The Surgical Quality Care Program (SQC Program) is a quality improvement initiative. It rewards participating musculoskeletal surgeons for consistently implementing our occupational health best practices. These best practices are designed to improve the outcomes of workers injured on the job.
What this means to the patient
Surgeon(s) that are engaged in administrative best practices address:
- Utilization of the department’s Medical Treatment Guidelines and Opioid Prescribing Guidelines
- Remove obstacles that inhibit the workers’ release to work
- Utilization of their Surgical Health Services Coordinator (SHSC) as a resource to answer questions and help navigate the workers’ care
What this means to the surgeon and their clinic
The SQC Program offers surgeons and their clinics both financial and non-financial rewards.
- Monetary incentives proportional to best practice adoption (See the Provider Incentives tab to learn more).
Participation in the SQC Program offers tools and resources that are not readily available. These may include:
- Performance reports to identify trends
- Access to an SHSC
Benefits tied to the occupational health best practices
How the SQC Program’s six occupational health best practices (BPs) are meaningful to the patient.
|Best Practice (BP)||Significance||Expectation||Performance Threshold|
|Best Practice 1: Appropriate Opioid Prescribing (mandatory for any incentive)||
|Best Practice 2: Utilization Review (mandatory for medium adoption level incentive and above).||
|Best Practice 3: Complete and submit an Activity Prescription Form (APF) before and after surgery.||
|Best Practice 4: Perform surgeries within 21 days of authorization.||
|Best Practice 5: Before surgery, establish release-to-work plans and goals with the patient.||
|Best Practice 6: Review and integrate communications from ancillary providers into the rehab plan.||
|Important things to know:
* Emergent surgery is defined as injury date followed by surgery within 11 calendar days.
* * Although opioids are often indicated to manage severe acute postoperative pain, recent studies show that patients often receive more opioids for home use than are necessary for pain related to many procedures. There is no optimal number of pills for a given procedure, but this measure is intended to serve as a general framework for managing postoperative pain, while minimizing leftover pills. The measure does not preclude a surgeon from issuing a second prescription for more complicated procedures if the patient needs more than 7 days of opioids. For those exceptional cases that warrant more than 14 days of opioid treatment, the surgeon should re-evaluate the patient before refilling opioids and taper off opioids within 6 weeks after surgery. 7 days is measured from the days filled portion of the prescription only.
SQCP participating surgeons should use the following codes once the informational reporting is complete and their updated adoption levels are determined:
Billing Code: 1086M
Service: Best Practice Incentive - Surgical
Description: Billed and payable at initial visit/consultation with worker.
Maximum Fee: Payable once in the life of the claim per surgeon for the first two surgeons. Payment level based on assigned adoption level for each individual surgeon. Fees effective January 1, 2024. The first two providers will be assessed through dates of service on billing, so the first bills to be received will be those which are included in this calculation. Refer to MARFS (January 2024 update) for more information.
- Sustaining Adopter: $525
- High Adopter: $305
- Medium Adopter: $230
- Low Adopter: $155
- No Adoption: $0
- Not payable to ARNPs or PA-Cs.
- Still payable during the Global Surgical Period.
- Not tied to the Activity Prescription Form (APF).
- Payment based on adoption level from the last scheduled reporting.
An adoption level will be assigned to each SQC Program participant as determined by how thoroughly the surgeon has implemented the occupational health best practices over the six-month review period.
- No Adoption:
- Fails to meet best practice 1 (appropriate opioid prescribing), AND
- Does not meet Low Adopter requirements.
- Low Adopter:
- Must meet best practice 1 (appropriate opioid prescribing), AND
- One other best practice (best practice 2 - 6).
- Medium Adopter:
- Must meet best practice 1 (appropriate opioid prescribing) and best practice 2 (75% utilization review), AND
- Two other best practices (best practice 3 -6).
- High Adopter:
- Awarded exclusively to surgeons that achieve a Utilization Review of 85%, AND
- Meet or exceed the threshold for all the remaining best practices (best practice 1, 3, 4, 5, and 6).
- Cannot be achieved without the services of a Surgical Health Services Coordinator (SHSC).
- Sustaining Adopter:
- Meets High Adopter requirements for consecutive reporting periods (18 months).
The SQC Program is restricted to musculoskeletal surgeons who:
- Regularly perform surgeries as Hand, Orthopedic, or Neuro surgeons*.
- Are credentialed within the L&I MPN with an active L&I provider ID.
- Provide treatment for state-fund or self-insured workers.
- Have a completed, signed, and accepted SQC Program Supplemental Application.
* Podiatrists within a surgical clinic are also eligible to participate.
Providing Timely Reporting:
The department would like to provide timely and actionable provider reporting. For this to occur, SQC Program requests that all Activity Prescription Forms (APFs) be submitted electronically (through either Health Information Exchange or through direct entry on My L&I).
The Surgical Health Services Coordinators (SHSCs) help providers, workers, and employers in many ways.
Learn more about Health Services Coordination, qualifications, and standard work that is performed.
Benefits of having an SHSC
- Reduce transition times to and from surgical care.
- Assist workers, employers and health care providers navigate L&I processes.
- Identify and mitigate barriers to treatment, recovery and return to work.
- Improve release/return-to-work planning.
- Removes some of your administrative burden by responding to requests from claim managers, vocational counselors and employers.
A clinic may either be the SHSC's employer or the SHSC’s client through a community resource.
While SHSCs are not L&I employees, some community health care partners offer SHSCs. Reach out to us for more information.
SHSC billable services
SHSCs must first get an L&I Provider ID in order to bill services to state-fund claims.
|Surgical Coordination Intake (SCI)||1083M||Payable once in the life of the claim||$160.43|
|Surgical Health Services Coordinators’ Standard Services||1088M||Billable in six-minute increments for activities that remove claim/treatment barriers or positively influence the recovery and/or release to work.||$9.87|
Frequently Asked Questions
Workers' compensation patients are different in two key ways. First their coverage is limited to the impact of the work injury or illness. Second, their claim manager is tracking both their medical and return-to-work recovery.
The L&I team is working with all surgeons, whose clinic participates in the Ortho-Neuro Project, to transition them to SQC Program. If your surgical clinic does not currently participate, please contact us at SQCProgram@Lni.wa.gov and we will place you on an enrollment wait list.
SQC Program reports will be produced 90 days after the reporting period ends. Reporting will be quarterly, with reports for 1/1/23 - 3/31/24 being informational to allow surgeons and their clinic managers to adjust to the new best practices. Electronic submission of the Activity Prescription Form is an important part of timely and accurate reporting.
This best practice program is designed for musculoskeletal surgeons. We are able to enroll podiatrists who are part of a participating surgical clinic. At this time, we have no plans to expand to other surgical specialties.
L&I does not plan to enroll PA-Cs or ARNPs into the SQC Program at this time. Access to Surgical Health Services Coordinators (SHSCs) services are available to all mid-levels within participating surgical clinics.
Best practice programs are voluntary and supplemental applications outline all program requirements and expectations. A new supplemental application is required of all providers participating in the SQC Program.
We will work closely with participating clinics to determine specific target dates. Provider performance measures start 1/1/2024 and will count towards their updated adoption/incentive level. We recommend hiring an SHSC before that time. Please note that there is standard work, training, and review for these roles that should be considered as part of the overall hiring target date.
A SHSC does not need to be a full time resource, and a SHSC can be shared with another surgical clinic. The Surgical Best Practice Pilot showed that SHSCs help surgeons, workers, and employers.
Community SHSC resources are available through our COHE health care partners. L&I will make them aware of each surgical clinic needing their assistance. If they have capacity, they will be available to support the requesting surgical clinic with SHSC services.
L&I has developed online training specifically for SHSCs. L&I will spend time training them on care coordination software (MAVEN/OHMS), and will monitor SHSC performance through qualitative and quantitative reporting. Performance is shared with the surgical clinics and the SHSC. Lastly, L&I holds regular SHSC meetings to answer questions and share information, as well as a voluntary training for all SHSCs/HSC every two years.
Surgeons are not required to be the attending provider on a claim, but it does make communication and coordination with L&I claim managers easier if the surgeon becomes the attending provider during the global surgical period.
L&I requests that all participating surgical clinics disenroll from COHE. Most surgical clinics signed up for COHE because they wanted access to health service coordinators, which is now available through SQC Program. In addition, surgeons feedback has been that there is confusion between COHE and surgical best practices. SHSCs will support best practices both early in the claim and during the surgical period. We recommend surgeons disenroll from COHE within 90 days of hiring an SHSC.
You or your PA-C should sign off on the Physical Medicine Progress Report (PMPR) to confirm that you are informed about the worker's rehabilitation plan and so that you can collaborate with the PT/OT to make adjustments as needed.
If you don't document your released to work conversation with the worker as part of your chart notes, your SHSC will not be aware of it and cannot document it as part of the fifth best practice. As a result, you will have a lower adoption/incentive level.
As part of our continuous improvement evaluation, we reviewed Ortho-Neuro reporting and found that reporting at a group level did not clearly communicate best practice performance to individual surgeons, nor did it serve as an incentive for improvement for those surgeons who performed lower than the high adoption level, but received high adoption incentives.
Surgeons transitioning from the Ortho-Neuro project will receive multiple informational reports prior to any change. Adoption/incentive levels will be updated in October 2024. Surgeons who are new to the program will enter at a low adoption level until a reporting period is complete and data is available.
Yes! If you complete an APF because a worker has a change in capacity or restrictions, please bill 1073M for the APF. 1071M (the Ortho-Neuro incentive billing code) should not be billed on new patients beyond 12/31/2023.
1086M is charged once, upon the surgeon's first visit with the worker. It is not tied to the APF. This incentive is paid for the first two surgeons on the claim. When designing this updated incentive, the L&I team wanted it to be easier to use and reflect the full spectrum of best practice care.
If a worker is not seeing you for the first time for a specific condition, we ask you to review the number of incentives (1071M) you've already charged. If you've charged two or more 1071Ms for the worker, do not use 1086M or 1071M after 12/31/2023. Your incentive has reached its cap for the worker. If you haven't charged two or more 1071Ms for a worker, please charge the 1086M at their next visit.
Please contact the SQC Program Lead to get exception approval when you are the third surgeon or more to see the worker: SQCProgram@Lni.wa.gov.
- SQCP Quick Reference Card.pdf
- Surgical Health Services Coordinator Comprehensive Manual and Toolkit
- Surgical Quality Care Program Manual
- Surgical Health Services Coordinator’s Supplemental Provider Application for Surgical Quality Care Program
- Musculoskeletal Surgeon’s Supplemental Provider Application for the Surgical Quality Care Program