Surgical Quality Care Program

About our Program

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

Surgeons who are engaged in administrative best practices address:

Utilization of the department’s Medical Treatment Guidelines and Opioid Prescribing Guidelines
Remove obstacles which 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).

Tools and resources that are not readily available. These may include:

Performance reports to identify trends

Best Practices

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).	Improve the care of patients and help save lives by using best practices. Monitor patients on acute, sub-acute, and chronic opioid therapy. Aligns with state-wide best practices from the Bree Collaborative.	Monitor for aberrant behavior, lost prescriptions, multiple requests for early refills, opioids from multiple providers, unauthorized dosage escalation, apparent intoxication, etc. Meet opioid measures 1, 2, and 3 when at all possible.	Opioid Measure 1: ≥ 90% of all patients with an initial opioid prescription have ≤ 7 days. * * Opioid Measure 2: <5% of patients taking opioids are transitioned to chronic opioid therapy. Opioid Measure 3: ≥90% of patients on chronic opioid therapy (COT) are dosed at 50mg/day MED.
Best Practice 2: Utilization Review (mandatory for medium adoption level incentive and above).	The utilization review process compares requests for medical services to appropriate treatment guidelines and makes a recommendation based on that comparison. Utilization review supports our mission to provide only proper and necessary care for patients.	Ensures that all surgical requests meet the department's Medical Treatment Guidelines. This is a measure of current UR approval; the L&I claim manager will issue final determination and inform the requesting provider.	Low and medium incentive adoption levels: a surgeon must have 75% of utilization review requests approved. High and sustaining incentive adoption levels: a surgeon must have 85% of utilization review requests approved.
Best Practice 3: Complete and submit an Activity Prescription Form (APF) before and after surgery.	Outlines the treatment plan along with recovery expectations when there is a change in patient restrictions. Helpful to many parties tied to the claim (ex: patient, employer, surgical health services coordinator.	Surgeon meets with patient in the 90 days prior to the non-emergent * surgery and submits an APF. Surgeon (or their PA) meets with the patient in the 60 days following surgery and submits an APF.	At least 85% of surgical claims will have a pre and post surgical APF submitted by the appropriate provider.
Best Practice 4: Perform surgeries within 21 days of authorization.	Taken from a "whole patient" perspective, a timely surgery may help to eliminate some preventable permanent conditions, thus improving recovery.	Schedule authorized surgeries promptly. Procedures preformed outside of the 21 days aren't considered timely for this quality indicator's performance threshold.	At least 80% of claim manager authorized surgeries occur within 21 calendar days of the claim managers' notice of authorization.
Best Practice 5: Before surgery, establish release-to-work plans and goals with the patient.	Sets a return to work expectation with the patient and a goal for them to work towards. Prevents the patient from actualizing a prolonged post-op disability condition. Encourages patient to start a conversation with their employer about opportunities for light duty work or reduced hours.	A successful outcome involves more than pathophysiology. Returning to work is part of achieving maximal physical recovery. Prolonged disability affects a patient's career, their economic well being, and their life. Key messages for the released-to-work discussion.	For at least 85% of non-emergent* surgical claims, the surgeon will have met with the patient and jointly established some release to work plans and goals prior to surgery (not on the day of surgery).
Best Practice 6: Review and integrate communications from ancillary providers into the rehab plan.	L&I has made it easier for surgeons to be informed about the patient's rehabilitative process with the Physical Medicine Progress Report (PMPR). Offers an ability to correct/modify recovery plan without an office visit.	The surgeon (or their PA) should review and sign the PMPR. Return the signed PMPR to the ancillary provider AND to L&I. These PMPRs can be a resource in building/maintaining the patient's care plans, filling out more accurate APFs and/or job analyses.	A surgeon or PA will have reviewed and signed off on 90% of the PMPRs they've received within 14 calendar days of the date they were received.
Important things to know: Best Practice 3 (pre-surgery APF) and Best Practice 5 (released-to-work discussion) must be completed by the surgeon. Best Practice 3 (post-surgery APF) and Best Practice 6 (PMPR) may be completed by the surgeon or their PA. Best Practice 5 (released-to-work discussions) and Best Practice 6 (PMPR) are measured through the surgical health services coordinators' review of the provider's chart note and not the APF. (Refer to Key Messages for more information).

^{* 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.}

Provider Incentives

SQCP participating surgeons should use the following codes once the 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 is based on assigned adoption level from the last scheduled reporting for each individual surgeon. Refer to the latest information about surgeon incentive levels. This table will be updated periodically.

Refer to MARFS for more information.

Note: To ensure accurate payment, providers are required to document their participation in the program in their chart notes when billing 1086M.

Comments:

Not payable to ARNPs or PA-Cs.
Still payable during the Global Surgical Period.
Not tied to the Activity Prescription Form (APF).

Adoption levels

An adoption level will be assigned to each SQC Program participant as determined by how the surgeon has implemented the occupational health best practices over the three-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 practices 3 -6).
High Adopter:
- Awarded exclusively to surgeons who achieve a Utilization Review of 85%, AND
- Meet or exceed the threshold for all the remaining best practices (best practices 1, 3, 4, 5, and 6).
- Cannot be achieved without the services of a Surgical Health Services Coordinator (SHSC).
- Surgeon must submit APFs utilizing submission (Health Information Exchange or direct entry through My L&I).
Sustaining Adopter:
- Meets High Adopter requirements for consecutive reporting periods (18 months).

Requirements and Eligibility

The SQC Program is restricted to musculoskeletal surgeons who:

Regularly perform surgeries as Hand, Orthopedic, or Neurosurgeons*.
Are credentialed within the L&I MPN and have an active L&I provider ID.
Provide treatment for state-fund or self-insured workers.
Have an SQC Program Supplemental Application accepted by L&I.

* Podiatrists within a surgical clinic are also eligible to participate.

SHSC Coordination

The Surgical Health Services Coordinators (SHSCs) help surgeons, workers, and employers in many ways.

Learn more about Health Services Coordination, qualifications, and standard work that is performed.

Benefits of having an SHSC

Reduces transition times to and from surgical care.
Assists workers, employers, and surgeons navigate L&I processes.
Identifies and mitigates barriers to treatment, recovery, and return to work.
Improves release/return-to-work planning.
Removes some of your administrative burden by responding to requests from claim managers, vocational counselors, and employers.

SHSC billable services

SHSCs are not L&I employees. SHSCs must first be approved by L&I and get an L&I Provider ID in order to bill services to state-fund claims. Please refer to MARFS for the latest SHSC billing codes and amounts.

Frequently Asked Questions

Why do I have to treat workers' compensation patients differently than my other patients?

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.

What if I haven't participated previously, can I join the program now?

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.

When can I expect reports about my performance?

SQC Program reports will be produced 5 months after the quarterly reporting period ends. The L&I Project Lead will notify surgeons and their clinic management when reporting will affect their adoption/incentive level.

When will you open the program to other surgical specialties?

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.

When will the program incentivize mid-levels?

L&I does not plan to enroll PA-Cs or APRNs into the SQC Program at this time. Access to Surgical Health Services Coordinators (SHSCs) services are available to all providers within a participating surgical clinic.

Why do I have to complete and sign a supplemental application?

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.

When must I hire a Surgical Health Services Coordinator (SHSC)?

SHSCs are not required to participate in the SQC Program. Provider performance measure reporting started 1/1/2024 and SHSCs do impact adoption/incentive calculations. 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.

How will I know if my clinic can support a SHSC?

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.

When can a community SHSC support my clinic?

Community SHSC resources are currently unavailable through our COHE health care partners. L&I continues to work with community teams to make a community SHSC available.

Who will train my SHSC?

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.

Why must I be the attending provider on a claim?

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.

What if I'm already enrolled in a COHE? Why must I disenroll from COHE? When must I disenroll from COHE?

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 the 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 are working with our COHEs to schedule surgical clinic disenrollments.

Why do I have to sign off on the PMPR?

You or your PA-C/APRN 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.

Why must I document my released to work conversation with the worker?

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.

When does my adoption/incentive level change?

Surgeons transitioning from the Ortho-Neuro project will receive multiple informational reports prior to any change. the L&I Project Lead will notify surgeons and their clinic management before reporting will impact their adoption/incentive level. Surgeons who are new to the program will enter at a low adoption level until a reporting period is complete and data is available.

Can I still bill for an Activity Prescription Form (APF) every time I see the worker?

Yes! If you complete an APF because a worker has a change in capacity or restrictions, please bill 1073M for the APF.

How does the new incentive (1086M) work?

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.

Do I use 1086M with my existing workers?

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.

What if I'm the third surgeon or more to see the worker?

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.