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EMERGENCY DEPARTMENT COHE ORIENTATION
EMERGENCY DEPARTMENTCOHE ORIENTATION
Welcome to the Center of Occupational Health and Education (COHE) Orientation!
COHE is a partnership between Washington State Department of Labor & Industries (L&I) and sponsoring health care organizations who treat state-funded workers’ compensation patients throughout the state.
Enrollment requirement is not complete until the Knowledge Assessment Quiz is completed and submitted to COHE.
Orientation Overview:
1. Brief Introduction to Workers’ Compensation- Types of Workers’ Compensation Claims
2. Background of Center of Occupational Health & Education (COHE)
- What is COHE- The COHE Model- Why do providers join
3. Occupational Health Best Practices - What they are and how to apply them
4. Resources and tools available to a COHE provider
1. Washington State Department of Labor & Industries (L&I) State Funded Claims
Employer and employee pay into a fund for Washington State to manage the employees’ worker compensation benefits. Providers are paid by Washington State Department of Labor & Industries (L&I). Several thousand employers are covered under the centralized L&I state fund system. COHE currently supports State Fund worker compensation claims ONLY.
2. Self-Insured Claims
Employer’s own insurance company pays workers’ compensation benefits directly to the worker and provider. Self-Insured employers choose to manage their own claims or have them managed by a third-party administrator (TPA) while ensuring their claim processes are similar to what State Funded coverage offers.
3. U.S. Government (OWCP, Longshore, Maritime, Rail) Federal Claims
Employees who work for the U.S. Government or for a Federally regulated Employer fall into this worker compensation group. Forms and processes differ from L&I State Fund or Self-Insured employers.
TYPES of Workers’ Compensation CLAIMS
Center of Occupational Health and Education (COHEs) is a community based program administered by the Washington State Department of Labor and Industries (L&I).
COHE works with medical providers, employers, and injured workers in communities to ensure timely, effective, and coordinated services for injured workers.
COHE Community of Eastern WA is sponsored by St. Luke’s Rehabilitation Institute and has offices in Spokane, Wenatchee, Yakima, and Tri-Cities.
Core COHE services:
• Train providers on best practices.• Help providers implement best practices in their facilities.• Coordinate worker care for the first year of treatment.• Engage with employers about return to work options.
What is COHE?
THE COHE MODEL:Workers’ compensation
COHE Mission: To improve injured worker’s medical recovery and prevent unnecessary disability through collaboration with health care providers, injured workers, employers, and L&I by integrating Occupational Health Best Practices into Eastern Washington communities.
Why do Providers join COHE?
Incentives
• Receive additional compensation when initiating an L&I state claim.
• Meet criteria for Top Tier incentives.
Best Practice Training
• Receive education in occupational health best practices.
• Preferred provider recognition on L&I Find-A-Doc.
Health Service Coordinator
(HSC)
• Access to HSCs for care coordination in the first year of a claim to resolve barriers and prevent prolonged disability.
COHE Medical Advisors
• Access to expert consultations related to occupational health and assessment of claim barriers.
COHE Best Practice #1Completion of L&I Report of Accident (ROA)
Complete Provider Portion of ROA.
Fax within 2 business days to L&I: 855.222.4652 or 360.902.5126
Reimbursement is based on completeness and how quickly L&I receives the ROA. File Fast Web filing is a $10 incentive.
Billing Code 1040M
Fee Schedule Reimbursement Faxed Form Web Filed ROA Received by L&I within 2 business days from 1st medical visit $ 61.63 $ 71.63
ROA Received by L&I 3-5 business days from 1st medical visit $ 41.09 $ 51.09
ROA Received by L&I 6-8 business days from 1st medical visit $ 31.09 $ 41.09
ROA Received by L&I 9 or more business days from 1st medical visit $ 21.09 $ 31.09
Get started with File Fast Web filing here: http://www.L&I.wa.gov/ORLI/ECS/default.asp?Pub=Provider
COHE Best Practice 1Report of Accident (ROA)
The medical provider completes the bottom portion of the ROA.
The ROA is the 1st official notice L&I receives of an injury or illness.
Submission of the ROA to L&I initiates a patient’s claim along with medical and wage benefits for the worker.
The ROA can be filed online via FileFast. The completed original ROA must still be faxed to L&I.
File Fast Web filing $10 incentive. Hot Claim ProcedureProcess ROA as a HOT CLAIM when the injured worker is admitted in your hospital (or transferred to another), has a catastrophic injury, or death has occurred. Fax HOT CLAIM to 360.902.4980
Box 1: List work-related medical diagnosis. e.g. contusion, strain/sprain, abrasion. Completion of each box is not only required but is essential for claim adjudication.
Diagnoses such as “pain” and “tenderness” are considered subjective and will not be allowed by L&I and will result in revision and delay of claim acceptance.
Box 2: Can be completed by support staff; ICD Codes are not required at ED.
Box 3 : Indicate the date you first saw patient for this condition.
Completion of each field is essential for claim adjudication
Pain, Tenderness
Box 4 : Indicate if this condition is due to a specific incident.
Box 5 : Objective Diagnosis/Findings. Be specific and detailed in your objective findings. Objective Medical Findings (OMFs) are described as a ‘finding’ that can be seen, felt, heard, measured, or reproduced (by provider) through examination or testing.
*L&I reviews boxes 1 & 5 against ED chart notes when making the determination for claim allowance or rejection.
Box 6: Indicate if more treatment is needed.
Completion of ROA
Pain, Tenderness
Box 7 : Work-relatedness/Causation. CHECK 1 BOX ONLY. : Checking “YES” or “PROBABLY” means, in your opinion, the condition is “more likely than not” (≥ 51%) work-related. Checking “POSSIBLY” or “NO” means the condition is (< 50%) work-related; the claim will likely be rejected.
*If selecting something other than yes, indicate reason in chart note.
Box 8: Miss work. If patient is medically unable to perform any work due to the injury, estimate how many days the patient will miss work.
*If releasing to modified duty select No and indicate restrictions on APF. Time loss begins if off work 4 or more days.
Completion of ROA
Box 14*, & Box 15a: Shaded areas may be completed by support staff. All other fields must be completed by health care provider.
*Box 14: For proper claim attribution and enhanced reimbursement, use your L&I Provider Number and not your NPI. If you work at multiple locations, provider attribution maybe delayed or made to the wrong clinic.
Box 16: Signature. Medical provider must sign & date ROA to initiate claim. If there is no Provider signature the claim will be rejected.
Completion of ROA
L&I # is specific to practicing location and preferred
General Hospital 123 456-7890 1234 ABC Lane Port Charles WA 98123
Completed ROA form
R Knee Sprain 12 25 19
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123456701 25 20
01 25 20AP Signature
Dr. COHE
X-ray negative, Decreased ROM, Swelling
RICE, NSAIDS, Ace Wrap, crutches
2
Reimbursement amount is based on the date in box 15b of the ROA (this exam date). If that box is blank, the payment system will use box 3 (Date you first saw patient for this condition). If both boxes are blank, payment will automatically revert to lowest reimbursement amount because there must be dates in order for the payment system to calculate any incentives.
COHE Best Practice #2Completion of L&I Activity Prescription Form (APF)
Complete this form during ED visit.
Provide a photo copy to injured worker at discharge.
Fax to L&I: 360.902.4567
Fee Schedule Reimbursement $53.41 Billing Code 1073M
Did you know that you can now complete and submit your APF online?
Complete and submit electronically here: Direct Data Entry
orHealth Information Exchange (HIE)
Note: 1. Electronic options are currently only available for workers covered by State Fund L&I (excludes Self Insurance).2. If you experience billing reimbursement issues for an APF, contact your HSC for assistance. It may be due to completion
errors.
COHE Best Practice 2Activity Prescription Form (APF)
• The APF is a communication tool to ensure the health care provider, injured worker, and claim manager are all on the same page.
• Communicates an injured worker's physical restrictions and ability to work as well as the provider's treatment plans.
• Complete 24/7 restrictions, restrictions apply at work and home.
• Emphasis on early return to work opportunities and discussion of physical restrictions.
• Certifies time-loss for injured worker.
• Focus on timeliness and completeness. Fax initial APF with ROA within 2 business days.
General Info: Please complete all areas under General Info and list work-related medical diagnosis. Support Staff can complete all sections except diagnosis. *Diagnosis must be added by provider.
Work Status: If patient is medically able to return to the job of injury (JOI) without restrictions (related to work injury). Mark patient as released to JOI and note date. Then Skip to “Plans” section on APF.
Completion of APF
*
Work Status: If patient is able to return to work and requires modified duty, indicate with start and end date. If patient is medically unable to perform any work due to the injury, estimate how many days the patient will miss work.
Make sure there are no time gaps or overlaps in any of the date ranges indicated in the Work Status and Plans sections. * This is an estimated date and should cover patient until follow up appointment, which generally occurs in 3 to 7 business days from ED visit.
Completion of APF
2 04 20 2 07 20*
2 01 20 2 03 20*
Measurable Objective Finding(s): Be specific and detailed in your objective findings. Remember, pain and tenderness are not considered objective findings.
Examples of findings L&I CANNOT accept: Pain, Tenderness, See chart notes.
Completion of APF
02 04 20 02 07 20
02 01 20 02 03 20
✔ Decreased ROM ✔ X-ray positive for fracture✔ Swelling✔ Muscle atrophySee Chart Notes Pain, Tenderness (More is needed)
Physical Restrictions/Capacities: Complete applicable parts of the grid as it relates to patient’s injury and *indicate any additional patient restrictions in “Other Restrictions / Instructions” box. *ED providers are required to complete Grid for patients current capacities and/or restrictions. A blank space = not restricted.
Complete 24/7 restrictions, even when not released to any work, patients have restrictions for home.
Completion of APF
c(e.g. Keep wound clean & dry,
Wear right arm in sling)
* If listing other restrictions here use terms: “Never, Seldom, Occasional, Frequent, Constant”
Weight Reference Sheet
Produced by L&I 4/16/2007 in collaboration withHome Depot & Fred Meyer
Employer Notified: : Make notation on APF when contacting the employer on first visit or any subsequent communication; documentation must be made in SOAP-ER notes.
Note to Claim Manager: Indicate any notes to claim manager, such as will be requesting MRI.
Completion of APF
02 01 20
Complete Plans section of APF: Please check all that apply in both columns.
Sign and date document.
Provide a copy of APF to patient.
Completion of APF
L&I COHE Website http://www.L&I.wa.gov/ClaimsIns/Providers/ProjResearchComm/OHS/default.asp L&I Provider Page https://L&I.wa.gov/for-medical-providers Claim Account Center (CAC) https://secure.L&I.wa.gov/home/ Determine Employer Insurance https://www.L&I.wa.gov/insurance/self-insurance/look-up-self-insured-employers-tpas/index File Fast http://www.L&I.wa.gov/ORLI/ECS/FileFast.asp Find A Doc https://L&I.wa.gov/claims/for-workers/find-a-doctor/ Transfer of Care https://L&I.wa.gov/forms-publications/f245-037-000.pdf
QUALIS/Comagine http://www.qualishealth.org/healthcare-professionals/washington-labor-industries L&I Medical Treatment Guidelines https://L&I.wa.gov/patient-care/treating-patients/treatment-guidelines-and-resources/ L& I Best Practices https://L&I.wa.gov/patient-care/workshops-training/attending-provider-resource-center/occupational-health-best-practices
L&I Fee Schedule and Payment Policy (MARFS) https://lni.wa.gov/patient-care/billing-payments/fee-schedules-and-payment-policies/
L&I FAX #s for COHEROA 360.902.5126APF + Other claim documentation 360.902.4567HOT Claims (catastrophic, death, hospitalization, immediate Surgery) 360.902.4980
Scorecards will be sent out Quarterly to your director.
Additional Resources
Health Service Coordinator (HSC)Coordination of Care
We are here to help you and your patient with the L&I process! https://www.gocohe.com/COHE-Staff/
If you have further questions or feedback about this module
please contact [email protected] or call toll free 509.456.3222 or 866.247.2643
