from the work conditioning program, the work conditioning provider shall notify the employer, insurance carrier and/or any referral source, and include the following information:

a.  Current clinical status and degree of restoration.

b.  Recommendations regarding return to work.

c.  Recommendations for follow-up services.