Recent Development in the 1010 Process in Louisiana Workers’ Compensation Law
Evaluation and Management Visits
This fall, the Louisiana Administrative Code was revised to provide clarification as to an employee’s request and an employer’s/insurer’s approval of routine evaluation and management (“EM”) visits. An EM visit is defined as a routine visit with an employee’s treating physician for the purpose of documenting the employee’s functional improvement from previously authorized medical care, service and treatment. These visits are billed under the following Current Procedural Terminology Codes: 99201 through 99205 and 99211 through 99215.
Louisiana Workers’ Compensation law currently provides that a health care provider shall not incur more than a total of $750 in non-emergency diagnostic testing or treatment without the mutual consent of the employer/insurer and the employee. As EM visits are considered “treatment,” they have always required this mutual consent in the form of a signed 1010 Form IF the total treatment exceeded $750.
The Louisiana Administrative Code was amended to remove the administrative burden of having to submit and review a 1010 Form for every EM visit after the $750 threshold has been met. However, this revision still requires 1010 Forms for EM visits in certain circumstances.
LAC 40:2715(D)(2) now provides that a 1010 Form shall be required to initiate the request for authorization of the first EM visit that occurs beyond the $750 threshold. If this initial 1010 Form is approved as medically necessary, a 1010 Form shall not be required for any subsequent EM visit with the employee’s treating physician within the first year of the accident date, but not to exceed 12 visits (including any EM office visits prior to the first 1010 Form). An employer/insurer may deny any of the 12 EM visits for reasons other than medical necessity (i.e. causation, compensability and medical relatedness).
A 1010 Form will then be required for an EM visit after the 12th visit or after one year from the date of the accident. If that 1010 Form is approved as medically necessary, a 1010 Form is only required on every fourth EM visit thereafter. The employer/insurer may authorize more visits over a defined period of time and may deny any EM visits after the 12th visit, or after one year from the accident, as not medically necessary.