EEOICPA BULLETIN NO. 03-14
Issue Date: April 7, 2003
Effective Date: April 7, 2003
Expiration Date: April 7, 2004
Subject: Revised use of Medical Condition Status codes in ECMS.
Background: This bulletin covers changes to how existing medical condition status codes A, C, D, & R will be coded in ECMS.
This change is necessary in order to reflect the true status of the medical development at the time of adjudication. It will enable the CE to accurately record the medical history of the claim and assist in identifying when the medical portion of a claim is completed. Previously, for case denials, the CE was instructed to change all medical status codes to D. With this procedural change, that will no longer be required, and the medical cond status code will be related to the medical evidence that is known at the time of the Recommended Decision.
In addition, the C code in the Energy Case Management System (ECMS) medical cond status listbox in the Medical Condition screen is being redefined from "RECLASSIFIED" to "COVERED".
Reference: ECMS Frequently Asked Questions (FAQs).
Purpose: To notify District Office personnel regarding the change in ECMS usage of the A, C, D, & R codes in the medical cond status listbox in the Medical Condition screen.
Applicability: All staff.
Claimed Medical Condition(s)
·Using the R status code: When a medical condition is added in ECMS, either at the time of case creation or in the adjudication of a claim, the medical cond status listbox in the Medical Condition screen will default to an R status code. The R status code equals what is "Reported" on the EE-1 or EE-2 form by the claimant. For all covered conditions claimed under EEOICPA, the R code will remain unchanged during the adjudication of a claim until the medical development has been completed. The status effect dt in the Medical Condition screen remains blank.
·Non-covered conditions: As described in item #7 from Bulletin 03-06 for non-covered medical conditions, the medical condition status code defaults to R in the ECMS medical cond status listbox for "REPORTED." For non-covered conditions, this status code will not be changed by the CE to A or D, since those codes are exclusively reserved for covered conditions. An A or D status would never be used in conjunction with a claimed non-covered medical condition because the condition was never developed and thus is neither accepted nor denied.
For example, if a claimant submits an EE-1 form claiming cancer but only worked for a beryllium vendor (where cancer is not a covered condition under EEOICPA), this would be an instance where the cancer would be a non-covered condition. Therefore, the claimed medical condition (cancer) would stay as an R status code in the medical cond status listbox.
·Cancer conditions at NIOSH: When a case is sent to NIOSH, all pending cancer medical condition status codes in the ECMS medical cond status listbox remain in an R or "Reported" status. The determination of acceptance or denial for medical conditions sent to NIOSH can not be made until after the dose reconstruction is returned. Even though the medical evidence confirms that the employee has cancer (thus the case is at NIOSH), that condition could not be given an A or "Accepted" status in the ECMS medical cond status listbox until the probability of causation is determined to be at least 50%. Conversely, if the probability of causation is less than 50%, the medical condition would be coded D or "Denied" in the ECMS medical cond status listbox since the covered condition is denied.
For Covered Medical Conditions (i.e. cancer, beryllium sensitivity, chronic beryllium disease, chronic silicosis)
·Using the A status code: For each covered medical condition claimed on an EE-1 or EE-2, if the CE determines that the medical evidence meets the criteria necessary to accept the condition, the CE enters an A in the ECMS medical cond status listbox for "ACCEPTED" in the Medical Condition screen. This does not mean the case is accepted, just that the medical adjudication is complete for each claimed condition and the evidence is acceptable. The case could then either be accepted or denied, but the A would signify the medical development was complete and that the medical evidence met the established criteria for the particular claimed medical condition.
For claimed medical conditions with a diagnosis date prior to the filing date, the status effect dt in the Medical Condition screen must be the date the claim is postmarked or the date the claim is received by DOL or a Resource Center, whichever is the earliest determinable date but not earlier than July 31, 2001.
For claimed medical conditions with a diagnosis date after the filing date, the status effect dt in the Medical Condition screen must be equal to the date of diagnosis.
·Using the C status code: For cases that are ready for a recommended decision and contain covered medical conditions that have not been fully developed due to insufficient employment or survivor issues, the CE enters a C in the ECMS medical cond status listbox for "COVERED." This means that the medical condition is covered under the Energy Employees Occupational Illness Compensation Program Act (EEOICPA), though by the time a recommended decision was rendered, the medical development was incomplete and the case was denied for a non-medical reason.
For example, on an EE-1 form, cancer is checked. During the adjudication of the claim however, covered employment could not be verified. Since this effectively prevents payment of compensation or benefits, adjudication of the medical portion ceases and a recommended decision is rendered. At this point, the CE places the C code in the ECMS medical cond status listbox for "COVERED." This would identify those cases that have not been fully adjudicated for medical evidence in the event the claimant submits additional employment evidence later on.
·Using the D status code: For claims in which all medical development is complete, whether or not employment is verified, and the evidence still does not establish (a) that the employee had the condition or (b) that the medical statutory evidence has been met, the CE enters a D in the ECMS medical cond status listbox for "DENIED" when the recommended decision is issued.
For example, a claimant has filed for beryllium sensitivity (BeS) and the employment has been verified. The medical evidence does not support that the employee had BeS, and therefore the medical cond status would be changed to D for "Denied."
The CE enters the A, C, or D status codes into the ECMS medical cond status listbox when the case is in posture for a recommended decision.
Before a recommended decision is signed by a Senior Claims Examiner (SrCE), s/he must ensure that the correct medical condition status codes in the medical cond status listbox have been entered into ECMS. The SrCE is responsible for ensuring that ECMS accurately reflects the status of each claimed medical condition.
The Final Adjudication Branch (FAB) is responsible for ensuring that these medical cond status codes have been entered correctly by the DO prior to issuing a final decision. If additional medical evidence is submitted by the claimant prior to the issuance of a final decision, the FAB follows the established procedure and remands the case to the DO.
If the case is remanded from FAB to the district office, due to the receipt of new medical evidence, the CE addresses the remand issue and develops the medical condition. If the new evidence changes the status of the medical condition, the CE is required to update the medical cond status listbox with the actual status reflective of the new medical development.
Backfill will not be required on claims where a final decision has been issued. However, for any case still being adjudicated (for example, a remanded case) and for cases with final approvals that are being further developed for possible new approved medical conditions, it is the responsibility of all claims adjudication personnel to review and bring all medical condition records into compliance with this bulletin.
Disposition: Retain until incorporated into the Federal (EEOICPA) Procedure Manual.
PETER M. TURCIC
Director, Division of Energy Employees
Occupational Illness Compensation
Distribution List No. 1: Claims Examiners, Supervisory Claims Examiners, Technical Assistants, Customer Service Representatives, Fiscal Officers, FAB District Managers, Operation Chiefs, Hearing Representatives, District Office Mail & File Sections