Functional gains documentation is vital for understanding an injured worker’s functional response and evaluating the effectiveness of treatment. Documentation of functional status and measurable goals is not just recommended as “best practice,” but is required. DOWC Rule 16-9 indicates documentation must include the treatment status or patient’s functional response to current treatment.
Exhibit 1 specifies the initial visit levels documentation for 99204 and 99205. “For the provider to achieve an ‘extended’ history of present illness (HPI) in an initial patient/injured worker’s visit, it is necessary for the provider to discuss the impact of the patient/injured worker’s work-related injury(s) to the patient/injured worker’s job duties.”
Exhibit 1 indicates the established visit levels of documentation for 99214 and 99215. “For the provider to achieve an ‘extended’ HPI in an established patient/injured worker’s visit, it is necessary to document a detailed description of the patient’s progress since the last visit that
includes pertinent objective functional gains, such as activities of daily living, physical therapy goals and return to work.”
Documentation such as “injured worker improving” or “injured worker at 25% of goal” lacks sufficient detail. Documentation that lacks specific detail provides no measurable or useful information for determining the injured worker’s gains or losses during treatment. Functional gains that are not being met should be reevaluated and a new treatment plan should be determined.
Below are common examples of documentation that do not portray functional status or functional response to treatment.
- Injured worker goal – “get back to normal”
- “Pain level is 5/10”
- “Injured worker is improving, physical therapy is helping”
- “IW is approximately 25% of the way toward meeting the physical requirements of her job”
- “Patient reports no improvement 0/10”
- “Range of motion improving”
Functional gains that can be objectively measured include:
- Increased ability to perform activities of daily living
- Decrease in opioid or medication use
- Increased range of motion, coordination strength, endurance and/or positional tolerance
- Decreased work restrictions for modified duties and return to work
- Subjective reports of decreased pain and increased function when correlated with objective findings