DWD 81.08(11)(b)
(b) Surgical evaluation or chronic management is necessary if the patient continues with symptoms and objective 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. The purpose of surgical evaluation is to determine whether surgery is necessary in the treatment of a patient who has failed to recover with initial nonsurgical care. If the patient is not a surgical candidate, then chronic management is necessary.
DWD 81.08(11)(b)1.
1. Surgical evaluation, if necessary, may begin as soon as 8 weeks after, but shall begin no later than 12 weeks after, beginning initial nonsurgical management. An initial recommendation or decision against surgical therapy does not preclude surgery at a later date.
DWD 81.08(11)(b)2.
2. Surgical evaluation may include the use of appropriate medical imaging techniques. The imaging technique shall be chosen on the basis of the suspected etiology of the patient's condition, but a health care provider shall follow the guidelines in
s. DWD 81.05. Medical imaging studies that do not meet these guidelines are not necessary.
DWD 81.08(11)(b)3.
3. Surgical evaluation may also include diagnostic blocks and injections. These blocks and injections are only necessary if their use is consistent with the guidelines of
sub. (1) (j).
DWD 81.08(11)(b)4.
4. Surgical evaluation may also include personality or psychosocial evaluation, consistent with the guidelines of
sub. (1) (i).
DWD 81.08(11)(b)5.
5. Consultation with other health care providers may be appropriate as part of the surgical evaluation. The need for consultation and the choice of consultant will be determined by the findings on medical imaging, diagnostic analgesic blocks, and injections, if performed, and the patient's ongoing subjective complaints and objective physical findings.
DWD 81.08(11)(b)6.
6. The only surgical procedure necessary for patients with regional thoracic back pain only is thoracic arthrodesis with or without instrumentation, which shall meet the guidelines of
sub. (6) and
s. DWD 81.12 (1) (d). For patients with failed surgery, spinal cord stimulators or intrathecal drug delivery systems may be necessary consistent with
sub. (6) (d).
DWD 81.08(11)(b)6.a.
a. If surgery is necessary, it shall be offered to the patient as soon as possible. If the patient agrees to the proposed surgery it shall be performed as expeditiously as possible consistent with sound medical practice.
DWD 81.08(11)(b)6.b.
b. If surgery is not necessary or if the patient does not wish to proceed with surgery, then the patient is a candidate for chronic management.
DWD 81.08(11)(c)
(c) If the patient continues with symptoms and objective physical findings after surgery has been rendered, or the patient refuses surgery, or the patient was not a candidate for surgery, and if the patient's condition prevents the resumption of the regular activities of daily life including regular vocational activities, then the patient may be a candidate for chronic management under
s. DWD 81.13.
DWD 81.08(12)
(12) Specific treatment guidelines for radicular pain. DWD 81.08(12)(a)(a) Initial nonsurgical treatment is appropriate for all patients with radicular pain under
sub. (1) (b) 2., and shall be the first phase of treatment. It shall be provided within the guidelines of
sub. (11) (a), with the following modifications: Epidural blocks and nerve root and peripheral nerve blocks are the only therapeutic injections necessary for patients with radicular pain only. If there is a component of regional thoracic back pain, therapeutic facet joint injections, facet nerve blocks, and trigger point injections may also be necessary.
DWD 81.08(12)(b)
(b) Surgical evaluation or chronic management is necessary 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. It shall be provided within the guidelines of
sub. (11) (b), with the following modifications: The only surgical procedures necessary for patients with radicular pain are decompression or arthrodesis. For patients with failed surgery, spinal cord stimulators or intrathecal drug delivery systems may be necessary consistent with
sub. (6) (d).
DWD 81.08(12)(c)
(c) If the patient continues with symptoms and objective physical findings after surgical therapy has been rendered or the patient refused surgical therapy or the patient was not a candidate for surgical therapy, and if the patient's condition prevents the resumption of the regular activities of daily life including regular vocational activities, then the patient may be a candidate for chronic management. Any course or program of chronic management for patients with radicular pain, with or without regional thoracic back pain shall be provided under the guidelines of
s. DWD 81.13.
DWD 81.08(13)(a)(a) Patients with myelopathy may require emergency surgical evaluation at any time during the course of their overall treatment. The health care provider may decide to proceed with surgical evaluation based on the type of neurologic changes observed, the severity of the changes, the rate of progression of the changes, and the response to any nonsurgical treatments. Surgery, if necessary, may be performed at any time during the course of treatment. Surgical evaluation and surgery shall be within the guidelines of
sub. (11) (b), with the following modifications:
DWD 81.08(13)(a)2.
2. The only surgical procedures necessary for patients with myelopathy are decompression and arthrodesis. For patients with failed surgery, spinal cord stimulators or intrathecal drug delivery systems may be necessary consistent with
sub. (6) (d).
DWD 81.08(13)(b)
(b) If the health care provider decides to proceed with a course of nonsurgical care for a patient with myelopathy, it shall follow the guidelines of
sub. (12) (a).
DWD 81.08(13)(c)
(c) If the patient continues with symptoms and objective physical findings after surgical therapy has been rendered or the patient refuses surgical therapy or the patient was not a candidate for surgical therapy, and if the patient's condition prevents the resumption of the regular activities of daily life including regular vocational activities, then the patient may be a candidate for chronic management. Any course or program of chronic management for patients with myelopathy shall be provided under the guidelines of
s. DWD 81.13.
DWD 81.08 History
History: CR 07-019: cr. Register October 2007 No. 622, eff. 11-1-07. DWD 81.09
DWD 81.09 Upper extremity disorders. DWD 81.09(1)
(1)
Diagnostic procedures for treatment of upper extremity disorders. DWD 81.09(1)(a)(a) A health care provider shall determine the nature of an upper extremity disorder before initiating treatment.
DWD 81.09(1)(b)
(b) A health care provider shall perform and document an appropriate history and physical examination. Based on the history and physical examination a health care provider shall at each visit assign the patient to the appropriate clinical category according to
subds. 1. to
6. A health care provider shall document the diagnosis in the medical record. Patients may have multiple disorders requiring assignment to more than one clinical category. This section does not apply to upper extremity conditions due to a visceral, vascular, infectious, immunological, metabolic, endocrine, systemic neurologic, or neoplastic disease process, fractures, lacerations, amputations, or sprains or strains with complete tissue disruption.
DWD 81.09(1)(b)1.
1. `Epicondylitis.' This clinical category includes medial epicondylitis and lateral epicondylitis, including ICD-9-CM codes 726.31 and 726.32.
DWD 81.09(1)(b)2.
2. `Tendonitis of the forearm, wrist, and hand.' This clinical category encompasses any inflammation, pain, tenderness, or dysfunction or irritation of a tendon, tendon sheath, tendon insertion, or musculotendinous junction in the upper extremity at or distal to the elbow due to mechanical injury or irritation, including the diagnoses of tendonitis, tenosynovitis, tendovaginitis, peritendinitis, extensor tendinitis, de Quervain's syndrome, intersection syndrome, flexor tendinitis, and trigger digit, including ICD-9-CM codes 726.4, 726.5, 726.8, 726.9, 726.90, 727, 727.0, 727.00, 727.03, 727.04, 727.05, and 727.2.
DWD 81.09(1)(b)3.
3. `Nerve entrapment syndromes.' This clinical category encompasses any compression or entrapment of the radial, ulnar or median nerves, or any of their branches, including carpal tunnel syndrome, pronator syndrome, anterior interosseous syndrome, cubital tunnel syndrome, Guyon's canal syndrome, radial tunnel syndrome, posterior interosseous syndrome, and Wartenburg's syndrome, including ICD-9-CM codes 354, 354.0, 354.1, 354.2, 354.3, 354.8, and 354.9.
DWD 81.09(1)(b)4.
4. `Muscle pain syndromes.' This clinical category encompasses any painful condition of any of the muscles of the upper extremity, including the muscles responsible for movement of the shoulder and scapula, characterized by pain and stiffness, including the diagnoses of chronic nontraumatic muscle strain, repetitive strain injury, cervicobrachial syndrome, tension neck syndrome, overuse syndrome, myofascial pain syndrome, myofasciitis, nonspecific myalgia, fibrositis, fibromyalgia, and fibromyositis, including ICD-9-CM codes 723.3, 729.0, 729.1, 729.5, 840, 840.3, 840.5, 840.6, 840.8, 840.9, 841, 841.8, 841.9, and 842.
DWD 81.09(1)(b)5.
5. `Shoulder impingement syndromes, including tendonitis, bursitis, and related conditions.' This clinical category encompasses any inflammation, pain, tenderness, dysfunction, or irritation of a tendon, tendon insertion, tendon sheath, musculotendinous junction, or bursa in the shoulder due to mechanical injury or irritation, including the diagnoses of impingement syndrome, supraspinatus tendonitis, infraspinatus tendonitis, calcific tendonitis, bicipital tendonitis, subacromial bursitis, subcoracoid bursitis, subdeltoid bursitis, and rotator cuff tendinitis, including ICD-9-CM codes 726.1 to 726.2, 726.9, 726.90, 727 to 727.01, 727.2, 727.3, 840, 840.4, 840.6, 840.8, and 840.9.
DWD 81.09(1)(b)6.
6. `Traumatic sprains or strains of the upper extremity.' This clinical category encompasses an instantaneous or acute injury that occurred as a result of a single precipitating event to the ligaments or the muscles of the upper extremity including ICD-9-CM codes 840 to 842.19. Injuries to muscles as a result of repetitive use, or occurring gradually over time without a single precipitating trauma, are considered muscle pain syndromes under
subd. 4. Injuries with complete tissue disruption are not subject to this section.
DWD 81.09(1)(c)
(c) A health care provider may order certain laboratory tests in the evaluation of a patient with upper extremity disorder to rule out infection, metabolic-endocrinologic disorders, tumorous conditions, systemic musculoskeletal disorders such as rheumatoid arthritis, or side effects of medications. Laboratory tests may be ordered at any time a health care provider suspects any of these conditions, but a health care provider shall justify the need for the tests ordered with clear documentation of the indications.
DWD 81.09(1)(d)
(d) Medical imaging evaluation of upper extremity disorders 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 the guidelines in
s. DWD 81.05. A health care provider shall document the appropriate indications for any medical imaging studies obtained.
DWD 81.09(1)(e)
(e) Electromyography and nerve conduction studies are only necessary for nerve entrapment disorders and recurrent nerve entrapment after surgery.
DWD 81.09(1)(f)
(f) A health care provider may not order the use of any of the following diagnostic procedures or tests for diagnosis of upper extremity disorders:
DWD 81.09(1)(g)
(g) All of the following diagnostic procedures or tests are considered adjuncts to the physical examination and are not necessary separately from the office visit:
DWD 81.09(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.
DWD 81.09(1)(i)
(i) A health care provider may order personality or psychosocial evaluations for evaluating patients who continue to have problems despite appropriate initial nonsurgical 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, a health care provider performing the evaluation shall consider all of the following:
DWD 81.09(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 81.09(1)(i)3.
3. Are there other personality factors or disorders that are interfering with recovery?
DWD 81.09(1)(i)5.
5. Are there any interpersonal conflicts interfering with recovery?
DWD 81.09(1)(i)6.
6. Does the patient have a chronic pain syndrome or psychogenic pain?
DWD 81.09(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 81.09(1)(j)
(j) Diagnostic analgesic blocks and injection studies are used to localize the source of pain and to diagnose conditions which fail to respond to appropriate initial nonsurgical management. All of the following guidelines apply to diagnostic analgesic blocks and injection studies:
DWD 81.09(1)(j)1.
1. Selection of patients, choice of procedure, and localization of the site of injection shall be determined by documented clinical findings indicating possible pathologic conditions and the source of pain symptoms.
DWD 81.09(1)(j)2.
2. These blocks and injections may also be used as therapeutic modalities and as such are subject to the guidelines of
sub. (5).
DWD 81.09(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 81.09(1)(k)1.
1. Functional capacity assessment or evaluation is not necessary during the first 12 weeks of initial nonsurgical treatment.
DWD 81.09(1)(k)2.
2. Functional capacity assessment or evaluation is necessary after the first 12 weeks of care in any of the following circumstances:
DWD 81.09(1)(k)3.
3. A functional capacity evaluation is not necessary to establish baseline performance before treatment or for subsequent assessments to evaluate change during or after treatment.
DWD 81.09(1)(k)4.
4. Only one completed functional capacity evaluation is necessary per injury.
DWD 81.09(1)(L)
(L) Consultations with other health care providers may be initiated at any time by a treating health care provider consistent with accepted medical practice.
DWD 81.09(2)
(2) General treatment guidelines for upper extremity disorders. DWD 81.09(2)(a)(a) All medical care for upper extremity disorders, appropriately assigned to a category of
sub. (1) (b) 1. to
6., 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) to
(16) as follows:
DWD 81.09(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. When the clinical category is changed the treatment plan shall be appropriately modified to reflect the new clinical category. The health care provider shall record any clinical category and treatment plan changes in the medical record. 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, unless the treatment or therapy is subsequently delivered to a different part of the body.
DWD 81.09(2)(c)
(c) When treating more than one clinical category or body part for which the same treatment modality is appropriate, then the treatment modality shall be applied simultaneously, if possible, to all necessary areas.
DWD 81.09(2)(d)
(d) In general, a course of treatment shall be divided into the following 3 phases:
DWD 81.09(2)(d)1.
1. First, all patients with an upper extremity disorder shall be given initial nonsurgical management, unless otherwise specified. Initial nonsurgical management may include any combination of the passive, active, injection, durable medical equipment, and medication treatment modalities listed in
subs. (3),
(4),
(5),
(8), and
(10), appropriate to the clinical category. The period of initial nonsurgical treatment begins with the first passive, active, injection, durable medical equipment, or medication modality initiated. Initial nonsurgical treatment shall result in progressive improvement as specified in
sub. (9).
DWD 81.09(2)(d)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) to
(16), and
s. DWD 81.12 (2). A treating health care provider may do the evaluation or may refer the patient to another health care provider.
DWD 81.09(2)(d)2.a.
a. Any patient who has had surgery may require postoperative therapy with active and passive treatment modalities. This therapy may be in addition to any received during the period of initial nonsurgical management.
DWD 81.09(2)(d)2.c.
c. A decision against surgery at any particular time does not preclude a decision for surgery made at a later date.
DWD 81.09(2)(d)3.
3. Third, for those patients who are not candidates for surgery or refuse surgery, 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 81.09(2)(e)
(e) 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 81.09(3)(a)(a)
General. Except as set forth in
par. (b) or
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 81.09(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 81.09(3)(b)1.
1. The patient is released to work or is permanently totally disabled and the additional passive treatment may result in progressive improvement in, or maintenance of, functional status achieved during the initial 12 weeks of passive care.
DWD 81.09(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 81.09(3)(b)4.
4. Management of the patient's condition includes active treatment modalities during this period.
DWD 81.09(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.
