BWC relies on managed care organizations (MCOs) to gather pertinent medical documentation from all treating providers
to make a decision about claim allowance. To perform this function efficiently, BWC, MCOs and providers need to know
the guidelines and criteria. BWC uses the medical documentation contained in the claim file as critical evidence in
making the decision. This evidence becomes even more critical when the claim is set for a hearing.
BWC developed a quick reference, BWC Diagnosis Determination Guidelines,
to provide criteria for diagnosis determination/coding decisions between BWC and MCOs for the 30
diagnosis/International Classification of Diseases (ICD-9) codes used most frequently The guidelines list the ICD-9
code with the diagnosis narrative description, subjective and objective exam findings, diagnostic tests (if applicable)
and findings for diagnosis substantiation.
You can view and/or download the BWC Diagnosis Determination Guidelines. Use them as reference tools. Do not use them
to direct medical care or to authorize medical treatment
