ancillary pearls for better claim management...this presentation shall not be construed as an...

October 27, 2016

Ancillary Pearls for Better Claim Management A Workers’ Compensation Continuing Education Course

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This course was previously presented on March 17, 2016. If you attended the course on that date and received continuing education credits from the CEU Institute, you cannot submit for the same credits for this offering. If you have any questions regarding your continuing education credits received from Optum webinars, please contact [email protected].

This course has been approved for 1-hour of CE for the following license types: Pre-approved Adjuster (AK, AL, CA, DE, FL, GA, ID, IL, IN, LA, MS, NC, NH, OR, TX, UT, WA, WY); Certified Case Manager (CCM); National Nurse; Certification of Disability Management Specialists (CDMS); Commission on Rehabilitation Counselor (CRC); for CE accreditation. For states that do not require prior approval, the adjuster is responsible for submitting their attendance certificate to the appropriate state agency to determine if continuing education credits can be applied.

This course is not approved for the following credit types: Adjuster credits in Oklahoma and Kentucky; Certified Medicare Secondary Payer (CMSP)

Administrative details

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1. Remain logged on for the entire webinar.

To Receive Continuing Education Credit

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2. Answer all three poll questions.


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2. Answer all three poll questions.

3. You will receive an email from the CEU Institute on our behalf approximately 24 hours after the webinar. This email will contain a link that you will use to submit for your CE credits. You will need to complete this task within 72 hours.


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No planner, presenter or content expert has a conflicting interest affecting the delivery of this continuing

education activity. Optum does not receive any commercial advantage nor financial remittance through

the provided continuing education activities.

Disclosure

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Medicine is an ever-changing science. As new research and clinical experience broaden our

knowledge, new treatment options and approaches are developed. The authors have checked with

sources believed to be reliable in their efforts to provide information that is complete and generally in

accord with the standards accepted at time of publication.

However, in view of the possibility of human error or changes in medical sciences, neither Optum nor

any other party involved in the preparation or publication of this work warrants the information contained

herein is in every respect accurate or complete, and are not responsible for errors or omissions or for

the results obtained from the use of such information. Readers are encouraged to confirm the

information contained herein with other sources.

This educational activity may contain discussion of published and/or investigational uses of agents that

are not approved by the Food and Drug Administration (FDA). We do not promote the use of any agent

outside of approved labeling. Statements made in this presentation have not been evaluated by

the FDA.

Medical Disclaimer

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• The display or graphic representation of any product or description of any product or service within

this presentation shall not be construed as an endorsement of that product by the presenter or any

accrediting body. Rather, from time to time, it may facilitate the learning process to include/use such

products or services as a teaching example.

• Accreditation of this continuing education activity refers to recognition of the educational activity only

and does not imply endorsement or approval of those products and/or services by any accrediting

body.

• CE credits for this course are administered by the CEU Institute. If you have any issues or questions

regarding your credits, please contact [email protected].

Disclaimer

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Presenters

Tron Emptage, M.A., R.Ph. Chief Clinical Officer

Robert Hall, M.D. Corporate Medical Director

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• Review the most common electromedical devices being used to treat work-related injuries and gain understanding in how they work and when they should be considered.

• Discuss the differences between manual wheelchairs, power wheelchairs and scooters, and learn the requirements necessary for the use of each.

• Gain insight into the differences between chiropractic care and physical therapy, and explore the advantages each has to offer in pain relief and restoration of function.

• Explore the differences between acute inpatient rehabilitation and subacute nursing facility rehabilitation programs.

Learning Objectives

Electromedical devices

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• Spinal cord stimulators (SCS)

• Transcutaneous electrical nerve stimulation (TENS)

• Neuromuscular electrical stimulation (NMES)

• Bone growth stimulators

Electromedical Devices

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• Electrodes are implanted

• Stimulation site is dependent upon where pain is located (dermatome)

• Programmable pulse generator is implanted

• Internal electrical impulses

Spinal Cord Stimulators

How it works

Clinical indications

Requirements

Possible complications

Cost and outcomes

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lead wire

electrodes inside lead

extension wire

pulse generator

How it works


Requirements


Cost and outcomes

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• Failed back surgery syndrome, a.k.a. post-laminectomy syndrome

• Complex regional pain syndrome (CRPS) Type 1

• Arachnoiditis

• Phantom limb pain syndrome

• Peripheral neuropathy


How it works


Requirements


Cost and outcomes

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• Chronic, intractable and neuropathic pain

• All other treatment options are trialed- SCS is a treatment of last resort

• Documented failure of other treatments

• Additional surgery is not indicated

• Patient is over 18 years of age

• Psychological screening has been completed

• Successful spinal cord stimulator trial


How it works


Requirements


Cost and outcomes

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• Infection

• Bleeding

• Headaches

• Seizures

• Spinal cord injury

• Pain


How it works


Requirements


Cost and outcomes

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• $40,000 - $50,000 after all associated costs

• $7,000 for battery replacement (rechargeable stimulators are available)

• Goals

– Improvement in pain relief and function

– Decrease pain medication use


How it works


Requirements


Cost and outcomes

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• External electrical stimulation

• Not recommended as a primary treatment modality

• TENS trial- Centers for Medicare and Medicaid Services (CMS)

• Types of pain treated

– Neuropathic pain – CRPS types I and II – Phantom limb pain syndrome

– Acute post-operative pain (30 days or less)

• Not reasonable and necessary for chronic low back pain – (CMS)

Transcutaneous Electrical Nerve Stimulation (TENS)

http://www.odg-twc.com/

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• Stimulates muscle contraction

• Used in rehabilitation to strengthen weakened muscles

• Strengthen quadriceps (muscle atrophy prevention) after knee surgery

• Not recommended in the treatment of pain

Neuromuscular Electrical Stimulation (NMES)

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SCS vs. TENS vs. NMES

SCS TENS NMES

• Internal device • Used to treat

‒ Failed back surgery syndrome

‒ CRPS Type I ‒ Arachnoiditis ‒ Phantom limb pain ‒ Peripheral neuropathy

• Intractable and chronic neuropathic pain

• Used as a last resort

• External device • Used to treat

‒ Neuropathic pain ‒ CRPS Types I and II ‒ Phantom limb pain ‒ Acute post-op pain

• Not a primary treatment modality

• Not recommended for chronic low back pain

• External device • Used to strengthen

weakened muscles and prevent muscle atrophy

• Not recommended for the treatment of pain

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• Spasticity

• Wound healing

• Fracture healing

Other uses for Electromedical Devices

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• High-risk Fractures

• Nonunions

• Delayed unions

• 5-10% of fractures will be complicated by delayed union or nonunion

– Further surgery

– Rehospitalization

– Delayed return to work

– Prolonged disability

Bone Growth Stimulation

Electrical Stimulation for Fracture Healing: Current Evidence

Indications

Risk factors

vs. Ultrasonic stimulation

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• Tobacco or nicotine use

– Smoking

– Smokeless tobacco

– Nicotine gum or patches

• Obesity

• Older age

• Severe anemia

• Alcoholism

• Kidney disease

• Diabetes

• Calcium and Vitamin D deficiency


http://www.orthoinfo.org/topic.cfm?topic=A00374

• Hypothyroidism

• Poor nutrition

• Anti-inflammatory medications

• Infection

• Complicated fracture

• Limited blood supply to fracture

– Femoral head and neck

– Scaphoid bone

Indications

Risk factors


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Electrical Stimulation for Fracture Healing: Current Evidence Bone stimulation for fracture healing: What's all the fuss?

There is insufficient evidence to recommend one stimulator over the other for nonunions.

Indications

Risk factors


Electrical stimulation Ultrasonic stimulation

• Can regulate the process of bone formation

• Increases mechanical strength of healing bone

• Increases incorporation of calcium ions in cartilage and bone cells

• Stimulates expression of genes involved in the healing process

• Should be used for fresh, high-risk fractures

Poll Question #1

Mobility

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• Endurance

• Upper body strength

• Increase the risk of repetitive use injuries

‒ Carpal tunnel syndrome

‒ Lateral epicondylitis (tennis elbow)

‒ Rotator cuff injury

• Modifications to decrease risk of injury

‒ Posterior wheel placement

‒ Technique

Manual Wheelchairs

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• Injuries that can result in the need for a PMD

– Spinal cord injury and paraplegia

– Brain injury

– Weakened heart and lung function

– Generalized muscle weakness

– Disabling pain

• Mobility challenges cannot be meaningfully improved with the use of

– Cane

– Walker

– Manual wheelchair

Power Mobility Devices (PMD)

Considerations for use

CMS coverage criteria

Scooter CMS coverage criteria

Power wheelchair CMS coverage criteria

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• Mobility limitation that significantly impairs one or more Mobility-Related Activities of Daily Living (MRADLs) in the home

• Mobility limitation cannot be sufficiently and safely resolved by using an appropriately fitted cane or walker

• Insufficient upper limb function to self-propel an optimally configured manual wheelchair in the home to perform MRADLs


https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network MLN/MLNProducts/downloads/pmd_DocCvg_FactSheet_ICN905063.pdf





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• Adequate strength, range of motion, and coordination for operation and transferring to and from the scooter and making turns

• Maintain postural stability and position while operating the scooter in the home

• Mental and physical capabilities are sufficient for safe mobility in the home

• Adequate access between rooms, maneuvering space and surfaces

• Will result in significant improvement in the patient’s ability to participate in MRADLs in the home







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• Unable to adequately propel an optimally configured manual wheelchair

• Does not meet the coverage criteria for a scooter

• Has the mental and physical capabilities to safely operate the power wheel chair (PWC), or if unable to safely operate the PWC, has a caregiver available, willing, and able to safely operate the PWC

• Adequate access between rooms, maneuvering space, and surfaces for the operation of the PWC in the home

• Using a PWC will significantly improve the patient’s ability to participate in MRADLs and the patient will use the PWC in the home

• Can be operated despite significant weakness or debility







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Scooter vs. Power Wheelchair


Scooter Power Wheelchair

• Fewer options for specialized cushions that can help prevent pressure sores

• Limited postural support

• Motion is controlled through the handlebar

• Large turning radius is needed

• Specialized seats and recline features reduce the risks of developing pressure sores

• Motion can be controlled through a

joystick, head control, chin control or a breath switch operated through a sip-and-puff mechanism

• Much less space is needed to turn which

can result in more practical use within the home

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• Determine if mobility limitations could be successfully managed with a manual wheelchair

• Neurological examination of the injured party should be completed to identify any underlying vision or cognitive difficulties

• Current measurements of height, weight, range of motion, strength, coordination and identification of any structural abnormalities, such as a curved spine (scoliosis), skin wounds or leg swelling, etc.

• Evaluation of the injured party’s home environment

Considerations for selecting the appropriate power mobility device


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Provider Requirements CMS coverage criteria


Face-to-face examination

• Medical history • Functional history • Physical examination • Diagnostic tests • Questions to answer ‒What is the mobility limitation? ‒ Interference with the performance of

activities of daily living? ‒Why can’t a cane or walker meet the patient’s

mobility needs? ‒Why can’t a manual wheelchair meet

this patient’s mobility needs? ‒Physical and mental abilities to operate

a PMD safely in the home?

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Provider Requirements CMS coverage criteria


Face-to-face examination 7-Element Order

• Medical history • Functional history • Physical examination • Diagnostic tests • Questions to answer ‒What is the mobility limitation? ‒ Interference with the performance of

activities of daily living? ‒Why can’t a cane or walker meet the patient’s

mobility needs? ‒Why can’t a manual wheelchair meet

this patient’s mobility needs? ‒Physical and mental abilities to operate

a PMD safely in the home?

• Patient’s name • Date of patient’s face-to-face examination • Pertinent diagnoses/conditions that relate to the

need for the PMD • Description of the item ordered • Time length of need • Treating provider’s signature • Date of provider’s signature

Poll Question #2

Lower limb prostheses

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• The type of lower limb prosthesis is dependent upon the patient's K-level for ambulation abilities.

• K-levels are defined by Medicare, based on an individual's ability or potential to ambulate and navigate his/her environment.

Lower Limb Prostheses and K-Levels

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K-Levels for Lower Limb Prostheses

http://www.oandp.org/olc/course_extended_content.asp?frmCourseId=ACA066EC-443A-4822-822C-89BC1CBD684E&frmTermId=k-levels

K-Level Functional Potential of Amputee

K0 No ability or potential to ambulate or transfer safely with or without assistance and a prosthesis does not enhance quality of life or mobility.

K1 Ability or potential to use a prosthesis for transfers or ambulation on level surfaces at fixed cadence.

K2 Ability or potential for ambulation with the ability to traverse low-level environmental barriers such as curbs, stairs or uneven surfaces.

K3 Ability or potential for ambulation with variable cadence - a typical community ambulatory with the ability to traverse most environmental barriers may have activity that demands prosthetic use beyond simple locomotion.

K4 Ability or potential for ambulation that exceeds basic ambulation skills, exhibiting high impact, stress or energy levels.

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K-Levels for Lower Limb Prostheses

http://www.oandp.org/olc/course_extended_content.asp?frmCourseId=ACA066EC-443A-4822-822C-89BC1CBD684E&frmTermId=k-levels

K-Level Functional Potential of Amputee Type of Prosthesis

K0 No ability or potential to ambulate or transfer safely with or without assistance and a prosthesis does not enhance quality of life or mobility.

Not eligible for prosthesis

K1 Ability or potential to use a prosthesis for transfers or ambulation on level surfaces at fixed cadence.

External keel, SACH feet or single-axis ankle/feet, single-axis, constant friction knee

K2 Ability or potential for ambulation with the ability to traverse low-level environmental barriers such as curbs, stairs or uneven surfaces.

Flexible-keel feet and multi-axial ankle/feet, single-axis, constant friction knee

K3 Ability or potential for ambulation with variable cadence - a typical community ambulatory with the ability to traverse most environmental barriers may have activity that demands prosthetic use beyond simple locomotion.

Flex foot and flex-walk systems, energy storing feet, multi-axial ankle/feet, or dynamic response feet, fluid and pneumatic control knee, microprocessor knee

K4 Ability or potential for ambulation that exceeds basic ambulation skills, exhibiting high impact, stress or energy levels.

Any ankle foot system appropriate, any ankle knee system appropriate, including microprocessor

Rehabilitation

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• Skeletal and neuromuscular systems

• Adjustments/manipulation

• Joint mobility restoration

• Pain relief

• Muscle relaxation

• Modalities

• Official Disability Guidelines (ODG): ‒ Acute, subacute, chronic low back pain ‒ Chronic pain if caused by a musculoskeletal condition

Chiropractic Care

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• Skeletal and neuromuscular systems

• Therapeutic exercise

• Home exercise program

• Neuroplasticity

• Movement dysfunction

• Posture improvement

• Restore muscle imbalances

• Strengthening

• Improvement in function

• Pain relief

Physical Therapy

• Reoccurrence prevention

• Mobility and assistive devices

• Home exercise program

• Modalities

• ODG: Number of sessions dependent upon diagnosis

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Chiropractic Care vs. Physical Therapy

Chiropractic care Physical therapy

• Adjustment/manipulation • Joint mobility restoration • Pain relief • Muscle relaxation • Modalities • ODG:

‒ Acute, subacute, chronic low back pain

‒ Chronic pain if caused by a musculoskeletal condition

• Movement dysfunction • Posture improvement • Restore muscle imbalances • Strengthening • Improvement in function • Pain relief • Reoccurrence prevention • Mobility and assistive devices • Home exercise program • Modalities • ODG: Number of sessions dependent

upon diagnosis

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• Cognitive behavioral therapy (CBT) is a form of therapy that helps people identify and develop skills to change negative thoughts, feelings and behaviors.

• CBT can be used together with other methods of pain management.

• Indications for CBT beyond pain management

‒ Insomnia

‒ Depression/anxiety

‒ Post-traumatic stress disorder

‒ Substance abuse

Cognitive Behavioral Therapy

Source WebMd

Thoughts create feelings

Feelings create behavior

Behavior creates thoughts


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• Encourages a problem-solving attitude

• Requires participation

• Fosters life skills


Thoughts create feelings

Feelings create behavior

Behavior creates thoughts


Source WebMd

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• Medical complexity

• Intensity of rehabilitation

• Hours of therapy per day

• Physician specialty and visits

• Nursing

• Neuropsychologist

• Prosthetist/orthotist availability

• Patient and family education

• Accreditation

• Coordinated interdisciplinary team approach

Considerations for Acute Inpatient Rehabilitation vs. Subacute Nursing Facility

http://www.westgablesrehabhospital.com/referral-sources/acute-rehab-vs-snf/

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• A collaborative approach

• The key factor that makes this model different from the multi-disciplinary model is that team members work together to achieve common goals

• Interdisciplinary approach is more effective because it allows for a more holistic, collaborative and patient-focused approach

• Patient and team work together to establish, evaluate and accomplish mutually agreed upon goals

Interdisciplinary Therapy

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• Stroke

• Spinal cord injury

• Congenital deformity

• Amputation

• Major multiple trauma

• Fracture of femur (hip fracture)

• Brain injury

Indications to enter acute inpatient rehabilitation

https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/InpatientRehabFacPPS/downloads/fs1classreq.pdf

60% RULE

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• Neurological disorders, including:

– Multiple sclerosis

– Motor neuron diseases

– Polyneuropathy

– Muscular dystrophy

– Parkinson’s disease

• Burns

• Active polyarticular rheumatoid arthritis, psoriatic arthritis and seronegative arthropathies

• Systemic vasculitis with joint inflammation

Indications to enter acute rehabilitation


60% RULE

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• Severe or advanced osteoarthritis involving two or more major weight bearing joints

• Knee or hip joint replacement, or both, during an acute hospitalization immediately preceding the inpatient rehabilitation stay.

• Meet one or more of the following criteria:

– Bilateral knee or bilateral hip joint replacement

– Extreme obesity with a Body Mass Index of at least 50

– Age 85 or older

Indications to enter acute rehabilitation


60% RULE

Poll Question #3

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• Spinal cord stimulators have specific indications and are considered a treatment of last resort.

• TENS units and neuromuscular electrical stimulation (NMES) have different applications.

• Fractures must meet requirements before bone growth stimulators should be considered.

• Significant differences exist between power wheelchairs and scooters.

• Lower limb prosthesis selection is highly dependent on the patient’s potential functional status.

• Chiropractic care and physical therapy are distinct forms of physical medicine.

• Cognitive behavioral therapy is helpful in correcting negative thoughts, feelings and behaviors.

• Subacute nursing facility rehabilitation and acute inpatient rehabilitation have major differences.

Summary

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• American Academy of Orthopaedic Surgeons. (2014, March). Nonunions. Retrieved 2016, from OrthoInfo: http://www.orthoinfo.org/topic.cfm?topic=A00374

• American Academy of Orthotists & Prosthetists. (n.d.). Outcome Measures in Lower Limb Prosthetics. Retrieved 2016, from Online Learning Center: http://www.oandp.org/olc/course_extended_content.asp?frmCourseId=ACA066EC-443A-4822-822C-89BC1CBD684E&frmTermId=k-levels

• Centers for Medicare & Medicaid Services. (2013, April 16). Inpatient Rehabilitation Facility Classification Requirements. Retrieved 2016, from CMS.gov: https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/InpatientRehabFacPPS/downloads/fs1classreq.pdf

• Centers for Medicare & Medicaid Services. (2016). Outreach and Education - Medicare Learning Network. Retrieved 2016, from CMS: https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network MLN/MLNProducts/downloads/pmd_DocCvg_FactSheet_ICN905063.pdf

• Goldstein C, S. S. (2010, March). Electrical stimulation for fracture healing: current evidence. Retrieved 2016, from National Center for Biotechnology Information, U.S. National Library of Medicine: http://www.ncbi.nlm.nih.gov/pubmed/20182239

• Indian Journal of Orthopaedics. (2009, April-June). Bone stimulation for fracture healing: What's all the fuss? Retrieved 2016, from NCBI: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2762251/

• Mayfield Brain & Spine. (2016). Retrieved 2016, from Mayfield Brain & Spine: www.mayfieldclinic.com

• SelectMark. (2016). Acute Rehab vs. SNF. Retrieved 2016, from West Gables Rehabilitation Hospital: http://www.westgablesrehabhospital.com/referral-sources/acute-rehab-vs-snf/

References

Questions?

Thank you

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CE credits for this course are administered by the CEU Institute. If you have any issues or questions regarding your credits, please

contact [email protected].

STS14-16708

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You will receive an email from the CEU Institute on our behalf approximately 24 hours after the webinar. This email will contain a link that you will use to submit for your CE credits. You must complete this task within 72 hours.

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