The efficiency of the daily operations of an occupational health facility have a great influence on client and patient acceptance. This chapter is a miscellany of practical recommendations for the smooth operation of the service.
Four general areas are covered: scheduling, billing, the preparation of protocols, and the preparation of letters of consultation.
The initial scheduling of appointments and the flow of traffic once the worker arrives presents a strong first impression to both client employer and worker-patient. A disorganized or confused process communicates a suspicion of confused medicine and conveys a very poor impression. The procedure outlined should help to avoid this problem.
Billing is well covered in most standard guides to practice management and health services administration. This is no particular approach that is unique to occupational health care facilities. Even so, a few tips may be useful and suggested billing codes for common occupational health services may be particularly helpful.
Many occupational health services are repetitive and are usually performed by nurses and laboratory staff. To ensure standardization and reproduceability of common procedures, it is important to prepare written "protocols", or step-by-step guidelines, that can be used to train new staff, to remind current staff to perform the procedures systematically, and to check performance for quality control. Protocols are illustrated using tuberculin skin testing as an example.
Writing letters of consultation is a special skill that consultants must learn in order to be effective. An appreciation for this skill is helpful in knowing how to evaluate and how to request a consultation.
The worker-patient must be informed of where they are to go and at what time. The employer must be assured that the visit is being handled expeditiously and efficiently. The staff at each station should have a schedule of the appointments so that they can direct the worker-patient and assist in keeping his or her as close to the time scheduled as possible. Departments such as radiology and laboratory medicine must be informed to expedite occupational medicine cases. Color coding of request slips is a good idea to avoid unnecessary fumbling with papers. The staff should make every effort to return the employee to work, if warranted, as soon as possible. Note the time of departure on the encounter form. It is important to notify the employer and the workers' compensation carrier of the date the employee is to return to work or will be released for further medical treatment as soon as the date is known, so that compensation benefits can be terminated. If additional procedures are required (radiological or laboratory) that may prolong the appointment or require additional time, contact the employers carrier or the employer and inform them of the delay, giving an estimate of when the report will be available.
At the conclusion of the appointment, or as soon as possible thereafter, the employer should be contacted by telephone and informed of the status of each employee if there is any concern over the employee's fitness to return to work. The employer is not entitled to know the diagnosis, only whether the worker is fit to work at the assigned job and, if not, whether or when he or she can be expected to return to work. Paperwork should be done within 24 hours if possible. Delay in sending out forms, bills, and reports is a principal cause of dissatisfaction among employers. Communication by telephone between the client and group avoids another common source of friction - lack of timely notification.
Poor morale among clinic staff often is reflected by inappropriate or passive-aggressive behavior toward workers, especially if they present for seemingly a minor health problem or for a routine periodic health evaluation. Comments that a person can wait because he or she is "just an industrial case" are much more common than most physicians would believe because they are always said out of hearing. Such comments are very destructive, as they convey an impression to the worker that his or her case is not very important to the staff. These comments are also promptly reported back to the employer or to others in the workplace and undermine credibility in the occupational health facility. It is therefore extremely important for staff to cooperate in providing respectful, punctual, and efficient care.
The following is a sample registration procedure to expedite the handling of injured or ill workers who present to a facility for treatment. When a patient presents to one's office of facility with a health problem, the receptionist or nursing staff must determine whether the disorder is work-related or not and whether the worker has authorization from the employer to be seen. The following procedure is a step-by-step outline for receptionists and office staff to follow in handling the patient. This procedure is designed for hospitals, clinics, and physician's offices. Similar procedures for check-in, treatment, referral, and follow-up might be followed by in-plant facilities but authorization would be implied and billing procedures would not apply.
If a patient has been treated for an occupational injury but returns later for the same or a new injury, a new authorization must be obtained.
Date: _____________ Time In: ______________ Time Out: ___________ _________________________________________________________________________ To be completed by Employer To be completed by Clinic Treatment Administered: ___________________________ [ ] Office Visit - Injury Treatment Employee Name [ ] Recheck or redress ___________________________ [ ] Medication Company Name [ ] Physical Exam ___________________________ [ ] Physical Therapy Company Address ___________________________ [ ] Refer to Specialist Company Phone [ ] Return visit Date: _______ Time: _______ ___________________________ Workers' Compensation Courier Work Status: [ ] Return to regular work Date: _______ ___________________________ Authorized Signature Modified Work Status: [ ] Physical Exam [ ] Medical [ ] No prolonged standing or walking Services [ ] Physical therapy [ ] No climbing, bending, stooping [ ] No prolonged sitting Modified Work: [ ] No work near moving machinery [ ] Limited use: right - left hand [ ] Available [ ] Weight-lifting restrictions [ ] Not available [ ] Call back requested. __________________________________________________________________________ __________________________________________________________________________ __________________________________________________________________________ __________________________________________________________________________ __________________________________________________________________________ Signature of Physician: __________________________________________________
Billing information should always be kept in a separate file from medical records. This expedites handling of the bill while the case is being worked up, keeps confidential financial information from the attention of staff dealing with the patient, and avoids unintended release of billing information if the file is suppoenaed or otherwise shared with others.
Billing for occupational health services is much like billing for any medical service. The bill should specify the patient's name, date of encounter, type of service provided, and fee. The bill should not specify the diagnosis or provide any personal details regarding the worker-patient, as these are confidential and the employer is not entitled to such information, unless communicated appropriately to a qualified occupational physician or nurse. Bills submitted to the workers' compensation board (WCB) should cover only continued occupational injuries or illnesses or services for evaluating a claim under consideration. Bills for direct health care services unrelated to work should never be submitted to the WCB. Services of a preventive nature, such as fitness-to-work evaluations, are usually covered by the employer as a business cost. Again, the bill should never divulge the medical condition of the worker or any personal information.
Billing for routine medical services, such as treatment procedures, office visits, and laboratory tests, is highly standardized and usually automated these days. Medical services are typically coded by a standard numerical coding system; in California, this is the California Standard Nomenclature, based on a system that assigns a "relative value" to each service. For example, a brief initial office visit for a new patient to establish a relatively simple medical problem (90000) carried a value of 5.9 but a comprehensive initial medical evaluation (90026) carried a value of 17.5 and a consultation for a complex medical problem (90625) carried a value of 29.0. These relative values are multiplied by a "conversion factor" (or standard fee schedule) to arise at the final fee for the service billed to the insurance company. For example, the comprehensive initial medical evaluation (90026) as billed to the California Workers' Compensation Board in 1983 would have been 17.5 (relative value) X $5.40 (conversion factor in 1983), or $94.50. The relative values are permanent under this system but the conversion factors change annually, allowing periodic adjustments without the need to renegotiate every conceivable medical service, an extremely time-consuming process. Table 13.1 shows the fee schedule current as of 1983 in California. As can be seen, surgical services carry a higher conversion factor than medical services; the relative values are intended to be consistent within but not across specialties, to allow independent adjustments of the fees. In recent years, the fee schedule for workers' compensation in California has been increasing steadily and the medical conversion factors have been slowly gaining ground.
In other jurisdictions, the workers' compensation fee schedule may be denied by other means. Since workers' compensation is a form of insurance, fees are responsive to the level usual and customary fees charged to insurance carriers in the state but are usually not quite as generous. With all these factors, there is great variation among states in the fee schedules payable for workers' compensation services. In Canada, services are typically paid at the same rate as stipulated in the fee schedule for the provincial health insurance plan and are even billed to the same agency; the only difference, ultimately, is from which account the bill is paid. The provincial insurance plan simply "back-bills" (charges for reimbursement) the workers' compensation board. This system avoids the common problem in the United States of having a bill hang in limbo, unpaid, while the insurance carrier and the workers' compensation board argue over whether the injury or illness is work-related.
A set of model service codes for specialized occupational medicine services compatible with the California Standard Nomenclature (CSN), has been developed to facilitate billing. These are presented in Table 13.2.
The majority of clinical services
provided by occupational medicine
practitioners are comparable to those
already encoded in the CSN, differing
only in the cognitive skills of the
practitioner. A few common services are
unique to occupational medicine, however,
because they pertain to on-site plant visits,
extensive consultations with employers,
and urgent consultations to deal with a
hazardous situation or other problem.
These services have no identifiers in the
present CSN, but occur sufficiently often
to require a code number for billing and
data management purposes.
"The 1974 Revision of the 1969 California
Relative Value Studies, Fifth Edition,
Revised, is hereby adopted and
incorporated herein by reference as
though set forth in full, including
procedures, unit values and follow-up
"The following conversion factors are
hereby adopted to be applied to the
sections contained in the official fee
schedule approved by the Division of
Industrial Accidents, State of
Medicine Section $ 5.40 Surgery Section $ 140.00 Radiology Section: Total Service $ 11.20 Professional Component $ 1.70 Pathology Section $ 1.35 Anesthesia Section $ 31.50
Proposed Numerical Codes for Specialized Occupational
Health Services Provided by a Physician, Compatible With California Standard Nomenclature
Suggested Code Name of Service Description of Service and Relative Values 98001 Initial On-Site Visit to client's location to (18.5) Consulation ascertain client's needs, requiring approximately 1 hour. 98011 Initial Office Visit by client to provider's office (17.5) Consulation to ascertain client's needs, requiring approximately 1 hour. 98101 Consultation Visit, Visit to client's location to evaluate (22.0)* On-Site a particular problem. 98131 Routine Telephone Telephonic consultation concerning an (BR) Consultation uncomplicated problem, approximately 30 minutes duration. 98201 Health Hazard Extensive survey and evaluation (BR) Evaluation of problem, may require team of professionals.* 98301 Follow-Up, Visit to plant to evaluate progress, (26.1) Limited approximately 3 hours. 98302 Follow-Up Visit to plant to assess progress in (15.5)* Evaluation resolving a complex situation. 98401 Emergency Visit, Visit on short notice to client's (29.0)* On-Site location to assist with problem which is urgent. 98431 Emergency Telephone Telephonic consultation on an urgent (BR) Consultation problem not requiring presence on-site, approximately 30 minutes. 98501 Instructional Visit, Visit to client's location to arrange (13.0) On-Site or present a scheduled instructional program. 98921 Consultation Time spent in research, report (15.5)* Services preparation, or conceptualizing approach and solution to problem. * Per hour ** Members of such a team may include industrial hygienists, safety engineers, epidemiologists, toxicologists, and specialized technical personnel as appropriate. BR By report, fees to be determined on an individual basis.
The 1974 RVS has a gap in the numerical sequence in the 98000 series; these numbers are also unused in the AMA Current Procedural Terminology. Why this gap exists is not know. The proposed coding system is based on the following scheme: 98XXX The third digit represents activity (0 = exploratory discussion, 1 = consultation, 2 = health hazard evaluation, 3 = follow-up, 4 = emergency, 5 = scheduled activity such as an educational presentation, 9 = research and literature review). The fourth digit represents location (0 = client's data bank, 3 = telephonic communication). The fifth digit is a specific identifier. This scheme has been flexible enough to cover all situations encountered but has ample latitude for expansion. The relative values assigned to the codes are mutiplied by a specific fee schedule that is regularly revised.
The obsolete code 99060 "environmental intervention" should be abandoned as inadequate for describing occupational medicine services. Codes already exist for periodic health evaluation (90088, relative value 11.0), multiphasic health testing (99090) preparation of special reports (99080), and administration of a programmed medical interview (99095). Except for 90088, fees for these services are all "by report", or at the discretion of the patient.
Each service represented by a code has a fee associated with it, usually reviewed and updated once or twice a year. Fee schedules are usually kept in a computer file that can be easily updated. Nurses, physicians, and other medical staff keep track of services rendered to patients on charge slips, usually checking off common services from a long check-list and writing in codes of more unusual services. Data from these charge slips are entered into the computer, which automatically matches the codes with the current fee schedule and generates the bills.
It is often useful to keep track of the types of services being delivered to employees of a particular company as a means of tracking that company's occupational health and safety performance and need for preventive services. Also, such information may reveal that a company is utilizing the facility only for a narrow range of services - such as acute care for work-related injuries - and could be approached by marketing personnel for other services such as preplacement or periodic evaluation.
Consultation services are usually more individualized. Examples of consultation services include evaluating the validity of a workers' compensation claim, reviewing a case under litigation for medical evidence, giving testimony as an expert witness, advising on corporate policy or procedures, and designing a screening protocol for workers exposed to a particular hazard at a plant. These services do not lend themselves to the usual billing arrangement. An accepted format for such bills is given in Table 13.3.
In occupational medicine, it is desirable that procedures be standardized whenever possible and that they be defensible later if a claim is questioned. This is especially true for diagnostic or screening tests applied to large groups of workers. As a practical matter, it is usually most convenient to write a protocol, a step-by-step guide to the conduct of a particular test or procedure. Such protocols should spell out the steps to be taken, those to be documented, quality control measures, and contingincies in the event of problems. Protocols should be developed with input and review from all parties concerned, including physicians, nurses, administrators, medical records personnel, and technicians. A simple but complete protocol can greatly reduce confusion and expedite the efficient processing of patients. They are absolutely necessary when many subjects are to be tested in the same way or when testing is to be done in more than one location by different personnel.
A written protocol is also
invaluable for teaching new staff and for
reviewing procedures with existing staff.
It lends itself to use in developing
criteria for evaluating the performance
of staff, as described in Chapter 31.
The very act of writing a protocol
forces one to think about each step in
the procedure and in so doing to identify
points at which decisions must be made
and where efficiencies can be introduced.
Table 13.3. Billing Format for Consultation Services
Re: (Patient or Plant Name, File Number)
To: (Employer's Name)
Attention: (Official Responsible)
Medical and consultative services rendered:
1. (Nature of activity) X hours at $XXX/hour $ XXX 2. " " 3. " " (etc.) ________ TOTAL $ X,XXX
Thank you for your prompt attention.
(Social Security Number)
The following example of a
protocol is for tuberculin skin testing,
an inexpensive and reliable screen for
exposure to tuberculosis. It was
designed to permit standardized,
reproducable testing to be done by nurses
in several locations of a multi-centered
medical group in compliance with accepted
procedures. Most protocols for this
purpose will likely be simpler but this
example shows the concept.
NOTE: A separate Appointment Book will be utilized and non-contract patients notified of pre-payment fee.
(Examination Room if available, or urses Station).
NOTE: If the patient's answer is "yes" - DO NOT TEST THE PATIENT. If the patient is unsure - seek medical (physician) assistance.
If the answer is "yes" - seek medical assistance
Tuberculin Syringe with #27-1/2 needle
(Sterile Technique) Solution of Purified Protein Derivative
(5 ml. vial - use 0.1 ml.)
Alcohol sponge Felt marking pen
If the patient delays beyond 72 hours, seek medical assistance in interpreting the test. NOTE: Tests cannot be read before 48 hours have elapsed.
If you feel a hard, button-like, firm area of "induration" in the skin, note where the edges are located.
Record this measurement in millimeters (mm).
A good letter of consultation should be concise, informative, helpful to the referring physician or agency, and as specific as possible in recommending measures for the patient's benefit.
Two actual letters of consultation are reproduced below. The first was prepared by an experienced occupational physician dealing with a very complicated case. It summarizes the case in enough detail to stand alone as a record, clarifies the issues of primary concern, stipulates what steps were taken with regard to medical confidentiality, educates the referring physician without assuming a condescending tone, outlines the recommended management of the case, and ends cordially. Compare this with the second letter, written by a full professor at a (non-Canadian) prestigious medical school. Despite the second clinician's excellent credentials, his consultation report is utterly useless by comparison to the first.
The first consultation report is recommended as a model to follow:
RE: Mr. A. __________________________
Dear Dr. B:
Thank you for referring Mr. A to
us for evaluation. I have also
received the subsequent
communication from Dr. C,
Occupational Health physician for
the D Corporation. I have
discussed with Mr. A the
propriety of sharing information
with Dr. C and have obtained his
written permission to disclose
pertinent information. He has no
objection and the corporate
policy of the D corporation
precludes communication of
confidential information from the
Occupational Health service to
management. Thus, by copy of
this letter I am reporting to Dr.
C as well in communicating our
Mr. A's history is well known to
you but I shall summarize it for
the record. He is a 32 year-old
male chemical plant worker who
since November 1985 has had a
series of unexplained
abnormalities on blood tests
taken as part of his routine
periodic health surveillance.
The cause of his mild liver
function abnormalities is not
clear but may be associated with
exposure on the job or endogenous
causes of which there are two
candidates. Mr. A has had a
persistant abnormality of his
serum cholesterol, raising the
possibility of an
hyperlipoproteinemia. He is also
an obligate heterozygote for one
of the mucopolysaccharidoses,
which affects his son.
His past medical history is
unremarkable except that his
family history is very strong for
coronary artery disease and
stroke in all close relatives.
He does not smoke and has not
drunk alcohol for at least eight
years. He is on a diabetic diet
but is taking no medication
except diclofenac for back pain
as needed. (This drug is known
to elevate transaminases and can
cause jaundice and hepatitis.)
He has no known allergies. He
has no history of hepatitis or
mononucleosis and has received no
Physical examination showed a
normal liver span and no palpable
spleen. He showed no xanthomata
although he did have
hyperpigmentation over his shins.
Examination of his pattern of
abnormality shows little
discernible pattern with the LDH
and the alkaline phosphatase
elevated. The transaminases are
variably elevated, only once
being synchronous, on 18 July
1985. In each case the
elevations have been minor,
except for the elevated SGPT on
that date. By comparison,
however, the serum cholesterol
has been consistently elevated
and the triglycerides have been
consistently and markedly
elevated. A lipoprotein
electropheresis was performed on
the request of Dr. C, of the D
Corporation, on 27 November 1986.
This shows an elevated pre-beta
and beta bands interpreted as
being either a primary or
secondary type 11B pattern.
This presents us with a very
interesting diagnostic dilemma.
I have reviewed what little
literature exists on the liver
function of individuals with this
disorder and have consulted with
our local University Hereditary
Diseases Program in an effort to
search out what is known. Liver
function abnormality in children
affected with the disorder
apparently occurs quite late as a
result of the storage disease and
is nonspecific in its
presentation. Although we can
find no specific report of
heterozygotes being tested for
liver function abnormalities, its
absence in the early stages of
homozygotes strongly argues
against its presence in their
parents in the absence of another
cause. Logically, there is no
reason why the heterozygote
condition should interfere with
normal liver function. Thus, I
think that we can safely dismiss
this as a cause of his condition.
Occupational exposures are of
concern. His most significant
exposure is benzene but there are
several other chemicals in the
two units in which he works that
could be hepatotoxic. In each
case, however, for
these chemical to cause
abnormalities he would
have had to have been
exposed at very high
concentrations do not
appear to be at all
likely in his
pattern of the
abnormality also argues
against a chemical
hepatitis, since one
would expect the
transaminases to be
elevated. Thus, I
believe that we can
is unlikely to be the
Mr. A does, clearly, have a type
IIB hyperlipoproteinemia and
given the family history it is
almost certain primary. He
clearly is significantly affected
clinically and is at some risk if
his elevated serum cholesterol
level is not brought under
control. It is my conclusion
that his unusual pattern of liver
function abnormalities probably
is the result of a low-grade
fatty liver associated with his
hyperlipoproteinemia. This would
explain its variable
presentation, the lack of
abnormalities, the occasional
elevation of the alkaline
phosphatase (which would be quite
unusual in chemical hepatitis)
and its association with the
Given the history and the
relatively benign clinical course
of his condition, I would be
reluctant to recommend a liver
biopsy. You may, however, be
more confident in the diagnosis
if a liver scan is performed to
rule out a space-occupying lesion
or if a serum 5'-nucleotidase is
elevated, confirming the
hepatitic origin of the elevated
alkaline phosphatase in the
absence of an elevation in the
bilirubin, since this pattern is
characteristic of fatty liver. I
would suggest following Mr. A
very closely because of his
hyperlipoproteinemia but I would
consider the liver function
abnormalities a very minor part
of the problem likely to correct
itself when the lipid abnormality
is brought under control.
Thank you very much for
referring this most
interesting case. I must
say I enjoyed sorting it
out and appreciate the
opportunity. Please let me
know how he gets along and
please do not hesitate to
give me a call if I can be
of further assistance.
The following example is not
recommended. Indeed, it is appalling to
think that a medical consultant would
actually have sent such a letter in
response to a serious referral.
It is presented just as it was received:
Dear Dr. X:
I examined Ms. Y after reviewing
the reports you kindly sent me.
Her symptoms are of 3 kinds.
Other provoking factor--photocopying devices, manufacturing area of her present job.
This set of symptomatology is
dated from the visits to the Z
factory between March and May,
1982, that were previously
Environment at home-- no unusual
exposures or contacts. Has 2
Siamese cats for many years. Now
Mrs. Y wants to know if her
reactions can be cumulative and
cause permanent illness. She
does not want to undergo standard
diagnostic allergy tests, but
would prefer a blood test that
could be checked regularly to
determine if she is improving.
Physical exam: BP 112/80
T-36.8oC FEV1-2.6 L FVC=3.1 L
EENT, lungs and heart were within
normal limits. A cystic
acneiform eruption was present on
the cheeks and upper torso.
non-specific symptoms attributed
to various chemical exposures
dating to a series of
work-related factory exposures in
Note that in this consultation letter the clinical description is vague and not convincingly associated with the exposure on the job by the consulting physician, in part because the consultant appears to have had no idea of what exposures her actual job might have entailed. The note is awkward in style and there are mistakes in format (e.g. "symptoms of 3 kinds" when four are given) and wording ("These have been present to some degree for over 1 year and thus are not intermittent...") that suggests a very casual dictation and probably casual thinking as well. The findings on physical examination do not relate to the complaint (e.g. fluid retention is described in the complaint but no mention is made of the presence or absence of edema on examination). Cystic acne is very unlikely to be associated with the kinds of chemical exposure encountered in a department store or on exposure to lacquer, but no attempt seems to have been made to find this out. Instead, the consultant flies "by the seat of his pants" giving a very general opinion that will deprive the patient of her job for no good reason. The letter also does not address the patient's own concerns about monitoring her improvement but reports test results (pulmonary function tests) that seemingly have nothing to do with her complaints. Finally, the letter insults the referring physician by suggesting referral of the case to another physician to provide "a continuum of medical attention".
This second letter is an extreme example of how not to write a consultation letter. It incorporates almost every serious mistake a consultant can make and therefore is well worth studying as an example of what to avoid.
Just as it is a responsibility of
the consultant to be responsive to the
questions being raised, it is incumbent
on the referring physician or agency to
state clearly what is being asked. The
following sample consultation form
contains most of the basic information a
consultant in occupational medicine needs
to know initially and provides a
convenient format for requesting a
consultation when required.
Patient's Name: ____________________ Insurance #: _____________________ Address: ___________________________ No Insurance #: ( ) Check ___________________________ Phone: ___________________________ Referring Physician: ___________________ AHCIP Referral #: ____________ Address: _______________________________ Physician's Phone: ___________ _______________________________ Specialty: ___________________ Patient's Current Occupation: _________________________________________ Occupational Status: ( ) Employed ( ) Disabled ( ) Unemployed ( ) Retired Chief Complaint: ______________________________________________________ What Questions Do You Wish Us to Address?: (Please use reverse of this sheet if needed.) _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ Other Physicians Who Have Evaluated Patient For This Problem: _________ _______________________________________________________________________ _______________________________________________________________________ Do You Wish Us to Telephone Our Findings Immediately?: ( ) Yes Date of Request: _______________ Doctor's Signature: _________________
California Medical Association. California Standard Nomenclature. San Francisco, Sutter Publications, 1979.
California edical Association. California Relative Value Studies, 1974 Revision. San Francisco, Sutter Publications, 1975.
Official Medical Fee Schedule for Services Rendered Under the California Workers' Compensation Laws. San Francisco California Workers' Compensation Institute, 1980, updated annually.