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Medical Narrative Requirements for NY Workers’ Comp CMS 1500 Claim

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Medical Narrative Requirements for NY Workers’ Comp CMS 1500 Claim

Submitting a New York State Workers’ Compensation claim was a maze of different forms. But in January 2019, the New York Workers’ Compensation Board (NY WCB) took a provider-friendly step of replacing almost all the forms with one form – the CMS 1500 claim form.

Providers will have to submit their NY Workers’ Comp claims in CMS 1500 form from 2021. Most practices are familiar with this, as it is the form used by nearly all payers.

One of the documents done away with is Form EC-4NARR. This was the Doctor’s Narrative Report. Though the form will be removed, a doctor’s narrative is still required, as an attachment to the CMS 1500 claim submission. Without an accompanying medical narrative, the Board will not consider it a valid submission.

The CMS 1500 medical narrative requirements

The Medical Narrative is a mandatory attachment with the CMS 1500 form. You need to submit an initial narrative report after the first treatment and subsequent reports for the follow-up visits. Templates for both are available on the NY WCB’s website.

Though providers need not necessarily use the template, it is advisable to use it for easier XML submissions.

While the templates are common for all specialties, they do vary slightly for Psychology, Ophthalmology and PT / OT.

In general, the provider’s narrative is acceptable, as long as it includes the three mandatory components that should be clarified to the Board.

  1. Work status
  2. Causal relationship
  3. Temporary impairment percentage

However, not all specialties can legally comment on all the three components. More details about what you can and can’t comment on can be found here:

Medical Report Template for CMS 1500

                   Medical Report Template

Work status

Your initial medical narrative report must determine if the patient has missed work because of the injury. You must provide:

• The date the patient first missed work
• The date the patient resumed limited work of any kind

If the patient is not working, write whether he/she can return to work, and any work limitations.

Moreover, for the subsequent report, you need to provide the work status re-evaluation which should include:

If the person is working, when did they resume the limited work or full work.

If not, then can the patient return to work as indicated earlier and will there be any limitations to work

Causal relationship

This requires you to decide whether the incident described by the patient is the cause of the injuries.
You must indicate if the patient’s complaints and your objective findings are consistent with the injury / illness history in both your initial and subsequent narrative reports.

Additionally, you need to mention if your current examination has caused any change in your previous opinion about the causation in your subsequent report.

Temporary impairment

This section requires you to determine the patient’s temporary impairment in the initial narrative report.
What is the percentage (0-100%) of temporary impairment?

You should describe your findings and explain how you determined the percentage.

For the subsequent narrative reports, you will have to comment whether there has been any change in the percentage of temporary impairment. Moreover, you need to mention how you determined that percentage. Lastly, mention the anticipated duration of the impairment.

Other inclusions

Apart from the three mandatory requirements, the initial and subsequent Medical narratives should also include:

History of the Injury/Illness:

How did the injury occur? What part of the body is affected?

In the subsequent report, you should describe any change in the symptoms and the impact of treatment.

Objective Findings/Clinical Evaluation:

Describe the physical findings, diagnostic tests and procedures, and treatment given at initial presentation.

In the follow-up report, describe any changes in the findings, any diagnostic reports in the interval, and any treatment given at follow-up visits.

Diagnoses/Assessment:

You should give a clear diagnosis, or differential diagnoses.

In the follow-up report, reassess your diagnosis, and comment on any change in condition and function.

Plan of Care:

In your initial as well as each subsequent medical narrative report, you should mention the proposed treatment, medications, treatment goals, diagnostic tests, work restrictions, referrals needed, and assistive devices prescribed. The prognosis for recovery and follow-up appointments should also be given in each report.

Timing of the initial and subsequent medical narrative

You must submit the first medical narrative as soon as possible after first providing treatment. This is the 48 Hours Initial Report.

You need to submit the Subsequent Progress Reports in 15 days or less after the first report. Moreover, you should submit reports for follow-up visits in case of prolonged treatments. These should not be more than 90 days apart.

You should remember to send all these reports to:

  • The Workers’ Compensation Board.
  • The workers’ compensation insurance carrier.
  • The self-insured employer.
  • The patient’s attorney or licensed representative.
  • If the claimant is not represented, send the copy to the claimant.

Identifiers of the medical narrative

The CMS 1500 form and accompanying medical narrative need the following:

  • Your signature, as the provider, in field 31 of the Form
  • Authorization number
  • Rating code
  • NPI number.

Summary

The CMS 1500 claim form was announced with the intention of simplifying claims for providers. While the form itself is standard and familiar, the additional medical narrative and attachments need meticulous, careful submission.

It is advisable to use the Board’s template for the medical narrative requirements to make things simpler for your practice when it comes to XML submissions. Once the XML submissions become mandatory, you will also require proper technology to make that happen. However, it would be better and easier to work with a NY WCB submission partner who can help you with the XML submission of the CMS 1500 claim and the medical narrative reports.

 

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