Current through Register Vol. 49, No. 13, September 23, 2024
Subpart 1.
Scope.
This part prescribes information the health care provider is
required to submit to the employer, insurer, or commissioner. This part does
not preclude any party or the commissioner from requesting supplementary
reports from the health care provider under Minnesota Statutes, section
176.231,
subdivision 4.
Subp. 2.
Health care provider report.
Within ten days of receipt of a request for information on the
prescribed health care provider report form from an employer, insurer, or the
commissioner, a health care provider must respond on the report form or in a
narrative report that contains the same information requested on the
form.
The health care provider's report form prescribed by the
commissioner must include the information required by items A to M:
A. information identifying the employee and
employer, and insurer, if known;
B.
date of first examination for this injury or disease by the health care
provider;
C. for reports dated
before October 1, 2015, the diagnosis and appropriate ICD-9-CM diagnostic codes
for the injury or disease. For reports dated on or after October 1, 2015, the
diagnosis and appropriate ICD-10-CM diagnostic codes for the injury or disease
must be used;
D. history of the
injury or disease as given by the employee;
E. the relationship of the injury or disease
to employment activities;
F.
information regarding any preexisting or other conditions affecting the
employee's disability;
G.
information about future treatment including, but not limited to, hospital
admission, surgery, or referral to another doctor;
H. information regarding any surgery that has
been performed;
I. information
regarding the employee's ability to work, any work restrictions, and dates of
disability;
J. information
regarding the employee's permanent partial disability rating, in accordance
with subpart
4;
K. information regarding whether the employee
is unable to return to former employment for medical reasons attributed to the
injury;
L. information regarding
maximum medical improvement in accordance with subpart
3; and
M. signature of health care provider, license
or registration number, and identification information.
Subp. 3.
Maximum medical
improvement.
For injuries occurring on or after January 1, 1984, or upon
request for earlier injuries, the health care provider must report to the
self-insured employer or insurer, maximum medical improvement, when
ascer-tainable, on the health care provider report form or in a narrative
report. "Maximum medical improvement" is a medical and legal concept defined by
Minnesota Statutes, section
176.011, subdivision
13a.
A. For purposes of subitems (1)
and (2), "the employee's condition" includes the signs, symptoms, physical and
clinical findings, and functional status that characterize the complaint,
illness, or injury. "Functional status" means the ability of an individual to
engage in activities of daily life and vocational activities. Except as
otherwise provided in item B:
(1) In
determining maximum medical improvement, the following factors shall be
considered by the health care provider as an indication that maximum medical
improvement has been reached:
(a) there has
been no significant lasting improvement in the employee's condition, and
significant recovery or lasting improvement is unlikely, even if there is
ongoing treatment;
(b) all
diagnostic evaluations and treatment options that may reasonably be expected to
improve or stabilize the employee's condition have been exhausted, or declined
by the employee;
(c) any further
treatment is primarily for the purpose of maintaining the employee's current
condition or is considered palliative in nature; and
(d) any further treatment is primarily for
the purpose of temporarily or intermittently relieving symptoms.
(2) The following factors should
be considered by the health care provider as an indication that maximum medical
improvement has not been reached:
(a) the
employee's condition is significantly improving or likely to significantly
improve, with or without additional treatment;
(b) there are diagnostic evaluations that
could be performed that have a reasonable probability of changing or adding to
the treatment plan leading to significant improvement; or
(c) there are treatment options that have not
been applied that may reasonably be expected to significantly improve the
employee's condition.
B. This item applies to musculoskeletal
injuries that fall within any category under parts
5223.0070,
5223.0080,
5223.0110 to
5223.0150, and
5223.0170 for dates of injury
before July 1, 1993, and that fall within any category under parts
5223.0370 to
5223.0390 and
5223.0440 to
5223.0550 for dates of injury on
or after July 1, 1993. When more than one year has elapsed since the date of a
musculoskeletal injury that falls within any of the above categories, the only
factors in determining maximum medical improvement shall be whether a decrease
is anticipated in the employee's estimated permanent partial disability rating
or a significant improvement is anticipated in the employee's work ability as
documented on the report of work ability described in subpart
6. If medical reports show no
decrease in the employee's estimated permanent partial disability or no
significant improvement in the employee's work ability in any three-month
period later than one year after the injury, the employee is presumed to have
reached maximum medical improvement. This presumption can only be rebutted by a
showing that a decrease in the employee's permanent partial disability rating
or significant improvement in the work ability has occurred or is likely to
occur beyond this three-month period. The medical reports relied upon as
establishing maximum medical improvement under this item must be served on the
employee in accordance with item C.
This item applies only to injuries of the musculoskeletal
system, except where the injury is a spinal cord injury resulting in permanent
paralysis, a head injury with loss of consciousness, or where surgery has been
performed within the previous six months. In these cases, the factors listed in
item A shall be used to determine maximum medical improvement.
C. If the employer or insurer does
not serve a notice of intention to discontinue benefits or a petition to
discontinue benefits under Minnesota Statutes, section
176.238,
at the same time a narrative maximum medical improvement report is served, then
the report must be served with a cover letter containing the information in
subitems (1) to (6). Serving the cover letter with the maximum medical
improvement report does not replace the notice of intention to discontinue
benefits or petition to discontinue benefits required by Minnesota Statutes,
section
176.238.
The cover letter must include:
(1)
information identifying the employee by name, worker identification number
(WID) or Social Security number, and date of injury;
(2) information identifying the employer and
insurer;
(3) the date the report
was mailed to the employee;
(4) a
statement that the attached report indicates that in the opinion of the health
care provider, the employee reached maximum medical improvement by the
specified date or an explanation that the attached reports indicate the
employee has reached maximum medical improvement under the circumstances
specified in item B;
(5) the
definition of maximum medical improvement as defined by Minnesota Statutes,
section
176.011, subdivision
13a; and
(6) the statement: "There
may be an impact on your temporary total disability benefits. If we propose to
stop your benefits, a notice of discontinuance of benefits will be sent to you
first. If you have any questions concerning your benefits or maximum medical
improvement, you may call the claims person at .............. or the workers'
compensation division at .............. (specify telephone numbers)."
Subp. 4.
Permanent partial disability.
The health care provider must render an opinion of permanent
partial disability when ascertainable, but no later than the date of maximum
medical improvement. The rating must be reported on the health care provider
report form or in a narrative report. In making a rating of permanent partial
disability, the health care provider must specify any applicable category of
the permanent partial disability schedule in effect for the employee's date of
injury. If a zero rating is appropriate, this rating must also be
reported.
The health care provider may refer the employee to another
health care provider for an opinion of the employee's permanent partial
disability rating if the primary health care provider feels unable to make the
determination in complicated cases involving impairments to more than one body
part or multiple citations under the permanent partial disability schedule. In
such cases, the treating provider must be available for consultation with the
evaluating provider, and must make all relevant medical records available,
without charge to the payer. The evaluating provider is entitled to
reimbursement from the payer for a consultation as limited by the medical fee
schedule.
Subp. 5.
Required reporting to division.
For those injuries that are required to be reported to the
division under Minnesota Statutes, section
176.231,
subdivision 1, the self-insured employer or insurer or third-party
administrator shall file with the division the health care provider report form
prescribed in subpart
2 or a narrative report that
indicates that the employee has reached maximum medical improvement, or that
indicates a preliminary or final permanent partial disability rating. The
commissioner shall, by written request under Minnesota Statutes, section
176.231,
subdivisions 3 and 7, require the filing of the health care provider report at
additional times as necessary to monitor compliance with Minnesota Statutes,
chapter 176, in accordance with Minnesota Statutes, sections
176.231,
subdivision 6, and 176.251. Reports dated before October 1, 2015, filed under
this subpart must include the appropriate ICD-9-CM diagnostic codes for the
injury or disease. Reports dated on or after October 1, 2015, filed under this
subpart must include the appropriate ICD-10-CM diagnostic codes for the injury
or disease.
Subp. 6.
Report of work ability.
Each primary health care provider as defined in part
5221.0430, subpart
1,
must complete and submit to the employee a report of work ability. A health
care provider providing service under the direction or prescription of another
provider is not required to complete a report of work ability.
A. For all work injuries, the primary health
care provider must complete a report of work ability within ten days of a
request by an insurer or at the intervals stated in subitems (1) to (3), unless
there are no restrictions or the restrictions are permanent and have been so
indicated in a report of work ability:
(1)
every visit if visits are less frequent than once every two weeks;
(2) every two weeks if visits are more
frequent than once every two weeks, unless work restrictions change sooner;
or
(3) upon expiration of the
ending or review date of the restriction specified in a previous report of work
ability. Open-ended durations of disability or restriction may not be
given.
B. The report of
work ability must be either on the form prescribed by the commissioner or in a
report that contains the same information as the report of work ability. The
report of work ability prescribed by the commissioner shall include:
(1) information identifying the employee and
employer, and insurer, if known;
(2) the date of the most recent
examination;
(3) information
stating whether the employee is able to work without restrictions, able to work
with restrictions, or unable to work;
(4) work restrictions stated in functional
terms, if the employee is able to work with restrictions;
(5) the date any restriction of work activity
is to begin and the anticipated ending or review date;
(6) the date of the next scheduled
visit;
(7) the signature of the
health care provider, license or registration number, and identification
information; and
(8) a notice to
the employee that a copy of the report must be promptly provided to the
employer or workers' compensation insurer and assigned qualified rehabilitation
consultant.
C. The
report of work ability must be based on the health care provider's most recent
evaluation of the employee's signs, symptoms, physical and clinical findings,
and functional status.
D. The
report of work ability must be provided to the employee and a copy of the
report must be placed in the employee's medical record. Promptly upon receipt,
the employee shall submit the report of work ability to the employer or the
insurer and the assigned qualified rehabilitation consultant. The commissioner
shall, by written request under Minnesota Statutes, sections
176.102,
subdivision 7, and 176.231, subdivisions 3 and 7, require the filing of a
report of work ability when necessary to monitor compliance with Minnesota
Statutes, chapter 176, in accordance with Minnesota Statutes, sections
176.231,
subdivision 6, and 176.251.
Subp.
7.
Payment and coding for required and supplementary
reporting.
A. No charge may be
assessed for completion of a health care provider report or report of work
ability required by subparts
2 and
6, or for a narrative or
other report prepared in lieu of a health care provider report or report of
work ability. If a provider itemizes this service on the billing form, the
provider must use code 99080 (special reports) when reporting this
service.
B. A payer or other party
may request supplementary reports from the health care provider for information
not required in the health care provider report or the report of work ability.
A provider may charge a reasonable amount for requested supplementary reports
using code 99199 (unlisted special service or report). Payment for
supplementary reports is not subject to the 85 percent payment limit as
specified in part
5221.0500, subpart
2, item F.
Subp. 8.
Proper filing of
documents with division.
A health care provider report or narrative report required by
the division under this part may be filed by facsimile or electronic
transmission, if available at the division. Filing is completed at the time
that the facsimile or electronic transmission is received by the commissioner.
A report received after 4:30 p.m. shall be deemed received on the next open
state business day. The filed facsimile or transmitted information has the same
force and effect as the original. Where the quality of the document is at
issue, the commissioner shall require the original document to be filed.
A narrative report filed with the division must, at the top of
the first page, identify the employee by name, social security number, and date
of injury. The name of the self-insured employer, insurer, and administrator if
appropriate, must also be identified. The filer must identify the reason the
report is submitted, and must highlight the corresponding pertinent sections of
the report.
Statutory Authority: MS s
175.171;
176.101;
176.135;
176.1351;
176.136;
176.231;
176.83
