rsa forms revisited felix1

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



Proposal to Update Current RSA forms

• Easier to follow• More room for notes/comments• More functional information• More specific– Spinal– Upper Extremity– Lower Extremity



FORM 221 RSA



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.



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



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



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.



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:


Date:


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.____ ft.________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.


_________Min._________Min.


_________Min._________Min.




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.):*


Date:


Date:


Date:


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.


________lb.

Max. ________ lb.Max. ________ lb.Max. ________ lb.Max. ____ lb.____ ft.________lb.

Max. ________ lb.Max. ________ lb.Max. ________ lb.Max. ____ lb.____ ft.________lb.


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 ______



Dexterity Test (Purdue, Minnesota, Bennett, VALPAR__) Score R _____ L_____ Score R _____L_____ Score R _____L_____ Score R ____ L_____



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.):*


Date:


Date:


Date:


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.


________lb.


________lb.


________lb.


________lb.


Stairs50 ft. speed walk6 min. walk test

Stairs____________50 ft. ______sec.6 min. ______ ft.




Balance Test



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.



Functional OutcomesModified Oswestry Disability QuestionnaireNeck Disability IndexQuad Visual Analog Scale

Score____________Score____________Score____________

Score___________Score___________Score___________





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



Provide a treatment plan



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



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



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

rsa forms revisited felix1

Technology

injured workers job

functional abilitieslifting

occupational therapist

current rsa forms easier

physical therapist

followmore room

control wc abuse

medical physician