Utah Labor Commission Restorative Services Authorization/Denial RSA Forms Revisited 9 th Annual Utah Labor Commission Worker’s Compensation Educational Conference Sept. 29, 2011
Utah Labor CommissionRestorative Services Authorization/Denial
RSA Forms Revisited
9th Annual Utah Labor Commission Worker’s Compensation Educational Conference
Sept. 29, 2011
Traditional Standard of Care
• Restorative Services – Medical Physician– Chiropractor– Physical Therapist– Occupational Therapist
• Focus of treatment– Reduce pain– Increase Range of Motion– Improve strength– Function (Activities of daily living, sports, work…)
9th Annual Utah Labor Commission Worker’s Compensation Educational
Conference Sept. 29, 2011
RSA HistoryRestorative Services Authorization/Denial
FORM 221 • Started in 1996 by the Utah Labor Commission• Established to focus restorative services
towards a return to function• Given as a guide to control WC abuse• Provided for communication between
provider, employer, and payor
9th Annual Utah Labor Commission Worker’s Compensation Educational
Conference Sept. 29, 2011
Proposal to Update Current RSA forms
• Easier to follow• More room for notes/comments• More functional information• More specific– Spinal– Upper Extremity– Lower Extremity
9th Annual Utah Labor Commission Worker’s Compensation Educational
Conference Sept. 29, 2011
FORM 221 RSA
9th Annual Utah Labor Commission Worker’s Compensation Educational
Conference Sept. 29, 2011
Restorative Services Authorization/Denial Patient’s Last Name:
First:
Middle:
Referring Physician: Date of Injury:
Social Security Number: Date of Birth: Height: Weight:
Employer:
Employer Address:
Phone: FAX:
Insurance Carrier:
Provider: Address:
Address: Adjuster Name:
Provider Discipline MD DO DC PT OT
Tax ID Number:
Phone: FAX:
Phone: FAX: Other Conditions or Complicating Factors that May Affect Recovery:
Diagnosis Specific to Industrial Claim:
Form 221 requires that the provider has an understanding about the
injured worker’s job.
9th Annual Utah Labor Commission Worker’s Compensation Educational
Conference Sept. 29, 2011
List from the patient’s essential job functions, measurable objective requirements needed to return to work without restrictions (i.e.: lifting, carrying, grip, pinch, reaching overhead, standing or sitting duration, etc.):*
Floor-Waist Max _______ lb. Freq. _______lb.Waist-Shoulder Max _______ lb. Freq. _______ lb. Overhead Max _______ lb. Freq. _______lb. Carrying Max _______ lb. Freq. __________lb. Push/Pull Horizontal force ________lb.
Functional ROM O=overhead, S=shoulder, H=horizontal, K=knee, F=floor
Obtain Job Description
• Interview injured worker• Call employer• Request written job description• Dictionary of Occupational Titles• On-site visit
9th Annual Utah Labor Commission Worker’s Compensation Educational
Conference Sept. 29, 2011
9th Annual Utah Labor Commission Worker’s Compensation Educational
Conference Sept. 29, 2011
9th Annual Utah Labor Commission Worker’s Compensation Educational
Conference Sept. 29, 2011
Identify the Injured Workers Current Functional Abilities
• Functional range of motion – Overhead, shoulder, horizontal, knee, floor
• Work place tolerances– Sitting, standing, walking, reaching, stoop, kneel,
climbing, etc.• Lifting / carrying / push/pull strength• Manual dexterity• Hours required to work per day
9th Annual Utah Labor Commission Worker’s Compensation Educational
Conference Sept. 29, 2011
Measure Functional Abilities
• Lifting, carrying, push/pull• Sitting, standing, stooping, squatting, kneeling• Walking, climbing stairs or ladder• Grip and Pinch strength• Manual dexterity• Balance• Etc.
9th Annual Utah Labor Commission Worker’s Compensation Educational
Conference Sept. 29, 2011
Report Measured Functional AbilitiesRSA SPINE
List from the patient’s essential job functions, measurable objective requirements needed to return to work without restrictions (i.e.: lifting, carrying, reaching overhead, standing or sitting duration, bending, etc.):*
Capabilities Recorded on First Visit
Date:
Capabilities on 8th Visit
Date:
Capabilities on 14th Visit
Date:
Capabilities on 20th Visit
Date:
Floor-Waist Max lb.________ Freq. _______Waist-Shoulder Max lb. _______ Freq. _______
Overhead Max lb. _______ Freq. _______ Carrying Max lb. _______ Freq. _________
Push/Pull Horizontal force _____ lb.
Max. ________ lb.Max. ________ lb.Max. ________ lb.Max. ____ lb.____ ft.
________lb.
Max. ________ lb.Max. ________ lb.Max. ________ lb.
Max. ____ lb.____ ft.________lb.
Max. ________ lb.Max. ________ lb.Max. ________ lb.
Max. ____ lb.____ ft.________lb.
Max. ________ lb.Max. ________ lb.Max. ________ lb.
Max. ____ lb.____ ft.________lb.
Functional ROM O=overhead, S=shoulder, H=horizontal, K=knee, F=floor O S H K F O S H K F O S H K F O S H K F
Sitting tolerance _______ Min.Standing tolerance _______ Min.Squat/stoop/bending Constant/ Frequent/Occasional
_________Min._________Min.
Constant / Freq. / Occ.
_________Min._________Min.
Constant / Freq. / Occ.
_________Min._________Min.
Constant / Freq. / Occ.
_________Min._________Min.
Constant / Freq. / Occ.
9th Annual Utah Labor Commission Worker’s Compensation Educational
Conference Sept. 29, 2011
Report Measured Functional AbilitiesRSA UPPER EXTREMITY
List from the patient’s essential job functions, measurable objective requirements needed to return to work without restrictions (i.e.: lifting, carrying, grip, pinch, reaching overhead, standing or sitting duration, etc.):*
Capabilities Recorded on First Visit
Date:
Capabilities on 8th Visit
Date:
Capabilities on 14th Visit
Date:
Capabilities on 20th Visit
Date:
Floor-Waist Max _______ lb. Freq. _______lb.Waist-Shoulder Max _______ lb. Freq. _______ lb. Overhead Max _______ lb. Freq. _______lb. Carrying Max _______ lb. Freq. __________lb. Push/Pull Horizontal force ________lb.
Max.________ lb.Max.________ lb.Max.________ lb.Max. ___ lb. ____ft.
________lb.
Max. ________ lb.Max. ________ lb.Max. ________ lb.Max. ____ lb.____ ft.
________lb.
Max. ________ lb.Max. ________ lb.Max. ________ lb.Max. ____ lb.____ ft.________lb.
Max. ________ lb.Max. ________ lb.Max. ________ lb.Max. ____ lb.____ ft.________lb.
Functional ROM O=overhead, S=shoulder, H=horizontal, K=knee, F=floor O S H K F O S H K F O S H K F O S H K F
Grip Strength 2nd grip spanRapid Exchange Grip (REG)Pinch Strength
Max. R_____ L_____ REG R_____ L _____Key R_____ L _____Palmar R_____L_____Tip R______ L ______
Max. R_____ L_____ REG R_____ L _____Key R_____ L _____Palmar R____L_____Tip R_____ L ______
Max. R_____ L_____ REG R_____ L _____Key R_____ L _____Palmar R____L_____Tip R_____ L ______
Max. R_____ L_____ REG R_____ L _____Key R_____ L _____Palmar R____L_____Tip R_____ L ______
Dexterity Test (Purdue, Minnesota, Bennett, VALPAR__) Score R _____ L_____ Score R _____L_____ Score R _____L_____ Score R ____ L_____
9th Annual Utah Labor Commission Worker’s Compensation Educational
Conference Sept. 29, 2011
Report Measured Functional AbilitiesRSA LOWER EXTREMITY
List from the patient’s essential job functions, measurable objective requirements needed to return to work without restrictions (i.e.: lifting, carrying, walking, climbing, squatting, standing or sitting duration, balance, etc.):*
Capabilities Recorded on First Visit
Date:
Capabilities on 8th Visit
Date:
Capabilities on 14th Visit
Date:
Capabilities on 20th Visit
Date:
Floor-Waist Max _______ lb. Freq. _______ lb. Waist-Shoulder Max _______ lb. Freq. _______ lb. Overhead Max _______ lb. Freq. _______ lb. Carrying Max _______ lb. Freq. _______ lb. Push/Pull Horizontal force ______ lb.
Max. ________ lb.Max. ________ lb.Max. ________ lb.Max. ____ lb.____ ft.
________lb.
Max. ________ lb.Max. ________ lb.Max. ________ lb.Max. ____ lb.____ ft.
________lb.
Max. ________ lb.Max. ________ lb.Max. ________ lb.Max. ____ lb.____ ft.
________lb.
Max. ________ lb.Max. ________ lb.Max. ________ lb.Max. ____ lb.____ ft.
________lb.
Functional ROM O=overhead, S=shoulder, H=horizontal, K=knee, F=floor O S H K F O S H K F O S H K F O S H K F
Stairs50 ft. speed walk6 min. walk test
Stairs____________50 ft. ______sec.6 min. ______ ft.
Stairs____________50 ft. ______sec.6 min. ______ ft.
Stairs____________50 ft. ______sec.6 min. ______ ft.
Stairs____________50 ft. ______sec.6 min. ______ ft.
Balance Test
9th Annual Utah Labor Commission Worker’s Compensation Educational
Conference Sept. 29, 2011
Obtain the Injured Worker’s Perceived Functional Abilities
• Functional Ability Questionnaires– Modified Oswestry Disability Questionnaire– Neck Disability Questionnaire– Disabilities of the Arm, Shoulder and Hand (DASH)– Hand Function Sort– Lower Extremity Functional Scale (LEFS)– Knee Outcome– Etc.
9th Annual Utah Labor Commission Worker’s Compensation Educational
Conference Sept. 29, 2011
Functional OutcomesModified Oswestry Disability QuestionnaireNeck Disability IndexQuad Visual Analog Scale
Score____________Score____________Score____________
Score___________Score___________Score___________
Score___________Score___________Score___________
Score___________Score___________Score___________
9th Annual Utah Labor Commission Worker’s Compensation Educational
Conference Sept. 29, 2011
Disability of the Arm, Shoulder and Hand (DASH)Hand Function Sort Score __________
Score __________Score__________Score __________
Score__________Score __________
Score__________Score __________
Patient’s Reported Average Pain Intensity (0 to 10 Scale) /10 /10 /10 /10
Patient’s Reported Average Pain Frequency (% of the Day: 0-10-20-30-40-50-60-70-80-90-100%) % % % %
Lower Extremity Functional Scale (LEFS)Knee Outcome
Score _______Score _______
Score________Score ________
Score________Score ________
Score________Score ________
Patient’s Reported Average Pain Intensity (0 to 10 Scale) /10 /10 /10 /10
Patient’s Reported Average Pain Frequency (% of the Day: 0-10-20-30-40-50-60-70-80-90-100%)
% % % %
Acknowledge the Injured Worker’s PAIN
9th Annual Utah Labor Commission Worker’s Compensation Educational
Conference Sept. 29, 2011
Provide a treatment plan
9th Annual Utah Labor Commission Worker’s Compensation Educational
Conference Sept. 29, 2011
Treatment Plan: (Visits 1-8, include frequency) ٱ Manual Therapy ٱ Manipulation ٱ Therapeutic Exercise ٱ Ultrasound ٱ Electrical Stim ٱ FCE Testing ٱ ADL Instruction ٱ Neuromuscular re-education ٱ Others List:
Visits 1-8 Visits 9-14 Visits 15-20
Expected number of visits to reach stated functional goals:
Communicate with Payor
9th Annual Utah Labor Commission Worker’s Compensation Educational
Conference Sept. 29, 2011
Attended / Prescribed Visits (Prescribed visits are those that should have been scheduled as per the plan of care)
/ / /
Provider Comments:
Provider signature Date:
Payor Communicates with Provider
9th Annual Utah Labor Commission Worker’s Compensation Educational
Conference Sept. 29, 2011
Payor: Approval for Future Visits (Yes – No) Y /N for visits
9-14Y / N for visits
15-20Y / N for visits
21-26Payor: Signature
Date:
Payor Comments
9th Annual Utah Labor Commission Worker’s Compensation Educational
Conference Sept. 29, 2011