Workers’ Compensation Medical Director’s Office Bulletins

Date: January 4, 2012

To: All Workers' Compensation Medical Providers:

This bulletin addresses the treatment of an exacerbation in workers with injuries that are covered by the Medical Treatment Guidelines (MTG).

What is an exacerbation?

An exacerbation is a temporary worsening of a prior condition by an exposure/injury. Following a transient increase in symptoms and signs, and a decrease in function, the person recovers to baseline status or what it would have been had the exacerbation not occurred.

Is a variance required to treat an exacerbation of an injury covered by the MTG?

In a recent Workers' Compensation Board Panel decision the Panel notes that:

1. a variance is not required for the initial treatment of an exacerbation, when the care provided is consistent with the MTG (i.e.: within acute or sub-acute durational limits), and
2. treatment of an exacerbation that is not consistent with the MTG requires a variance when, for example, the proposed treatment exceeds the recommended durational limits.

What are the documentation requirements to support the identification and treatment of an exacerbation?

The Panel decision sets out the documentation criteria the provider must fulfill to support the treatment of an exacerbation. The medical provider must fully document:

1. when and how the exacerbation occurred,
2. the objective changes from baseline function,
3. the expected type and frequency of treatments anticipated to return the patient to baseline function, and
4. the patient's response to treatment through documented measures of objective functional improvement.

The documentation of objective changes from baseline function should contain all of the following: symptoms, corresponding physical exam findings, measured deterioration and an explanation of how these elements result in deterioration in the functional ability to meet daily and work related activities.

What is not an exacerbation?

The decision addresses what is not an exacerbation. For example, a medical provider cannot request care for an exacerbation that will occur in the future. Medical justification for treatment is not met when a request is for treatment of future exacerbations and is not supported by actual documentation as described under documentation criteria above.

When is treatment of an exacerbation consistent with the MTG?

The treatment of an exacerbation must be within the recommended durational limits of the MTG and comply with the General Principles of the MTG (i.e.: treatment should be focused on restoring a patient's health and function to its pre-exacerbation status, patient should demonstrate a positive response or objective functional improvement with objective functional gains toward the ultimate goal of the patient's return to pre-exacerbation baseline functional ability). The provider must re-evaluate the efficacy of the treatment and the treatment should be modified or discontinued if the treatment is not producing positive results, or in appropriate circumstances, the diagnosis should be reconsidered.

What MTG General Principles are most relevant in treating an exacerbation?

General Principles 1, 3, 4, 5 and 10:

Of particular note, Principle #5 addresses the importance of patient education to facilitate self-management of symptoms and prevention of injury.

Principle 1: Medical Care

Medical Care and treatment required as a result of a work-related injury should be focused on restoring functional ability required to meet the patient's daily and work activities and return to work, while striving to restore the patient's health to its pre-injury status in so far as is feasible.

Principle 3: Positive Patient Response

Positive Patient Response or positive results are defined primarily as functional gains which can be objectively measured.

Objective functional gains include, but are not limited to:

• Positional tolerances;
• Range of motion;
• Strength;
• Endurance; and/or
• Activities of daily living.

When evaluating a patient's response, subjective complaints of pain and function should be considered and given relative weight when the pain has an anatomic and physiologic correlation.

Principle 4: Re-Evaluate Treatment

Efficacy of the treatment or modality should be documented by the provider and if a treatment is not producing positive results, the provider should:

• Modify or discontinue the treatment regime; or
• Reconsider the diagnosis in the event of a poor response to a rational intervention.

Principle 5: Education

No treatment plan is complete without addressing issues of individual or group education as means of facilitating self-management of symptoms and prevention of future injury.

Principle 10: Active Interventions

Active Interventions emphasizing patient responsibility, such as therapeutic exercise and/or functional treatment, are generally emphasized over passive modalities, especially as treatment progresses. Generally, passive and palliative interventions are viewed as a means to facilitate progress in an active rehabilitation program with concomitant attainment of objective functional gains.

How can objective functional improvement be documented when treating a patient with an exacerbation?

There are three basic components for documenting objective functional improvement:

1. Initial evaluation
   • What was the patient's functional ability pre-exacerbation and what are the patient's objective functional findings/abilities at the time of the exacerbation?
2. Re-evaluation
   • What are the patient's objective functional findings/abilities now (i.e.: at the time of the re-evaluation)?
   • Has the patient's function returned to baseline as defined in the pre-exacerbation examination?
        √  If yes, goals have been reached and no further therapy is needed at this time.
3. Goals
   • If function has not returned to baseline, based on your assessment of the patient's condition, what functional gains do you expect from the patient at the next evaluation?
     What type of treatment is planned to reach these goals?
   • Ultimate goals: Focused on return to pre-exacerbation functional ability (i.e: pre-exacerbation daily and work activities).

What forms should be used when treating an exacerbation?

For the initial treatment of an exacerbation that is consistent with the MTG, a completed C-4.2, Doctor's Progress Report, or EC-4NARR, Doctor's Narrative Report, which contains all the required documentation would be sufficient to fulfill the MTG requirements. When treatment of an exacerbation is not consistent with the MTG, a variance (MG-2, Attending Doctor's Request for Approval of Variance and Carrier's Response) is required.

For questions or further information, please contact the Board's Medical Director's Office at: WCBMedicalDirectorsOffice@wcb.ny.gov.

¹Matter of Livingston County, 2011 NY Wrk Comp 79905338