Since the new WCRC contractor took over, we have seen an increase in the amount of diagnostics and physical therapy allocated by CMS resulting in many counter higher determinations. These counter higher amounts seem to be an increase between 5 to 10% of the submitted MSA amount.
Per the WCMSA Reference Guide, x-rays are allocated every 3 to 5 years and yearly if there was or will be a major joint replacement. MRIs are allocated every 5 to 7 years. CMS states these are guidelines only and determinations are made on a case-by-case basis. Other factors are considered such as the life expectancy, past surgeries, functional status, age of injury, treatment patterns, and provider recommendations. The trend we are now seeing is x-rays allocated every 3 years and MRIs allocated every 5 years regardless of these other factors. With the prior review contractor, these factors appeared to be taken into consideration as there were fewer counter higher determinations based on an increase in diagnostic services.
There are no physical therapy guidelines provided in the WCMSA Reference Guid, however, based on years of tracking CMS determinations, physical therapy (PT) is usually allocated at 12 sessions every 5 years for exacerbations. Additional physical therapy is also included post-operatively with the amount based on the type of surgery; 18 sessions for an arthroscopy; 36 sessions for a total knee replacement or total shoulder replacement; 24 sessions for cervical, thoracic or lumbar surgery; and 24 sessions for a total hip replacement. The prior review contractor seemed to take the type of injury and treatment patterns into consideration and accept the submitter’s allocation for PT if it was reasonable. The new review contractor appears to be increasing PT by allocating 12 sessions every 5 years for every orthopedic condition regardless of the type of injury and treatment patterns.
Here are a few example of CMS’ counter higher determinations based on increased diagnostics and/or PT.
Date of injury noted as 08/02/2012 for cumulative trauma with the following diagnoses: bilateral carpal tunnel syndrome, bilateral shoulder pain, bilateral knee pain, bilateral ankle/foot pain, cervicalgia, and low back pain. The life expectancy (LE) is 13 years. Future medical treatment included bilateral shoulder arthroscopies and bilateral ankle, right knee, and lumbar surgery. CMS included routine PT at 96 sessions for life expectancy; post-operative left shoulder PT at 18 sessions; post-operative right shoulder PT at 18 sessions; post-operative right knee PT at 18 sessions; post-operative right ankle PT at 18 sessions; post-operative left ankle PT at 18 sessions; and post-operative PT at 24 sessions for the lumbar surgery. X-rays were included every 3 years or a total of 4 in LE for the following body parts: cervical spine, bilateral shoulders, bilateral wrists, lumbar spine, bilateral knees, and bilateral ankles. MRIs were included every 5 years or a total of 2 in LE for all of these body parts except the wrists. The total amount of PT included in the allocation is 210 session in a 13 year LE. The submitted MSA amount was $93,483 and did not include the lumbar surgery per carrier’s request. The CMS counter higher determination was $180,217 as a result of the inclusion of the lumbar surgery and significant amount of diagnostics and PT.
Date of injury is 04/06/2007 for bilateral shoulder pain, bilateral knee pain, cervicalgia, and low back pain. LE is 19 years. Future medical treatment included bilateral knee arthroscopies, right shoulder arthroscopy, and lumbar decompression and fusion. 36 sessions of PT were included for exacerbations. Post-operative PT was included as follows: 24 sessions left knee arthroscopy; 24 sessions right knee arthroscopy; 24 sessions lumbar surgery; and 36 sessions for right shoulder arthroscopy. This is a total of 144 PT sessions for a 19 year LE. Submitted MSA amount was $246,941 with CMS counter higher amount of $269,957 due to increased PT.
Date of injury is 02/20/2015 for left shoulder pain, left wrist pain, left hand pain, left thumb sprain, left middle finger sprain, left ring finger sprain, left little finger sprain, and cervicalgia. LE is 12 years. Current treatment is medication management only with pain management. 24 sessions of PT were included for each of these body parts: left shoulder, left wrist, and cervical spine or a total of 72 sessions in LE. Submitted MSA amount was $21,106 with CMS counter higher amount of $28,578 due to increased PT.