Wis. Admin. Code Department of Workforce Development DWD 81.04 - General treatment guidelines; excessive treatment

(1) GENERAL.

(a) All treatment shall be medically necessary treatment. A health care provider shall evaluate the medical necessity of all treatment under par. (b) on an ongoing basis. This chapter does not require or permit any more frequent examinations than would normally be required for the condition being treated but may require ongoing evaluation of the patient that is medically necessary and consistent with accepted medical practice.

(b) The health care provider shall evaluate at each visit whether initial nonsurgical treatment for the low back, cervical, thoracic, and upper extremity conditions specified in ss. DWD 81.06 to is effective 81.09 according to subds. 1. to 3. No later than any applicable treatment response time in ss. DWD 81.06 to 81.09, the health care provider shall evaluate whether the passive, active, injection, or medication treatment modality is resulting in progressive improvement as specified in all of the following:

1. The patient's subjective complaints of pain or disability are progressively improving, as evidenced by documentation in the medical record of decreased distribution, frequency, or intensity of symptoms.

2. The objective clinical findings are progressively improving, as evidenced by documentation in the medical record of resolution or objectively measured improvement in physical signs of injury.

3. The patient's functional status, especially vocational activities, is progressively improving, as evidenced by documentation in the medical record or successive reports of work ability of less restrictive limitations on activity.

(c) Except as otherwise provided under ss. DWD 81.06(3) (b), 81.07(3) (b), 81.08(3) (b), and 81.09(3) (b), if there is not progressive improvement in at least 2 criteria of par. (b) 1. to 3., the modality shall be discontinued or significantly modified, or the health care provider shall reconsider the diagnosis. The evaluation of the effectiveness of the treatment modality may be delegated to an allied health professional directly providing the treatment.

(d) The health care provider shall use the least intensive setting appropriate and shall assist the patient in becoming independent in the patient's own care to the extent possible so that prolonged or repeated use of health care providers and medical facilities is minimized.

(2) DOCUMENTATION. A health care provider shall maintain an appropriate record of any treatment provided to a patient. An appropriate record is a legible health care service record or report that substantiates the nature and necessity of a health care service being billed and its relationship to the work injury.

(3) NONOPERATIVE TREATMENT. A health care provider shall provide a trial of nonoperative treatment before offering or performing surgical treatment unless the treatment for the condition requires immediate surgery, unless an emergency situation exists, or unless the accepted standard of initial treatment for the condition is surgery.

(4) CHEMICAL DEPENDENCY. A health care provider shall maintain diligence to detect incipient or actual chemical dependency to any medication prescribed for treatment of the patient's condition. In cases of incipient or actual dependency, the health care provider shall refer the patient for appropriate evaluation and treatment of the dependency.

(5) DEPARTURE FROM GUIDELINES. A health care provider's departure from a guideline that limits the duration or type of treatment in this chapter may be appropriate in any of the following circumstances:

(a) There is a documented medical complication.

(b) Previous treatment did not meet the accepted standard of practice and meet the guidelines in this chapter for the health care provider who ordered the treatment.

(c) The treatment is necessary to assist the patient in the initial return to work where the patient's work activities place stress on the part of the body affected by the work injury. The health care provider shall document in the medical record the specific work activities that place stress on the affected body part, the details of the treatment plan, and treatment delivered on each visit, the patient's response to the treatment, and efforts to promote patient independence in the patient's own care to the extent possible so that prolonged or repeated use of health care providers and medical facilities is minimized.

(d) The treatment continues to meet 2 of the following 3 criteria, as documented in the medical record:

1. The patient's subjective complaints of pain are progressively improving as evidenced by documentation in the medical record of decreased distribution, frequency, or intensity of symptoms.

2. The patient's objective clinical findings are progressively improving, as evidenced by documentation in the medical record of resolution or objectively measured improvement in physical signs of injury.

3. The patient's functional status, especially vocational activity, is objectively improving, as evidenced by documentation in the medical record or successive reports of work ability of less restrictive limitations on activity.

(e) There is an incapacitating exacerbation of the patient's condition. Additional treatment for the incapacitating exacerbation shall comply with and may not exceed the guidelines in this chapter.

Notes

Wis. Admin. Code Department of Workforce Development DWD 81.04

CR 07-019: cr. Register October 2007 No. 622, eff. 11-1-07.