053-10 Wyo. Code R. §§ 10-20 - Payment for Medical Services and Professional Fees
(a)
Claims for medical services provided to an injured worker for a compensable
injury, and any associated fees charged by professionals, will be denied if:
they fail to comply with the following standards for content of medical
records:
(i) If handwritten, medical notes
must be legible to anyone reading them,
(ii) If handwritten notes are illegible,
medical notes must be typewritten,
(iii) Medical notes must include date of
patient visit,
(iv) Medical notes
must specify the reason for the encounter/visit and be described using the
injured worker's own words,
(v)
Medical notes must include a history and physical exam focused relative to
injured worker's complaint to include a description of the findings of the
examine relating to the reason for the complaint,
(vi) Medical notes must specify the diagnosis
relative to the injured worker presenting complaint,
(vii) Medical notes must delineate a course
of treatment consistent with the diagnosis,
(viii) The studies ordered of the injured
worker must pertain to the complaint being addressed,
(ix) Medical notes must delineate the
education instruction to the injured worker,
(x) Medical notes must contain an indication
of the specifics of the follow-up care plan and include return-to-work
expectations.
(xi) Medical notes
must include authentication by the treating provider that adhere to the
following criteria:
(A) A signature and date
by the treating provider shall constitute authentication.
(B) A signature shall include the treating
provider's first and last name and appropriate credentials (i.e. "P.A.",
"D.O.", or "M.D.").
(C) Electronic
signatures may be accepted, provided the signature includes a date, timestamp,
and a printed statement such as "electronically signed by" or
"verified/reviewed by."
(D) Rubber
stamps may be utilized in situations where the treating provider has a physical
disability that prevents them from manually or electronically signing the
documentation for authentication. By affixing the rubber stamp, the treating
provider certifies their review of the document.
Notes
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