DWD 81.05(2)(n)1.
1. When there is a history of significant acute trauma as the precipitating event of the patient's condition, and fracture, dislocation, or fracture dislocation is suspected.
DWD 81.05(2)(n)2.
2. When the history, signs, symptoms, or laboratory studies indicate possible tumor, infection, or inflammatory lesion.
DWD 81.05(2)(n)5.
5. Before beginning a course of treatment with spinal adjustment or manipulation.
DWD 81.05(2)(n)6.
6. Eight weeks after an injury if the patient continues with symptoms and physical findings after the course of initial nonsurgical care and if the patient's condition prevents the resumption of the regular activities of daily life, including regular vocational activities.
DWD 81.05(2)(o)
(o) A health care provider may not order anterior-posterior and lateral X-rays of the lumbosacral spine for any of the following:
DWD 81.05(2)(p)
(p) A health care provider may order oblique X-rays of the lumbosacral spine for any of the following:
DWD 81.05(2)(p)1.
1. To follow up abnormalities detected on anterior-posterior or lateral X-ray.
DWD 81.05(2)(p)3.
3. To follow up spondylolysis or spondylolisthesis not adequately diagnosed by other necessary imaging procedures.
DWD 81.05(2)(q)
(q) A health care provider may not order oblique X-rays of the lumbosacral spine as part of a package of X-rays including anterior-posterior and lateral X-rays of the lumbosacral spine.
DWD 81.05(2)(r)
(r) A health care provider may not order electronic X-ray analysis of plain radiographs and diagnostic ultrasound of the lumbar spine for diagnosis of any of the low back conditions in
s. DWD 81.06 (1) (b).
DWD 81.05 History
History: CR 07-019: cr. Register October 2007 No. 622, eff. 11-1-07. DWD 81.06(1)
(1)
Diagnostic procedures for the evaluation of low back pain. DWD 81.06(1)(a)(a) A health care provider shall determine the nature of the low back condition before initiating treatment.
DWD 81.06(1)(b)
(b) A health care provider shall perform and document an appropriate history and physical examination. Based on the history and physical examination the health care provider shall assign the patient at each visit to the appropriate clinical category under
subds. 1. to
4. The health care provider shall document the diagnosis in the medical record. For the purposes of
subds. 2. and
3., “radicular pain" means pain radiating distal to the knee, or pain conforming to a dermatomal distribution, and accompanied by anatomically congruent motor weakness, or reflex changes. This section does not apply to fractures of the lumbar spine, or low back pain due to an infectious, immunologic, metabolic, endocrine, neurologic, visceral, or neoplastic disease process.
DWD 81.06(1)(b)1.
1. Regional low back pain, includes referred pain to the leg above the knee unless it conforms to an L2, L3, or L4 dermatomal distribution and is accompanied by anatomically congruent motor weakness or reflex changes. Regional low back pain includes the diagnoses of lumbar, lumbosacral, or sacroiliac strain, sprain, myofascial syndrome, musculoligamentous injury, soft tissue injury, spondylosis, and other diagnoses for pain believed to originate in the discs, ligaments, muscles, or other soft tissues of the lumbar spine or sacroiliac joints and that effects the lumbosacral region, with or without referral to the buttocks or leg, or both above the knee, including ICD-9-CM codes 720 to 720.9, 721, 721.3, 721.5 to 721.90, 722, 722.3, 722.32, 722.5, 722.51, 722.52, 722.6, 722.9, 722.90, 722.93, 724.2, 724.5, 724.6, 724.8, 724.9, 732.0, 737 to 737.9, 738.4, 738.5, 739.2 to 739.4, 756.1 to 756.19, 847.2 to 847.9, 922.3, 926.1, 926.11, and 926.12.
DWD 81.06(1)(b)2.
2. Radicular pain, with or without regional low back pain, with static or no neurologic deficit. This includes the diagnoses of sciatica; lumbar or lumbosacral radiculopathy, radiculitis, or neuritis; displacement or herniation of intervertebral disc with myelopathy, radiculopathy, radiculitis, or neuritis; spinal stenosis with myelopathy, radiculopathy, radiculitis, or neuritis; and any other diagnoses for pain in the leg below the knee believed to originate with irritation of a nerve root in the lumbar spine, including ICD-9-CM codes 721.4, 721.42 721.91, 722.1, 722.10, 722.2, 722.7, 722.73, 724.0, 724.00, 724.02, 724.09, 724.3, 724.4, and 724.9. In these cases, neurologic findings on history and physical examination are either absent or do not show progressive deterioration.
DWD 81.06(1)(b)3.
3. Radicular pain, with or without regional low back pain, with progressive neurologic deficit. This includes the same diagnoses as
subd. 2., except this subdivision applies when there is a history of progressive deterioration in the neurologic symptoms and physical findings which include worsening sensory loss, increasing muscle weakness, or progressive reflex changes.
DWD 81.06(1)(b)4.
4. Cauda equina syndrome, which is a syndrome characterized by anesthesia in the buttocks, genitalia, or thigh and accompanied by disturbed bowel and bladder function, including ICD-9-CM codes 344.6, 344.60, and 344.61.
DWD 81.06(1)(c)
(c) A health care provider may not order laboratory tests in the evaluation of a patient with regional low back pain, radicular pain, or cauda equina syndrome, except for any of the following:
DWD 81.06(1)(c)1.
1. When a patient's history, age, or examination suggests infection, metabolic-endocrinologic disorders, tumorous conditions, systemic musculoskeletal disorders, such as rheumatoid arthritis or ankylosing spondylitis.
DWD 81.06(1)(d)
(d) Laboratory tests may be ordered any time a health care provider suspects any of the conditions in
par. (c), if the health care provider justifies the need for the tests ordered with clear documentation of the indications.
DWD 81.06(1)(e)
(e) Medical imaging evaluation of the lumbosacral spine shall be based on the findings of the history and physical examination and may not be ordered before a health care provider's clinical evaluation of the patient. Medical imaging may not be performed as a routine procedure and shall comply with all of the guidelines in
s. DWD 81.05 (1) and
(2). A health care provider shall document the appropriate indications for any medical imaging studies obtained.
DWD 81.06(1)(f)
(f) A health care provider may not order electromyography and nerve conduction studies for regional low back pain as defined in
s. DWD 81.06 (1) (b) 1. A health care provider may order electromyography and nerve conduction studies as a diagnostic tool for radicular pain and cauda equina syndrome as defined in
s. DWD 81.06 (1) (b) 2. to
4. after the first 3 weeks of radicular symptoms. Repeat electromyography and nerve conduction studies for radicular pain and cauda equina syndrome are not necessary unless a new neurologic symptom or progression of existing finding has developed that in itself would warrant electrodiagnostic testing. Failure to improve with treatment is not an indication for repeat testing.
DWD 81.06(1)(g)
(g) A health care provider may not order the use of any of the following procedures or tests for the diagnosis of any of the clinical categories in
par. (b) 1. to
4.:
DWD 81.06(1)(g)1.
1. Surface electromyography or surface paraspinal electromyography.
DWD 81.06(1)(h)
(h) A health care provider may not order computerized range of motion or strength measuring tests during the period of initial nonsurgical management but may order these tests during the period of chronic management when used in conjunction with a computerized exercise program, work hardening program, or work conditioning program. During the period of initial nonsurgical management, computerized range of motion or strength testing may be performed but shall be done in conjunction with an office visit with a health care provider's evaluation or treatment, or physical or occupational therapy evaluation or treatment.
DWD 81.06(1)(i)
(i) A health care provider may order personality or psychosocial evaluations for evaluating patients who continue to have problems despite appropriate care. A treating health care provider may perform this evaluation or may refer the patient for consultation with another health care provider in order to obtain a psychological evaluation. These evaluations may be used to assess the patient for a number of psychological conditions that may interfere with recovery from the injury. Since more than one of these psychological conditions may be present in a given case, the health care provider performing the evaluation shall consider all of the following:
DWD 81.06(1)(i)2.
2. Does the patient exhibit an emotional reaction to the injury, such as depression, fear, or anger, that is interfering with recovery?
DWD 81.06(1)(i)3.
3. Are there other personality factors or disorders that are interfering with recovery?
DWD 81.06(1)(i)5.
5. Are there any interpersonal conflicts interfering with recovery?
DWD 81.06(1)(i)6.
6. Does the patient have a chronic pain syndrome or psychogenic pain?
DWD 81.06(1)(i)7.
7. In cases in which surgery is a possible treatment, are psychological factors likely to interfere with the potential benefit of the surgery?
DWD 81.06(1)(j)
(j) All of the following are guidelines for diagnostic analgesic blocks or injection studies and include facet joint injection, facet nerve injection, epidural differential spinal block, nerve block, and nerve root block:
DWD 81.06(1)(j)1.
1. These procedures are used to localize the source of pain before surgery and to diagnose conditions that fail to respond to initial nonsurgical management.
DWD 81.06(1)(j)2.
2. These injections are invasive and are not necessary when done as diagnostic procedures only, unless noninvasive procedures have failed to establish the diagnosis.
DWD 81.06(1)(j)3.
3. Selection of patients, choice of procedure, and localization of the level of injection may be determined by documented clinical findings indicating possible pathologic conditions and the source of pain symptoms.
DWD 81.06(1)(j)4.
4. These blocks and injections may also be used as therapeutic modalities and are subject to the guidelines of
sub. (5).
DWD 81.06(1)(k)
(k) Functional capacity assessment or evaluation is a comprehensive and objective assessment of a patient's ability to perform work tasks. The components of a functional capacity assessment or evaluation include neuromusculoskeletal screening, tests of manual material handling, assessment of functional mobility, and measurement of postural tolerance. A functional capacity assessment or evaluation is an individualized testing process and the component tests and measurements are determined by the patient's condition and the requested information. Functional capacity assessments and evaluations are performed to determine and report a patient's physical capacities in general or to determine work tolerance for a specific job, task, or work activity.
DWD 81.06(1)(k)1.
1. A functional capacity assessment or evaluation is not necessary during the period of initial nonsurgical management.
DWD 81.06(1)(k)2.
2. A functional capacity assessment or evaluation is necessary in any of the following circumstances:
DWD 81.06(1)(k)3.
3. A functional capacity evaluation may not establish baseline performance before treatment or for subsequent assessments to evaluate change during or after treatment.
DWD 81.06(1)(k)4.
4. A health care provider may direct only one completed functional capacity evaluation per injury.
DWD 81.06(1)(L)
(L) Consultations with other health care providers may be initiated at any time by the treating health care provider consistent with accepted medical practice.
DWD 81.06(2)
(2) General treatment guidelines for low back pain. DWD 81.06(2)(a)(a) All medical care for low back pain appropriately assigned to a clinical category in
sub. (1) (b) is determined by the diagnosis and clinical category that the patient has been assigned. General guidelines for treatment modalities are set forth in
subs. (3) to
(10). Specific treatment guidelines for each clinical category are set forth in
subs. (11),
(12), and
(13), as follows:
DWD 81.06(2)(a)3.
3. Subsection (13) governs cauda equina syndrome and radicular pain with progressive neurologic deficits.
DWD 81.06(2)(b)
(b) A health care provider shall, at each visit, reassess the appropriateness of the clinical category assigned and reassign the patient if warranted by new clinical information including symptoms, signs, results of diagnostic testing and opinions, and information obtained from consultations with other health care providers. If the clinical category is changed, the treatment plan shall be appropriately modified to reflect the new clinical category. A change of clinical category may not in itself allow a health care provider to continue a therapy or treatment modality past the maximum duration specified in
subs. (3) to
(10) or to repeat a therapy or treatment previously provided for the same injury.
DWD 81.06(2)(c)
(c) In general, a course of treatment for low back problems is divided into the following 3 phases:
DWD 81.06(2)(c)1.
1. First, all patients with low back problems, except patients with progressive neurologic deficit or cauda equina syndrome under
sub. (1) (b) 3. or
4., shall be given initial nonsurgical management which may include active treatment modalities, passive treatment modalities, injections, durable medical equipment, and medications. These modalities and guidelines are described in
subs. (3),
(4),
(5),
(8), and
(10). The period of initial nonsurgical treatment begins with the first active, passive, medication, durable medical equipment, or injection modality initiated. Initial nonsurgical treatment shall result in progressive improvement as specified in
sub. (9).
DWD 81.06(2)(c)2.
2. Second, for patients with persistent symptoms, initial nonsurgical management is followed by a period of surgical evaluation. This evaluation shall be completed in a timely manner. Surgery, if necessary, shall be performed as expeditiously as possible consistent with sound medical practice and
subs. (6),
(11),
(12),
(13), and
s. DWD 81.12. A treating health care provider may do the evaluation or may refer the patient to another health care provider.
DWD 81.06(2)(c)2.a.
a. Patients with radicular pain with progressive neurological deficit or cauda equina syndrome may require immediate surgical therapy.
DWD 81.06(2)(c)2.b.
b. Any patient who has had surgery may require postoperative therapy in a clinical setting with active and passive treatment modalities. This therapy may be in addition to any received during the period of initial nonsurgical care.
DWD 81.06(2)(c)2.d.
d. A decision against surgery at any particular time does not preclude a decision for surgery at a later date.
DWD 81.06(2)(c)3.
3. Third, for those patients who are not candidates for or refuse surgical therapy, or who do not have complete resolution of their symptoms with surgery, a period of chronic management may be necessary. Chronic management modalities are described in
s. DWD 81.13 and may include durable medical equipment as described in
sub. (8).
DWD 81.06(2)(d)
(d) A treating health care provider may refer the patient for a consultation at any time during the course of treatment consistent with accepted medical practice.
DWD 81.06(3)(a)(a)
General. Except as set forth in
par. (b) and
s. DWD 81.04 (5), a health care provider may not direct the use of passive treatment modalities in a clinical setting as set forth in
pars. (c) to
(i) beyond 12 calendar weeks after any of the passive modalities in
pars. (c) to
(i) are initiated. There are no limitations on the use of passive treatment modalities by the patient at home.
DWD 81.06(3)(b)
(b)
Additional passive treatment modalities. A health care provider may direct an additional 12 visits for the use of passive treatment modalities over an additional 12 months if all of the following apply:
DWD 81.06(3)(b)1.
1. The patient is released to work or is permanently totally disabled and the additional passive treatment shall result in progressive improvement in, or maintenance of, the functional status that was achieved during the initial 12 weeks of passive care.
DWD 81.06(3)(b)3.
3. A health care provider documents in the medical record a plan to encourage the patient's independence and decreased reliance on health care providers.
DWD 81.06(3)(b)4.
4. Management of the patient's condition includes active treatment modalities during this period.
DWD 81.06(3)(b)5.
5. The additional 12 visits for passive treatment does not delay the required surgical or chronic pain evaluation required by this chapter.
DWD 81.06(3)(b)6.
6. Passive care is not necessary while the patient has chronic pain syndrome.
DWD 81.06(3)(c)
(c)
Adjustment or manipulation of joints. For purposes of this paragraph, “adjustment or manipulation of joints" includes chiropractic and osteopathic adjustments or manipulations. All of the following guidelines apply to adjustment or manipulation of joints:
DWD 81.06(3)(c)2.
2. Maximum treatment frequency is up to 5 times per week for the first one to 2 weeks decreasing in frequency until the end of the maximum treatment duration period in
subd. 3.
DWD 81.06(3)(d)
(d)
Thermal treatment. For purposes of this paragraph, “thermal treatment" includes all superficial and deep heating and cooling modalities. Superficial thermal modalities include hot packs, hot soaks, hot water bottles, hydrocollators, heating pads, ice packs, cold soaks, infrared, whirlpool, and fluidotherapy. Deep thermal modalities include diathermy, ultrasound, and microwave. All of the following guidelines apply to thermal treatment:
