Proper Submission of Required Reports

Medical reports are required under Wisconsin Administrative Code section DWD 80.02 (2)(e) whenever:

• Temporary disability exceeds 3 weeks; OR
• Permanent disability has resulted from the injury; OR
• The injured worker has received treatment for an eye injury 3 or more times outside the place of employment; OR
• The injured worker has undergone surgery as a result of injury.

Submit medical reports to the Division when:

• The injured worker has been released to return to work; OR
• Has reached maximum medical improvement (MMI) at the end of the healing period

Overview

An employee who reports a work-related injury waives any physician-patient privilege with respect to any condition reasonably related to the condition for which the employee claims compensation.

The health care provider shall, upon request, provide any party or the department with requested information or written material reasonably related to the injury.

The allowable charges for copies of certified medical records are the greater of 45 cents per page or $7.50 per request plus the actual cost of postage. Charges for paper copies of medical records sold to the patient or a person authorized by the patient to receive the medical records are not subject to Wisconsin sales tax. In addition, sales of electronic copies of medical records that are transmitted electronically are also not subject to Wisconsin sales tax.

Practitioner's Final Medical Report:

A treating practitioner may charge a reasonable fee for the completion of the final report, but may not require prepayment of that fee. If there is a dispute regarding the fee being charged for the report, the dispute may be submitted to the department for resolution under s. 102.16 (2) Wis. Stats.

A treating practitioner may charge a reasonable fee for completing a final report not to exceed $100.

1. Patient information
2. History & diagnosis
3. End of Healing (or Maximum Medical Improvement) information
4. Permanent disability information (stated below are some additional requirements):
1. Finger injuries
• Complete both sides of the medical report
• Submit comparative x-rays for all amputations beyond the distal joint
• Dominant hand identification is needed when an amputation is greater than 2/3 of the distal joint
2. Eye injuries
• Complete form WKC-16A
3. Knee injuries
• If surgery was performed, need type & number of procedure(s)
• Copy of all operative reports should be submitted
4. Back injuries
• If surgery was performed, state type & number of procedure(s) and number of spinal levels involved
• Copy of all operative reports should be submitted
• Prior disability & prognosis
• Physician /Chiropractor signature

• Physicians, chiropractor, psychologist, psychiatrist, podiatrist and dentist
• • Advanced practice nurse prescribers, dentists and physician assistants can sign the medical report and diagnosis the disability; however, they cannot determine if injuries were work-related or assess temporary or permanent disability.

Overview

A medical report will be considered to be a "final report" when:

• the doctor has stated whether or not any permanent disability has resulted from the injury
• the last examination established an end of healing and the employee has been released from treatment, or is treating strictly to prevent further deterioration in the condition of the employee or to maintain the existing status of such condition
• the report was completed by the treating physician, podiatrist, surgeon, psychologist or chiropractor.
• Doctors of dentistry, physician assistants and advanced practice nurse prescribers may not complete a final report addressing the extent of disability
• the rating given is based on the Wisconsin Administrative Code Section DWD 80.32, rather than AMA or other guidelines

Use of WKC-16 Medical Report On Industrial Injury

• Sample of form WKC-16
• The WKC16 medical report should be requested from the treating physician, when an end of healing has occurred
• The WKC16 medical report should be requested from the treating physician when permanent partial disability has been assessed.

• Sample of form WKC-16B
• WKC-7760-P - Guide for Wisconsin Doctors - Using the WKC-16B for Worker's Compensation
• Injured worker has applied for a Hearing
• Insurer would like physician to complete in order to provide competent medical testimony without necessity of having the physician take time off from their schedules to appear at the hearing

WKC-12-E, Employer's First Report of Injury or Disease

This form is for the employer to report every work-related injury to its insurance company. If an employee is out more than 3 days due to a work-related injury, or there is PPD, a copy is to be sent to the Worker's Compensation Division by the employer's worker's compensation insurance carrier, not by the employer (unless the claim is a fatality). Except for fatalities, the information on this form must be sent electronically by the employer's worker's compensation carrier to the WC Division.

The following contains some brief instructions that will help you to write better injury descriptions. These consist of three basic parts: cause of the injury, nature of the injury and objects/substances/activities involved in the injury. Descriptions should be specific, concise and to the point

1. Cause of the Injury

This part of the description answers the general question "what was the employee doing when the accident occurred?" Give us specific details about the activities involved. Some examples include "carrying boxes across the factory floor", "driving a fork lift", "operating a deep fryer", etc.

2. Nature of the Injury

This part answers the question "what is the injury?" The answer should include the part of body affected, on what side of the body the injury occurred (if applicable) and how the body part was affected. For example, "fractured left wrist", "contusion to forehead and neck strain", "2^nd degree burn both hands and stomach", etc.

3. Objects/Substances/Activities Involved

The specific question "what was happening and what was involved at the moment the injury occurred?" is answered by this part of the injury description. Discuss the immediate cause of the injury and anything involved. For example, "tripped over pipe and fell", "forklift struck door frame, hit head on roll cage", "dropped basket into fryer, hot grease splashed up onto employee", etc.

Overview

The employer must complete all relevant sections on this form and submit it to the employers workers compensation insurance carrier or third party administrator within seven (7) days after the date of a work related injury which causes permanent or temporary disability resulting in compensation for lost time. The employer's insurance carrier or third party administrator may request that this form also be used to immediately report any injury requiring medical treatment, even though it does not involve lost work time.

For any work injury resulting in a fatality the employer must also submit this form directly to the Department of Workforce Development within 24 hours of the fatality. The form can be faxed to (608) 267-0394 or reported by calling (608) 266-1340.

An employer exempt from the duty to insure under s. 102.28, Wis. Stats., and an insurance carrier administering claims for an insured employer are required to submit this form to the Department or Workforce Development within 14 days of the date of work injury.

Mandatory Information

In order to accurately administer claims each of the following sections of this form must be completed.

Employee Section: Provide all requested information to identify the injured employee. If an employee has multiple dates of employment, the "Date of Hire" is the date the employee was hired for the job on which he or she was injured.

Employer Section: Provide all requested information to identify the injured workers employer at the time of injury. Provide the name and Federal Employer Identification Number (FEIN) for the insurance carrier or self-insured employer responsible for the workers compensation expenses for this injury. Also identify the third party claim administrator if applicable.

Wage Information Section: Provide the information requested regarding the injured employee's wage and hours worked for the job being performed at the time of injury.

Injury Information Section: Provide information regarding the date and time of injury. Provide a detailed description of the injury, including part of body injured, the specific nature of the injury (i.e. fracture, strain, concussion, burn, etc.) and the use of any objects or tools (i.e. saw, ladder, vehicle, etc.) that may have caused the injury. Provide the name of the person preparing this report and the telephone number at which they may be reached if additional information is needed.