About

What is the Activity Prescription Form (APF)?

Providers complete APFs to communicate the worker’s:

  • Ability to work
  • Functional capacities
  • Physical restrictions
  • Treatment plan

APFs are also used to help:

  • Employers develop modified work plans while their worker is recovering.
  • L&I claim managers understand the worker’s ongoing treatment and medical progress, and to authorize time-loss benefits.
  • Vocational rehabilitation counselors (VRCs) build appropriate return to work plans.
  • Workers understand what they can do. It can be used as a motivator in their healing process.

Who may ask the provider to complete an APF?

  • The Claim Manager
  • The worker’s Vocational Rehabilitation Counselor (VRC)
    • A VRC may request an APF to clarify or update information about the worker’s physical capacity or condition.
  • Self-Insured Employers (SIEs) or their 3rd party administrators
    • May request, but the APF is paid for by the employer

NOTE: L&I does not pay for APFs completed at the request of:

  • Attorneys, or
  • Employers covered by L&I

Record keeping

If there are multiple claims for a worker, put all claim numbers on the:

  • APFs
  • Bills
  • Chart notes
  • Reports
  • Give a copy of the APF to the worker, so they can show it to their employer
  • Keep APFs, chart notes, reports and other information in your files for a minimum of 5 years for audit purposes.

Other forms employers may request:

Employers may contact their worker’s attending provider to clarify what work he or she may do safely during recovery by asking him or her to:

You can remind employers to review the completed APFs that are a part of the worker's claim file in the Claim & Account Center.

Questions?

For questions about the APF - call the Provider Hotline 1-800-848-0811.

Frequency

When does the provider complete the APF?

According to occupational health best practices, an APF should be submitted:

  • With the Report of Accident (ROA) or Physician Initial Report (PIR)
  • For time-loss claims, within 4 weeks of the claim established date
  • When documenting a change in the worker's:
    • Medical/work status
    • Functional capacities
    • Physical restrictions

When is the provider required to submit an APF?

If the worker: Then the provider must submit an APF:
Is released to work without restrictions.
  • With the Report Of Accident (ROA) / Provider’s Initial Report (PIR)
  • If you changed the worker’s capacities/restrictions
    • This includes removing restrictions
Has a simple injury without restrictions, such as a:
  • Simple eye injury
  • Laceration without tendon or nerve involvement
  • Only with the ROA/PIR
Has a simple injury with restrictions that do not require limiting the worker to light or modified duty.For example:
  • "Keep the wound dry by using a waterproof glove."
  • "Elevate the leg for 5 minutes every hour for 3 days."
  • With the ROA/PIR
  • If you changed the worker’s capacities/restrictions
    • Includes removing restrictions
Has work-related physical restrictions that must be followed in order to do light-duty work.
  • With the ROA/PIR
  • Within 4 weeks of claim established date
  • Whenever there is a change in:
    • Work status
    • Capacities/restrictions
    • This includes removing restrictions

Is an office visit necessary if L&I or the self-insured employer asks you to complete an APF?

If you: Office visit? Then:
Examined the worker within the last 30 days No Use information from your last visit as the basis for your opinion.
Are uncertain about the worker's current need for treatment or work restrictions or it has been more than 30 days since you examined this worker Yes Schedule an appointment with the worker as soon as possible.
Are no longer treating this worker No Notify L&I you are no longer treating this worker
Concluded treatment Yes Complete the portions of the APF that apply to the worker's medical status when you conclude treatment, including the "Plans" section. Note: Includes removing restrictions
Completing

What information is the provider required to include on the APF?

Section of form: Required in this section:
General info Complete all fields:
  • Patient ID labels may be used
  • Diagnosis: Provide the primary diagnosis, reason for today’s visit
    • ICD codes or written descriptions

Work status One or more selections required. If making multiple selections, ensure there are no gaps between dates. It is okay to estimate dates.
Measurable Objective Findings (also referred to as Objective Medical Findings) If the worker is not able to return to full duty, Objective Medical Findings (OMFs) must be documentedExamples of acceptable OMFs:
  • X-rays
  • Swelling
  • Muscle atrophy
  • Increase/decrease range of motion (ROM)
    • Accompanying chart note must include measurements
OMFs must be verifiable and documented, for example:
  • Physical examination
  • Laboratory tests
  • Diagnostic procedures
  • Muscle spam
Examples of NOT acceptable subjective complaints:
  • Pain
  • Tenderness
  • Fatigue
Estimate what the worker can do at work and at home unless released to job of injury Including functional capacities will enable employers to identify appropriate light/modified duty jobs. Functional capacities must be provided even when the patient is not released to any work.
  • Must apply to your patient at all times: All day, every day of the week, even when off work.
Must be supported by the OMFs you’ve documented and noted on the form.

Other restrictions Use this section if none of the listed capacities apply to this worker. For example:
  • “Keep hand dry”
  • “Patient unable to drive due to medication(s)”
Employer Notified Is not required, but is recommended so the Claims Manager is aware of this outreach.
Note to claim Manager Is not required, but can be used to draw the claim manager's attention to a specific issue. For Example:
  • “I am the new Attending Provider (AP)”
  • “Pending surgical authorization”
Plans Please check all that apply, in both columns. If the patient is not “Released to the job of injury without restrictions” then “next scheduled visit” date should be no later than the estimated end date in the work status section. Impairment ratings If this claim is ready to close and you are qualified to rate your patient's permanent impairment, please send a rating report. Qualified attending health-care providers include doctors currently licensed in medicine and surgery (including osteopathic and podiatric) or dentistry, and chiropractors who are department-approved examiners.
Sign You must sign, date, and indicate your provider type.
Billing

How do health care providers bill for the Activity Prescription Form?

Activity Prescription Forms (APFs) are payable only when all required sections of the form are complete and legible.

Code Description Limit
1073M Activity Prescription Form (F242-385-000) A provider may submit up to 6 APFs per worker within the first 60 days of the initial visit date and then up to 4 times per 60 days thereafter.

Notes:

Who can bill for completion of an APF?

  • Doctors, as defined in WAC 296-20-01002 (app.leg.wa.gov) including:
    • Attending doctors
    • Transfer doctors
    • Concurrent care doctors
    • Consultants
  • Advanced Registered Nurse Practitioners (ARNPs)
  • Physician Assistants (PAs)

The APF is not payable to:

  • Occupational therapists
  • Physical therapists
  • Office staff

Billing for Self Insurance

Healthcare providers should send their bills, reports, requests for authorization, and other correspondence directly to the employer or their Third Party Administrator.

Note: For more information, review Chapter 2 of our policies

Other billing codes to be aware of

  • Local code 1074M: Written response to Vocational Rehabilitation Counselor (VRC) or employer requests for information on return to work
    • Limit: As requested, per insurer, employer, or VRC, but not to exceed one per provider, per worker, per day.
  • CPT® codes 99441 to 99443 and 98966 to 98968: To bill health care providers' telephone call/consultation regarding care of injured workers

If you need to learn more about billing L&I

Please visit: Billing L&I Using Provider Express Billing (PEB)

Submitting/Ordering

Order and submit an Activity Prescription Form (APF)

Complete and submit electronically:

  • Direct Data Entry (available January 2019) or
  • Health Information Exchange (HIE)

NOTE: Electronic options are currently only available for workers covered by L&I.