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Chapter 4.5. Division of Workers' Compensation
Subchapter 1. Administrative Director--Administrative Rules
Article 5.5.2. Medical treatment utilization schedule
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§9792.24.3. Postsurgical Treatment Guidelines.


(a) As used in this section, the following definitions apply:

  (1) "General course of therapy" means the number of visits and/or time interval which shall be indicated for postsurgical treatment for the specific surgery in the postsurgical physical medicine treatment recommendations set forth in subdivision (d)(1) of this section.  


  (2) "Initial course of therapy" means one half of the number of visits specified in the general course of therapy for the specific surgery in the postsurgical physical medicine treatment recommendations set forth in subdivision (d)(1) of this section.  


  (3) "Postsurgical physical medicine period" means the time frame that is needed for postsurgical treatment and rehabilitation services beginning with the date of the procedure and ending at the time specified for the specific surgery in the postsurgical physical medicine treatment recommendations set forth in subdivision (d)(1) of this section. For all surgeries not covered by these guidelines the postsurgical physical medicine period is six (6) months.  


  (4) "Surgery" means a procedure listed in the surgery chapter of the Official Medical Fee Schedule with follow-up days of 90 days.  


  (5) "Visit" means a date of service to provide postsurgical treatment billed using the physical medicine section of the Official Medical Fee Schedule.  


(b) Application

  (1) The postsurgical treatment guidelines apply to visits during the postsurgical physical medicine period only and to surgeries as defined in these guidelines. At the conclusion of the postsurgical physical medicine period, treatment reverts back to the applicable 24-visit limitation for chiropractic, occupational and physical therapy pursuant to Labor Code section 4604.5(d)(1).  


(c) Postsurgical Patient Management

  (1) Only the surgeon who performed the operation, a nurse practitioner or physician assistant working with the surgeon, or a physician designated by that surgeon can make a determination of medical necessity and prescribe postsurgical treatment under this guideline.  


  (2) The medical necessity for postsurgical physical medicine treatment for any given patient is dependent on, but not limited to, such factors as the comorbid medical conditions; prior pathology and/or surgery involving same body part; nature, number and complexities of surgical procedure(s) undertaken; presence of surgical complications; and the patient's essential work functions.  


  (3) If postsurgical physical medicine is medically necessary, an initial course of therapy may be prescribed. With documentation of functional improvement, a subsequent course of therapy shall be prescribed within the parameters of the general course of therapy applicable to the specific surgery. If it is determined that additional functional improvement can be accomplished after completion of the general course of therapy, physical medicine treatment may be continued up to the end of the postsurgical physical medicine period.  


  (4) Patients shall be reevaluated following continuation of therapy when necessary or no later than every forty-five days from the last evaluation to document functional improvement to continue physical medicine treatment. Frequency of visits shall be gradually reduced or discontinued as the patient gains independence in management of symptoms and with achievement of functional goals.  


  (A) In the event the patient sustains an exacerbation related to the procedure performed after treatment has been discontinued and it is determined that more visits are medically necessary, physical medicine treatment shall be provided within the postsurgical physical medicine period.  


  (B) In cases where no functional improvement is demonstrated, postsurgical treatment shall be discontinued at any time during the postsurgical physical medicine period.  


  (5) Treatment is provided to patients to facilitate postsurgical functional improvement.  


  (A) The surgeon who performed the operation, a nurse practitioner or physician assistant working with the surgeon, or physician designated by that surgeon, the therapist, and the patient should establish functional goals achievable within a specified timeframe.  


  (B) Patient education regarding postsurgical precautions, home exercises, and self-management of symptoms should be ongoing components of treatment starting with the first visit. Intervention should include a home exercise program to supplement therapy visits.  


  (C) Modalities (CPT [as defined in section 9789.10(d)] codes 97010 through 97039) should only be performed in conjunction with other active treatments. Although these modalities are occasionally useful in the post surgical physical medicine period, their use should be minimized in favor of active physical rehabilitation and independent self-management.  


(d) Postsurgical Physical Medicine Treatment Recommendations

  (1) The postsurgical physical medicine treatment recommendations, as listed below, indicate frequency and duration of postsurgical treatment for specific surgeries. The specified surgeries in these guidelines are not all inclusive. Requests for postsurgical physical medicine treatment not included in these guidelines shall be considered pursuant to section 9792.21(c). The physical medicine treatment recommendations (listed alphabetically) are adapted from the Official Disability Guidelines (ODG) except where developed by the Division of Workers' Compensation and indicated as "[DWC]." The postsurgical physical medicine period is identified by an asterisk [*] as developed by DWC.  


  Postsurgical Treatment Guidelines  


  Ankle & Foot  


  Exercise program goals should include strength, flexibility, endurance, coordination, and education. Patients can be advised to do early passive range-of-motion exercises at home by a therapist. (Colorado, 2001) (Aldridge, 2004) This RCT (randomized controlled trial) supports early motion (progressing to full weight-bearing at 8 weeks from treatment) as an acceptable form of rehabilitation in surgically treated patients with Achilles tendon ruptures. (Twaddle, 2007)  


  Achilles tendon rupture (ICD9 727.67):  


  Postsurgical treatment: 48 visits over 16 weeks  


  *Postsurgical physical medicine treatment period: 6 months  


  Ankle Sprain (ICD9 845.0):  


  Postsurgical treatment: 34 visits over 16 weeks  


  *Postsurgical physical medicine treatment period: 6 months  


  Anterior tibial tendon [DWC]:  


  Postsurgical treatment: 8 visits over 3 months  


  *Postsurgical physical medicine treatment period: 6 months  


  Amputation of foot (ICD9 896):  


  Post-replantation surgery: 48 visits over 26 weeks  


  *Postsurgical physical medicine treatment period: 12 months  


  Post-amputation treatment [DWC]: 48 visits over 26 weeks  


  *Postsurgical physical medicine treatment period: 12 months  


  Amputation of toe (ICD9 895):  


  Post-replantation surgery: 20 visits over 12 weeks  


  *Postsurgical physical medicine treatment period: 6 months  


  Dislocation of the peroneal tendons [DWC]:  


  Postsurgical treatment: 8 visits over 3 months  


  *Postsurgical physical medicine treatment period: 6 months  


  Enthesopathy of ankle and tarsus (ICD9 726.7):  


  Postsurgical treatment: 9 visits over 8 weeks  


  *Postsurgical physical medicine treatment period: 4 months  


  Fracture of ankle (ICD9 824):  


  Postsurgical treatment: 21 visits over 16 weeks  


  *Postsurgical physical medicine treatment period: 6 months  


  Fracture of ankle, Bimalleolar (ICD9 824.4):  


  Postsurgical treatment (ORIF): 21 visits over 16 weeks  


  *Postsurgical physical medicine treatment period: 6 months  


  Postsurgical treatment (arthrodesis): 21 visits over 16 weeks  


  *Postsurgical physical medicine treatment period: 6 months  


  Fracture of ankle, Trimalleolar (ICD9 824.6):  


  Postsurgical treatment: 21 visits over 16 weeks  


  *Postsurgical physical medicine treatment period: 6 months  


  Fracture of one or more phalanges of foot (ICD9 826):  


  Postsurgical treatment: 12 visits over 12 weeks  


  *Postsurgical physical medicine treatment period: 6 months  


  Special Consideration [DWC]: Postsurgical physical medicine is rarely needed for ganglionectomy.  


  Fracture of tibia and fibula (ICD9 823):  


  Postsurgical treatment (ORIF): 30 visits over 12 weeks  


  *Postsurgical physical medicine treatment period: 6 months  


  Hallux rigidus (ICD9 735.2):  


  Postsurgical treatment: 9 visits over 8 weeks  


  *Postsurgical physical medicine treatment period: 4 months  


  Hallux valgus (ICD9 735.0):  


  Postsurgical treatment: 9 visits over 8 weeks  


  *Postsurgical physical medicine treatment period: 4 months  


  Hallux varus (ICD9 735.1):  


  Postsurgical treatment: 9 visits over 8 weeks  


  *Postsurgical physical medicine treatment period: 4 months  


  Metatarsal stress fracture (ICD9 825):  


  Postsurgical treatment: 21 visits over 16 weeks  


  *Postsurgical physical medicine treatment period: 6 months  


  Other hammer toe (ICD9 735.4):  


  Postsurgical treatment: 9 visits over 8 weeks  


  *Postsurgical physical medicine treatment period: 4 months  


  Peroneal tendon repair [DWC]:  


  Postsurgical treatment: 8 visits over 3 months  


  *Postsurgical physical medicine treatment period: 6 months  


  Posterior tibial tendonitis [DWC]:  


  Postsurgical treatment: 8 visits over 3 months  


  *Postsurgical physical medicine treatment period: 6 months  


  Posterior tibial tenosynovitis (partial or complete rupture) [DWC]:  


  Postsurgical treatment: 8 visits over 3 months  


  *Postsurgical physical medicine treatment period: 6 months  


  Burns  


  Recommended. Occupational therapy and physical therapy for the patient with burns may include respiratory management, edema management, splinting and positioning, physical function (mobility, function, exercise), scar management, and psychosocial elements. (Simons, 2003) As with any treatment, if there is no improvement after 2-3 weeks the protocol may be modified or re-evaluated.  


  Burns (ICD9 949):  


  Postsurgical treatment: 16 visits over 8 weeks  


  *Postsurgical physical medicine treatment period: 6 months  


  Cardiopulmonary [DWC]:  


  Coronary Stenting [DWC]:  


  Postsurgical treatment: 36 visits over 18 weeks  


  *Postsurgical physical medicine treatment period: 6 months  


  Heart Valve repair/replacement [DWC]:  


  Postsurgical treatment: 36 visits over 18 weeks  


  *Postsurgical physical medicine treatment period: 6 months  


  Percutaneous transluminal coronary angioplasty (PTCA) [DWC]:  


  Postsurgical treatment: 36 visits over 18 weeks  


  *Postsurgical physical medicine treatment period: 6 months  


  Carpal Tunnel Syndrome  


  Recommended as indicated below. There is limited evidence demonstrating the effectiveness of PT (physical therapy) or OT (occupational therapy) for CTS (carpal tunnel syndrome). The evidence may justify 3 to 5 visits over 4 weeks after surgery, up to the maximums shown below. Benefits need to be documented after the first week, and prolonged therapy visits are not supported. Carpal tunnel syndrome should not result in extended time off work while undergoing multiple therapy visits, when other options (including surgery for carefully selected patients) could result in faster return to work. Furthermore, carpal tunnel release surgery is a relatively simple operation that also should not require extended multiple therapy office visits for recovery. Of course, these statements do not apply to cases of failed surgery and/or misdiagnosis (e.g., CRPS (complex regional pain syndrome) I instead of CTS). (Feuerstein, 1999) (O'Conner-Cochrane, 2003) (Verhagen-Cochrane, 2004) (APTA, 2006) (Bilic, 2006) Post surgery, a home therapy program is superior to extended splinting. (Cook, 1995) Continued visits should be contingent on documentation of objective improvement, i.e., VAS (visual analog scale) improvement greater than four, and long-term resolution of symptoms. Therapy should include education in a home program, work discussion and suggestions for modifications, lifestyle changes, and setting realistic expectations. Passive modalities, such as heat, iontophoresis, phonophoresis, ultrasound and electrical stimulation, should be minimized in favor of active treatments.  


  Carpal tunnel syndrome (ICD9 354.0):  


  Postsurgical treatment (endoscopic): 3-8 visits over 3-5 weeks  


  *Postsurgical physical medicine treatment period: 3 months  


  Postsurgical treatment (open): 3-8 visits over 3-5 weeks  


  *Postsurgical physical medicine treatment period: 3 months  


  Elbow & Upper Arm  


  Arthropathy, unspecified (ICD9 716.9):  


  Postsurgical treatment, arthroplasty, elbow: 24 visits over 8 weeks  


  *Postsurgical physical medicine treatment period: 4 months  


  Cubital tunnel release [DWC]:  


  Postsurgical treatment: 20 visits over 3 months  


  *Postsurgical physical medicine treatment period: 6 months  


  Dislocation of elbow (ICD9 832):  


  Unstable dislocation, postsurgical treatment: 10 visits over 9 weeks  


  *Postsurgical physical medicine treatment period: 4 months  


  ECRB / ECRL debridement [DWC]:  


  Postsurgical treatment: 10 visits over 4 months  


  *Postsurgical physical medicine treatment period: 6 months  


  ECRB / ECCRL tenotomy [DWC]:  


  Postsurgical treatment: 10 visits over 4 months  


  *Postsurgical physical medicine treatment period: 6 months  


  Elbow diagnostic arthroscopy and arthroscopic debridement [DWC]:  


  Postsurgical treatment: 20 visits over 2 months  


  *Postsurgical physical medicine treatment period: 4 months  


  Elbow collateral ligament repair [DWC]:  


  Postsurgical treatment: 14 visits over 6 months  


  *Postsurgical physical medicine treatment period: 8 months  


  Enthesopathy of elbow region (ICD9 726.3):  


  Postsurgical treatment: 12 visits over 12 weeks  


  *Postsurgical physical medicine treatment period: 6 months  


  Fracture of humerus (ICD9 812):  


  Postsurgical treatment: 24 visits over 14 weeks  


  *Postsurgical physical medicine treatment period: 6 months  


  Fracture of radius/ulna (ICD9 813):  


  Postsurgical treatment: 16 visits over 8 weeks  


  *Postsurgical physical medicine treatment period: 4 months  


  Lateral epicondylitis/Tennis elbow (ICD9 726.32):  


  Postsurgical treatment: 12 visits over 12 weeks  


  *Postsurgical physical medicine treatment period: 6 months  


  Medial epicondylitis/Golfers' elbow (ICD9 726.31):  


  Postsurgical treatment: 12 visits over 12 weeks  


  *Postsurgical physical medicine treatment period: 6 months  


  Muscle or tendon transfers for elbow flexion [DWC]:  


  Postsurgical treatment: 30 visits over 5 months  


  *Postsurgical physical medicine treatment period: 8 months  


  Rupture of biceps tendon (ICD9 727.62):  


  Postsurgical treatment: 24 visits over 16 weeks  


  *Postsurgical physical medicine treatment period: 6 months  


  Sprains and strains of elbow and forearm (ICD9 841):  


  Postsurgical treatment/ligament repair: 24 visits over 16 weeks  


  *Postsurgical physical medicine treatment period: 6 months  


  Traumatic amputation of arm (ICD9 887):  


  Post-amputation treatment: without complications, no prosthesis [DWC]: 18 visits over 4 months  


  *Postsurgical physical medicine treatment period: 6 months  


  Post-amputation treatment: without complications, with prosthesis [DWC]: 30 visits over 6 months  


  *Postsurgical physical medicine treatment period: 9 months  


  Post-amputation treatment: with complications, no prosthesis [DWC]: 30 visits over 5 months  


  *Postsurgical physical medicine treatment period: 7 months  


  Post-amputation treatment: with complications and prosthesis [DWC]: 40 visits over 8 months  


  *Postsurgical physical medicine treatment period: 12 months  


  Post-replantation surgery: 48 visits over 26 weeks  


  *Postsurgical physical medicine treatment period: 12 months  


  Triceps repair [DWC]:  


  Postsurgical treatment: 24 visits over 4 months  


  *Postsurgical physical medicine treatment period: 6 months  


  Ulnar nerve entrapment/Cubital tunnel syndrome (ICD9 354.2):  


  Postsurgical treatment: 20 visits over 10 weeks  


  *Postsurgical physical medicine treatment period: 6 months  


  Forearm, Wrist, & Hand  


  (Not including Carpal Tunnel Syndrome - see separate post surgical guideline.)  


  Used after surgery and amputation. During immobilization, there was weak evidence of improved hand function in the short term, but not in the longer term, for early occupational therapy, and of a lack of differences in outcome between supervised and unsupervised exercises. Post-immobilization, there was weak evidence of a lack of clinically significant differences in outcome in patients receiving formal rehabilitation therapy, passive mobilization or whirlpool immersion compared with no intervention. There was weak evidence of a short-term benefit of continuous passive motion (post external fixation), intermittent pneumatic compression and ultrasound. There was weak evidence of better short-term hand function in patients given therapy than in those given instructions for home exercises by a surgeon. (Handoll-Cochrane, 2002) (Handoll-Cochrane, 2006)  


  Amputation of arm, below the elbow [DWC]:  


  Post-amputation treatment: without complications, no prosthesis: 18 visits over 4 months  


  *Postsurgical physical medicine treatment period: 6 months  


  Post-amputation: without complications, with prosthesis: 30 visits over 6 months  


  *Postsurgical physical medicine treatment period: 9 months  


  Post-amputation: with complications, no prosthesis: 30 visits over 5 months  


  *Postsurgical physical medicine treatment period: 7 months  


  Post-amputation: with complications and prosthesis: 40 visits over 8 months  


  *Postsurgical physical medicine treatment period: 12 months  


  Amputation of hand (ICD9 887):  


  Post-amputation treatment: without complications, no prosthesis [DWC]: 18 visits over 4 months  


  *Postsurgical physical medicine treatment period: 6 months  


  Post-amputation treatment: with complications, no prosthesis [DWC]: 24 visits over 5 months  


  *Postsurgical physical medicine treatment period: 7 months  


  Post-replantation surgery: 48 visits over 26 weeks  


  *Postsurgical physical medicine treatment period: 12 months  


  Amputation of thumb; finger (ICD9 885; 886):  


  Post-replantation surgery: 36 visits over 12 weeks  


  *Postsurgical physical medicine treatment period: 6 months  


  Post-amputation: Amputation of fingers without replantation [DWC]: 14 visits over 3 months  


  *Postsurgical physical medicine treatment period: 6 months  


  Post-amputation: Amputation of thumb without replantation [DWC]: 16 visits over 3 months  


  *Postsurgical physical medicine treatment period: 6 months  


  Arthropathy, unspecified (ICD9 716.9):  


  Postsurgical treatment, arthroplasty/fusion, wrist/finger: 24 visits over 8 weeks  


  *Postsurgical physical medicine treatment period: 4 months  


  Contracture of palmar fascia (Dupuytren's) (ICD9 728.6):  


  Postsurgical treatment: 12 visits over 8 weeks  


  *Postsurgical physical medicine treatment period: 4 months  


  Digital nerve repair [DWC]:  


  Postsurgical treatment: 8 visits over 4 months  


  *Postsurgical physical medicine treatment period: 6 months  


  DIP joint intraarticular fracture at middle or distal phalanx [DWC]:  


  Postsurgical treatment: 14 visits over 4 months  


  *Postsurgical physical medicine treatment period: 6 months  


  Dislocation of finger (ICD9 834):  


  Postsurgical treatment: 16 visits over 10 weeks  


  *Postsurgical physical medicine treatment period: 4 months  


  Dislocation of wrist (ICD9 833):  


  Postsurgical treatment (TFCC reconstruction): 16 visits over 10 weeks  


  *Postsurgical physical medicine treatment period: 4 months  


  Extensor tendon repair or tenolysis [DWC]:  


  Postsurgical treatment: 18 visits over 4 months  


  *Postsurgical physical medicine treatment period: 6 months  


  Extensor tenosynovectomy [DWC]:  


  Postsurgical treatment: 14 visits over 3 months  


  *Postsurgical physical medicine treatment period: 6 months  


  Flexor tendon repair or tenolysis Zone 2 and other than Zone 2 [DWC]:  


  Postsurgical treatment: Flexor tendon repair or tenolysis Zone 2: 30 visits over 6 months  


  *Postsurgical physical medicine treatment period: 8 months  


  Postsurgical treatment: Other than Zone 2: 20 visits over 3 months  


  *Postsurgical physical medicine treatment period: 6 months  


  Flexor tenosynovectomy [DWC]:  


  Postsurgical treatment: 14 visits over 3 months  


  *Postsurgical physical medicine treatment period: 6 months  


  Flexor tendon repair (forearm) [DWC]:  


  Postsurgical treatment: 12 visits over 4 months  


  *Postsurgical physical medicine treatment period: 6 months  


  Fracture of carpal bone (wrist) (ICD9 814):  


  Postsurgical treatment: 16 visits over 10 weeks  


  *Postsurgical physical medicine treatment period: 4 months  


  Fracture of metacarpal bone (hand) (ICD9 815):  


  Postsurgical treatment: 16 visits over 10 weeks  


  *Postsurgical physical medicine treatment period: 4 months  


  Fracture of one or more phalanges of hand (fingers) (ICD9 816):  


  Postsurgical treatment: Complicated, 16 visits over 10 weeks  


  *Postsurgical physical medicine treatment period: 4 months  


  Fracture of radius/ulna (forearm) (ICD9 813):  


  Postsurgical treatment: 16 visits over 8 weeks  


  *Postsurgical physical medicine treatment period: 4 months  


  Ganglion and cyst of synovium, tendon, and bursa (ICD9 727.4):  


  Postsurgical treatment: 18 visits over 6 weeks  


  *Special Consideration: Postsurgical physical medicine is rarely needed for ganglionectomy.  


  Intersection syndrome [DWC]:  


  Postsurgical treatment: 9 visits over 3 months  


  *Postsurgical physical medicine treatment period: 6 months  


  Median Nerve Repair: Forearm - Wrist [DWC]:  


  Postsurgical treatment: 20 visits over 6 weeks  


  *Postsurgical physical medicine treatment period: 6 months  


  PIP and MCP capsulotomy/capsulectomy [DWC]:  


  Postsurgical treatment: 24 visits over 2 months  


  *Postsurgical physical medicine treatment period: 4 months  


  PIP and MCP collateral ligament reconstruction [DWC]:  


  Postsurgical treatment: 18 visits over 4 months  


  *Postsurgical physical medicine treatment period: 6 months  


  PIP and MCP collateral ligament repairs [DWC]:  


  Postsurgical treatment: 12 visits over 4 months  


  *Postsurgical physical medicine treatment period: 6 months  


  PIP joint intraarticular fracture and or dislocation at proximal or middle phalanx [DWC]:  


  Postsurgical treatment: Postsurgical treatment: 20 visits over 6 months  


  *Postsurgical physical medicine treatment period: 8 months  


  Proximal row carpectomy [DWC]:  


  Postsurgical treatment:20 visits over 6 months  


  *Postsurgical physical medicine treatment period: 8 months  


  Nerve Repair: Elbow - Wrist [DWC]  


  Postsurgical treatment: 20 visits over 6 weeks  


  *Postsurgical physical medicine treatment period: 8 months  


  Radial styloid tenosynovitis (de Quervain's) (ICD9 727.04):  


  Postsurgical treatment: 14 visits over 12 weeks  


  *Postsurgical physical medicine treatment period: 6 months  


  Sprains and strains of elbow and forearm (ICD9 841):  


  Post-surgical treatment/ligament repair: 24 visits over 16 weeks  


  *Postsurgical physical medicine treatment period: 6 months  


  Synovitis and tenosynovitis (ICD9 727.0):  


  Postsurgical treatment: 14 visits over 12 weeks  


  *Postsurgical physical medicine treatment period: 6 months  


  Tendon transfer forearm, wrist or hand [DWC]:  


  Postsurgical treatment: 14 visits over 4 months  


  *Postsurgical physical medicine treatment period: 6 months  


  Tendon transfers - thumb or finger [DWC]:  


  Postsurgical treatment: 26 visits over 4 months  


  *Postsurgical physical medicine treatment period: 6 months  


  TFCC injuries-debridement (arthroscopic) [DWC]:  


  Postsurgical treatment:10 visits over 10 weeks  


  *Postsurgical physical medicine treatment period: 4 months  


  Trigger finger (ICD9 727.03):  


  Postsurgical treatment: 9 visits over 8 weeks  


  *Postsurgical physical medicine treatment period: 4 months  


  Ulnar nerve entrapment/Cubital tunnel syndrome (ICD9 354.2):  


  Postsurgical treatment: 20 visits over 10 weeks  


  *Postsurgical physical medicine treatment period: 6 months  


  Wrist - intercarpal ligament reconstruction or repair [DWC]:  


  Postsurgical treatment 20 visits over 6 months  


  *Postsurgical physical medicine treatment period: 8 months  


  Head  


  Patient rehabilitation after traumatic brain injury is divided into two periods: acute and subacute. In the beginning of rehabilitation therapist evaluates patient's functional status, later he uses methods and means of treatment, and evaluates effectiveness of rehabilitation. Early ambulation is very important for patients with coma. Therapy consists of prevention of complications, improvement of muscle force, and range of motions, balance, movement coordination, endurance and cognitive functions. Early rehabilitation is necessary for traumatic brain injury patients and use of therapy methods can help to regain lost functions and to come back to the society. (Colorado, 2005) (Brown, 2005) (Franckeviciute, 2005) (Driver, 2004) (Shiel, 2001)  


  Fracture of skull (ICD9 801):  


  Postsurgical treatment: 34 visits over 16 weeks  


  *Postsurgical physical medicine treatment period: 6 months  


  Hernia  


  Not recommended. No evidence of successful outcomes compared to surgery.  


  Hip, Pelvis and Thigh (femur)  


  A therapy program that starts immediately following hip surgery allows for greater improvement in muscle strength, walking speed and functional score. (Jan, 2004) (Jain, 2002) (Penrod, 2004) (Tsauo, 2005) (Brigham, 2003) (White, 2005) (National, 2003) A weight-bearing exercise program can improve balance and functional ability to a greater extent than a non-weight-bearing program. (Expert, 2004) (Binder, 2004) (Bolgla, 2005) (Handoll, 2004) (Kuisma, 2002) (Lauridsen, 2002) (Mangione, 2005) (Sherrington, 2004) Patients with hip fracture should be offered a coordinated multidisciplinary rehabilitation program with the specific aim of regaining sufficient function to return to their pre-fracture living arrangements. (Cameron, 2005) Accelerated perioperative care and rehabilitation intervention after hip and knee arthroplasty (including intense therapy and exercise) reduced mean hospital length of stay (LOS) from 8.8 days before implementation to 4.3 days after implementation. (Larsen, 2008)  


  Arthrodesis [DWC]:  


  Postsurgical treatment: 22 visits over 3 months  


  *Postsurgical physical medicine treatment period: 6 months  


  Arthropathy, unspecified (ICD9 716.9):  


  Postsurgical treatment, arthroplasty/fusion, hip: 24 visits over 10 weeks  


  *Postsurgical physical medicine treatment period: 4 months  


  Fracture of neck of femur (ICD9 820):  


  Postsurgical treatment: 24 visits over 10 weeks  


  *Postsurgical physical medicine treatment period: 4 months  


  Fracture of pelvis (ICD9 808):  


  Postsurgical treatment: 24 visits over 10 weeks  


  *Postsurgical physical medicine treatment period: 4 months  


  Osteoarthrosis and allied disorders (ICD9 715):  


  Post-surgical treatment: 18 visits over 12 weeks  


  *Postsurgical physical medicine treatment period: 6 months  


  Synovectomy [DWC]:  


  Postsurgical treatment: 14 visits over 3 months  


  *Postsurgical physical medicine treatment period: 6 months  


  Knee  


  Controversy exists about the effectiveness of therapy after arthroscopic partial meniscectomy. (Goodwin, 2003) Functional exercises after hospital discharge for total knee arthroplasty result in a small to moderate short-term, but not long-term, benefit. In the short term therapy interventions with exercises based on functional activities may be more effective after total knee arthroplasty than traditional exercise programs, which concentrate on isometric muscle exercises and exercises to increase range of motion in the joint. (Minns Lowe, 2007) Accelerated perioperative care and rehabilitation intervention after hip and knee arthroplasty (including intense therapy and exercise) reduced mean hospital length of stay (LOS) from 8.8 days before implementation to 4.3 days after implementation. (Larsen, 2008)  


  Amputation of leg (ICD9 897):  


  Post-replantation surgery: 48 visits over 26 weeks  


  *Postsurgical physical medicine treatment period: 12 months Post-amputation [DWC]: 48 visits over 6 months  


  *Postsurgical physical medicine treatment period: 8 months  


  Arthritis (Arthropathy, unspecified) (ICD9 716.9):  


  Postsurgical treatment, arthroplasty, knee: 24 visits over 10 weeks  


  *Postsurgical physical medicine treatment period: 4 months  


  Dislocation of knee; Tear of medial/lateral cartilage/meniscus of knee; Dislocation of patella (ICD9 836; 836.0; 836.1; 836.2; 836.3; 836.5):  


  Postsurgical treatment: (Meniscectomy): 12 visits over 12 weeks  


  *Postsurgical physical medicine treatment period: 6 months  


  Fracture of neck of femur (ICD9 820):  


  Postsurgical treatment: 18 visits over 8 weeks  


  *Postsurgical physical medicine treatment period: 6 months  


  Fracture of other and unspecified parts of femur (ICD9 821):  


  Postsurgical treatment: 30 visits over 12 weeks  


  *Postsurgical physical medicine treatment period: 6 months  


  Fracture of patella (ICD9 822):  


  Postsurgical treatment: 10 visits over 8 weeks  


  *Postsurgical physical medicine treatment period: 4 months  


  Fracture of tibia and fibula (ICD9 823):  


  Postsurgical treatment (ORIF): 30 visits over 12 weeks  


  *Postsurgical physical medicine treatment period: 6 months  


  Manipulation under Anesthesia (knee) [DWC]:  


  Postsurgical treatment: 20 visits over 4 months  


  *Postsurgical physical medicine treatment period: 6 months  


  Old bucket handle tear; Derangement of meniscus; Loose body in knee; Chondromalacia of patella; Tibialis tendonitis (ICD9 717.0; 717.5; 717.6; 717.7; 726.72):  


  Postsurgical treatment: 12 visits over 12 weeks  


  *Postsurgical physical medicine treatment period: 4 months  


  Sprains and strains of knee and leg; Cruciate ligament of knee (ACL tear) (ICD9 844; 844.2):  


  Postsurgical treatment: (ACL repair): 24 visits over 16 weeks  


  *Postsurgical physical medicine treatment period: 6 months  


  Low Back  


  As compared with no therapy, therapy (up to 20 sessions over 12 weeks) following disc herniation surgery was effective. Because of the limited benefits of therapy relative to massage, it is open to question whether this treatment acts primarily physiologically, but psychological factors may contribute substantially to the benefits observed. (Erdogmus, 2007)  


  Artificial Disc [DWC]:  


  Postsurgical treatment: 18 visits over 4 months  


  *Postsurgical physical medicine treatment period: 6 months  


  Fracture of vertebral column with spinal cord injury (ICD9 806):  


  Postsurgical treatment: 48 visits over 18 weeks  


  *Postsurgical physical medicine treatment period: 6 months  


  Fracture of vertebral column without spinal cord injury (ICD9 805):  


  Postsurgical treatment: 34 visits over 16 weeks  


  *Postsurgical physical medicine treatment period: 6 months  


  Intervertebral disc disorder with myelopathy (ICD9 722.7):  


  Postsurgical treatment: 48 visits over 18 weeks  


  *Postsurgical physical medicine treatment period: 6 months  


  Intervertebral disc disorders without myelopathy (ICD9 722.1; 722.2; 722.5; 722.6; 722.8):  


  Postsurgical treatment (discectomy/laminectomy): 16 visits over 8 weeks  


  *Postsurgical physical medicine treatment period: 6 months  


  Postsurgical treatment (arthroplasty): 26 visits over 16 weeks  


  *Postsurgical physical medicine treatment period: 6 months  


  Postsurgical treatment (fusion): 34 visits over 16 weeks  


  *Postsurgical physical medicine treatment period: 6 months  


  Spinal stenosis (ICD9 724.0):  


  See 722.1 for postsurgical visits  


  *Postsurgical physical medicine treatment period: 6 months  


  Neck & Upper Back  


  Displacement of cervical intervertebral disc (ICD9 722.0):  


  Postsurgical treatment (discectomy/laminectomy): 16 visits over 8 weeks  


  *Postsurgical physical medicine treatment period: 6 months  


  Postsurgical treatment (fusion, after graft maturity): 24 visits over 16 weeks  


  *Postsurgical physical medicine treatment period: 6 months  


  Degeneration of cervical intervertebral disc (ICD9 722.4):  


  See 722.0 for postsurgical visits  


  *Postsurgical physical medicine treatment period: 6 months  


  Fracture of vertebral column without spinal cord injury (ICD9 805):  


  Postsurgical treatment: 34 visits over 16 weeks  


  *Postsurgical physical medicine treatment period: 6 months  


  Fracture of vertebral column with spinal cord injury (ICD9 806):  


  Postsurgical treatment: 48 visits over 18 weeks  


  *Postsurgical physical medicine treatment period: 6 months  


  Shoulder  


  Acromioclavicular joint dislocation (ICD9 831.04):  


  AC separation, type III+: 8 visits over 8 weeks  


  *Postsurgical physical medicine treatment period: 6 months  


  Adhesive capsulitis (ICD9 726.0):  


  Postsurgical treatment: 24 visits over 14 weeks  


  *Postsurgical physical medicine treatment period: 6 months  


  Arthritis (Osteoarthrosis; Rheumatoid arthritis; Arthropathy, unspecified) (ICD9 714.0; 715; 715.9; 716.9):  


  Postsurgical treatment, arthroplasty, shoulder: 24 visits over 10 weeks  


  *Postsurgical physical medicine treatment period: 6 months  


  Brachial plexus lesions (Thoracic outlet syndrome) (ICD9 353.0):  


  Postsurgical treatment: 20 visits over 10 weeks  


  *Postsurgical physical medicine treatment period: 6 months  


  Complete rupture of rotator cuff (ICD9 727.61; 727.6):  


  Postsurgical treatment: 40 visits over 16 weeks  


  *Postsurgical physical medicine treatment period: 6 months  


  Dislocation of shoulder (ICD9 831):  


  Postsurgical treatment (Bankart): 24 visits over 14 weeks  


  *Postsurgical physical medicine treatment period: 6 months  


  Fracture of humerus (ICD9 812):  


  Postsurgical treatment: 24 visits over 14 weeks  


  *Postsurgical physical medicine treatment period: 6 months  


  Rotator cuff syndrome/Impingement syndrome (ICD9 726.1; 726.12):  


  Postsurgical treatment, arthroscopic: 24 visits over 14 weeks  


  *Postsurgical physical medicine treatment period: 6 months  


  Postsurgical treatment, open: 30 visits over 18 weeks  


  *Postsurgical physical medicine treatment period: 6 months  


  Sprained shoulder; rotator cuff (ICD9 840; 840.4):  


  Postsurgical treatment (RC repair/acromioplasty): 24 visits over 14 weeks  


  *Postsurgical physical medicine treatment period: 6 months  


  (2) Appendix C - Postsurgical Treatment Guidelines Evidence-Based Reviews (May, 2009)- is incorporated by reference into the MTUS as supplemental part of the Postsurgical Treatment Guidelines. A copy of Appendix C may be obtained from the Medical Unit, Division of Workers' Compensation, P.O. Box 71010, Oakland, CA 94612-1486, or from the DWC web site at http://www.dwc.ca.gov.  


  (3) Appendix E - Postsurgical Treatment Guidelines Work Loss Data Institute-Official Disability Guidelines References (May, 2009) - is incorporated by reference into the MTUS as supplemental part of the Postsurgical Treatment Guidelines. A copy of Appendix E may be obtained from the Medical Unit, Division of Workers' Compensation, P.O. Box 71010, Oakland, CA 94612-1486, or from the DWC web site at http://www.dwc.ca.gov.  



     Note: Authority cited: Sections 133, 4603.5, 5307.3 and 5307.27, Labor Code. Reference: Sections 77.5, 4600, 4604.5 and 5307.27, Labor Code.  


 HISTORY 
   
1. New section filed 6-18-2009; operative 7-18-2009 pursuant to  GovernmentCode section 11343.4 (Register 2009, No. 25).

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