DWD 81.12(2)(d)
(d)
Acromioplasty diagnosis. A health care provider may perform acromioplasty for the diagnosis of acromial impingement syndrome, ICD-9-CM codes 726.0 to 726.2. In addition to the diagnosis in this paragraph, both of the following conditions shall be satisfied to indicate that surgery is necessary:
DWD 81.12(2)(d)1.
1. The patient's condition has failed to improve in response to nonsurgical care after adequate initial nonsurgical care.
DWD 81.12(2)(d)2.
2. The patient's clinical findings exhibit pain with active elevation from 90 to 130 degrees, pain at night, and a positive impingement test.
DWD 81.12(2)(e)
(e)
Repair of acromioclavicular or costoclavicular ligaments. A health care provider may perform surgical repair of acromioclavicular or costoclavicular ligaments for the diagnosis of acromioclavicular separation, ICD-9-CM codes 831.04 to 831.14.
DWD 81.12(2)(e)1.
1. In addition to the diagnosis in this paragraph, the guidelines in
subds. 2. and
3. shall be satisfied for repair of acromioclavicular or costoclavicular ligaments.
DWD 81.12(2)(e)2.
2. The patient's condition or response to nonsurgical care includes any of the following:
DWD 81.12(2)(e)2.a.
a. Failure to improve after at least a one-week trial period in a support brace.
DWD 81.12(2)(e)3.
3. The patient's clinical findings exhibit localized pain at the acromioclavicular joint and prominent distal clavicle and radiographic evidence of separation at the acromioclavicular joint.
DWD 81.12(2)(f)
(f)
Excision of distal clavicle diagnosis. A health care provider may perform excision of the distal clavicle for any of the following diagnoses specified in
subd. 1. to
3.:
DWD 81.12(2)(f)2.
2. Osteoarthrosis of the acromioclavicular joint, ICD-9-CM codes 715.11, 715.21, and 715.31.
DWD 81.12(2)(g)
(g)
Criteria and indications for excision of distal clavicle. In addition to one of the diagnosis in
par. (f), all of the following conditions shall be satisfied for excision of distal clavicle:
DWD 81.12(2)(g)1.
1. The patient's condition failed to improve in response to nonsurgical care with adequate initial nonsurgical care.
DWD 81.12(2)(g)2.a.
a. Pain at the acromioclavicular joint, with aggravation of pain with motion of shoulder or carrying weight.
DWD 81.12(2)(g)2.b.
b. Confirmation that separation of the acromioclavicular joint is unresolved and prominent distal clavicle, or pain relief obtained with an injection of anesthetic for diagnostic or therapeutic trial.
DWD 81.12(2)(g)2.c.
c. Separation at the acromioclavicular joint with weight-bearing films or severe degenerative joint disease at the acromioclavicular joint noted on X-rays.
DWD 81.12(2)(h)
(h)
Repair of shoulder dislocation or subluxation, any procedure. DWD 81.12(2)(h)1.1. A health care provider may perform surgical repair of a shoulder dislocation for any of the following diagnoses:
DWD 81.12(2)(h)2.
2. In addition to one of the diagnoses in this paragraph, all of the following clinical findings shall exist for repair of a shoulder dislocation:
DWD 81.12(2)(h)2.a.
a. The patient exhibits a history of multiple dislocations or subluxations that inhibit activities of daily living.
DWD 81.12(2)(h)2.b.
b. X-ray findings are consistent with multiple dislocations or subluxations.
DWD 81.12(2)(i)1.1. A health care provider may perform surgical repair of a proximal biceps tendon for the diagnosis of proximal rupture of the biceps, ICD-9-CM code 727.62 or 840.8.
DWD 81.12(2)(i)2.
2. In addition to the diagnosis in
subd. 1., both of the following conditions shall be satisfied for repair of proximal biceps tendon:
DWD 81.12(2)(i)2.a.
a. The procedure may be done alone or in conjunction with another necessary repair of the rotator cuff.
DWD 81.12(2)(i)2.b.
b. The patient's clinical findings exhibit pain that does not resolve with attempt to use arm and palpation of “bulge" in upper aspect of arm.
DWD 81.12(2)(m)
(m)
Muscle pain syndromes. Surgery is not necessary for muscle pain syndromes.
DWD 81.12(2)(n)
(n)
Traumatic sprains and strains. Surgery is not necessary for the treatment of traumatic sprains and strains, unless there is clinical evidence of complete tissue disruption. Patients with complete tissue disruption may need immediate surgery.
DWD 81.12(3)(a)1.1. A health care provider may perform surgical repair of the anterior cruciate ligament, including arthroscopic repair, for any of the following diagnoses:
DWD 81.12(3)(a)2.
2. In addition to one of the diagnoses in this paragraph, all of the conditions in
subd. 2. a. to
c. shall be satisfied for anterior cruciate ligament reconstruction. Pain alone is not an indication.
DWD 81.12(3)(a)2.a.
a. The patient gives a history of instability of the knee described as “buckling or giving way" with significant effusion at time of injury, or description of injury indicates a rotary twisting or hyperextension occurred.
DWD 81.12(3)(a)2.b.
b. There are objective clinical findings of positive Lachman's sign, positive pivot shift, or positive anterior drawer.
DWD 81.12(3)(a)2.c.
c. There are positive diagnostic findings with arthrogram, magnetic resonance imaging scan, or arthroscopy, and there is no evidence of severe compartmental arthritis.
DWD 81.12(3)(b)1.1. A health care provider may perform patellar tendon realignment for the diagnosis of dislocation of patellar, open, ICD-9-CM code 836.3; or closed, ICD-9-CM code 836.4; or chronic residuals of dislocation.
DWD 81.12(3)(b)2.
2. In addition to the diagnosis in this paragraph, all of the following conditions shall be satisfied for a patellar tendon realignment:
DWD 81.12(3)(b)2.a.
a. The patient gives a history of rest pain as well as pain with patellofemoral movement, and recurrent effusion, or recurrent dislocation.
DWD 81.12(3)(b)2.b.
b. There are objective clinical findings of patellar apprehension, synovitis, lateral tracking, or Q angle greater than 15 degrees.
DWD 81.12(3)(c)1.1. A health care provider may perform a knee joint replacement for degeneration of articular cartilage or meniscus of knee, ICD-9-CM codes 717.1 to 717.4.
DWD 81.12(3)(c)2.
2. In addition to the diagnosis in this paragraph, all of the following conditions shall be satisfied for a knee joint replacement:
DWD 81.12(3)(c)2.a.
a. The patient exhibits limited range of motion, night pain in the joint, or pain with weight-bearing, and no significant relief of pain with an adequate course of initial nonsurgical care.
DWD 81.12(3)(c)2.b.
b. The patient's diagnostic findings confirm there is significant loss or erosion of cartilage to the bone, and positive findings of advanced arthritis, and joint destruction with standing films, magnetic resonance imaging scan, or arthroscopy.
DWD 81.12(3)(d)1.1. A health care provider may perform an ankle, tarsal, or metatarsal fusion for either of the following diagnoses:
DWD 81.12(3)(d)1.a.
a. Malunion or nonunion of fracture of ankle, tarsal, or metatarsal, ICD-9-CM code 733.81 or 733.82.
DWD 81.12(3)(d)2.
2. In addition to one of the diagnoses in this paragraph, the following conditions shall be satisfied for an ankle, tarsal, or metatarsal fusion. For initial nonsurgical care the patient shall have failed to improve with an adequate course of initial nonsurgical care that included any of the following:
DWD 81.12(3)(d)2.a.
a. Immobilization, which may include casting, bracing, shoe modification, or other orthotics.
DWD 81.12(3)(d)3.
3. The patient's clinical findings exhibit both of the following and
subd. 4.:
DWD 81.12(3)(d)3.a.
a. The patient gives a history of pain which is aggravated by activity and weight-bearing, and relieved by xylocaine injection.
DWD 81.12(3)(d)3.b.
b. There are objective findings on physical examination of malalignment or specific joint line tenderness, and decreased range of motion.
DWD 81.12(3)(d)4.
4. The patient's diagnostic findings include medical imaging studies confirming the presence of any of the following:
DWD 81.12(3)(e)1.1. A health care provider may perform ankle reconstruction surgery involving the lateral ligaments for any of the following diagnoses:
DWD 81.12(3)(e)2.
2. In addition to one of the diagnoses in
subd. 1., all of the clinical findings in
subd. 3. shall be satisfied for a lateral ligament ankle reconstruction. For initial nonsurgical care, the patient shall have received an adequate course of initial nonsurgical care, including one of the following:
DWD 81.12(3)(e)2.b.
b. A physical rehabilitation program that follows immobilization with support, cast, or ankle brace.
DWD 81.12(3)(e)3.
3. The patient's clinical findings shall include all of the following:
DWD 81.12(3)(e)3.c.
c. There are positive stress X-rays identifying motion at ankle or subtalar joint with at least a 15 degree lateral opening at the ankle joint, or demonstrable subtalar movement, and negative to minimal arthritic joint changes on X-ray, or ligamentous injury is shown on magnetic resonance imaging scan.
DWD 81.12(3)(e)4.
4. Prosthetic ligaments are not necessary for the treatment of lateral ligament ankle reconstruction.
DWD 81.12 History
History: CR 07-019: cr. Register October 2007 No. 622, eff. 11-1-07. DWD 81.13(1)
(1)
Scope. This section applies to chronic management of all types of physical injuries, even if the injury is not specifically governed by this chapter. If a patient continues with symptoms and physical findings after all appropriate initial nonsurgical and surgical treatment has been rendered, 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. The purpose of chronic management is twofold: the patient should be made independent of health care providers in the ongoing care of a chronic condition; and the patient shall be returned to the highest functional status reasonably possible.
DWD 81.13(1)(a)
(a) Personality or psychological evaluation may be necessary for patients who are candidates for chronic management. 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 81.13(1)(a)2.
2. Does the patient exhibit an emotional reaction to the injury, such as depression, fear, or anger, that is interfering with recovery?
