The WC196 Rehabilitation Communication form was created by the Division of Workers’ Compensation to report a physical or occupational therapist’s subjective and objective findings to the referring physician.
The subjective portion of the form records the patient’s self-report about improvement and the ability to perform job duties. The form documents the patient’s compliance with rehabilitation visits and the therapist’s assessment of the patient’s effort during rehabilitation.
The objective findings include range of motion measurements and manual muscle testing. The report records the name and results of the functional outcomes tool utilized. The specific, functional and measurable goals agreed on by the patient are recorded along with the time frame for completion. In subsequent visits, the percentage of achievement is documented. The assessment and plan are included on the form along with the signature of the therapist and the date of the visit.
Billing code DOWC Z0817 $15.61
If you have any questions or need additional information, please contact Pinnacol’s provider medical billing auditors at 303.361.4940 or billingsuccess@pinnacol.com.