Guidelines for Impairment Evaluations

Subject

Standard

Reference

Evaluation examiner requirements

r Impairment evaluation must be performed by a licensed physician. This includes allopathic, chiropractic, and osteopathic in most states.

“medical evaluation performed by a physician” (2.1 Defining Impairment Evaluations, 18)

r Physician must meet any state requirements to perform these evaluations.

“ state may restrict . . .some require additional state certification and other criteria” (2.2 Who Performs Impairment Evaluations?, 18)

r Evaluating physician was independent and unbiased in the exam and reporting process.

“role in performing an impairment evaluation is to provide an independent, unbiased assessment. . .” (2.3 Examiner’s Roles and Responsibilities, 18)

Background

r Physician documented that the examinee understood that the evaluation’s purpose was medical assessment only.

“needs to ensure that the examinee understand that the evaluation’s purpose is medical assessment, not medical treatment” (2.3 Examiner’s Roles and Responsibilities, 18)

r Physician provided the necessary medical assessment to the party requesting the evaluation, after acquiring the examinee’s written consent.

“to provide the necessary medial assessment to the party requesting the evaluation, with the examinee’s consent” (2.3 Examiner’s Roles and Responsibilities, 18)

History

r Provided narrative history of the medical condition(s) with the onset and course of the condition, symptoms, findings on previous examination(s), treatments, and responses to treatment, including adverse effects.  Included information relevant to the onset of the condition(s).  Referenced relevant investigations.  Included a detailed list of prior evaluations.

2.6a.1 (2.6 Preparing Reports, 21)

r Assessed current clinical status, including
   current symptoms
   review of systems
   physical examination
   list of contemplated treatment & rehab
   any anticipated reevaluation.
 

2.6a.3 (2.6 Preparing Reports, 21)

r Listed all diagnostic study results, and identified  outstanding pertinent diagnostic studies.
 

2.6a.4 (2.6 Preparing Reports, 21)

r Assessment included effects of function and identified abilities and limitations to performing activities of daily living.

“. . . including its effect on function, and identify abilities and limitations to performing activities of daily living as listed in Table 1-2” (2.3 Examiner’s Roles and Responsibilities, 18)

Examination

r Consistency and reliability of findings evaluated and discussed in report.

“must use the entire range of clinical skill and judgment when assessing whether or not the measurements or test results are plausible and consistent” (2.5 Consistency, 19)

r Reproducibility and reliability of findings assessed (measurements should fall within 10% of each other).

“Two measurements  . . . would be considered consistent if they fall within 10% of each other.  Measurements should also be consistent between two trained observers or by one observer on two separate occasions . . . “ (2.5d Interpolating, Measuring, and Rounding Off”, 20)

r Prosthetic or assistive device were removed prior to rating, excepting devices not easily removed, and glasses or contact lenses (unless expressly and specifically noted).

“If . . .device can be removed or its eliminated relatively easily, the physician should usually test and evaluate the organ system without the device” (2.5f Using Assistive Devices in Evaluations, 20)

Diagnoses and Clinical Assessment

r Discussed diagnoses and impairments.

2.6a.6 (2.6 Preparing Reports, 22)

r Discussed clinical course of condition(s) and whether further medical treatment is required.

2.6a.8 (2.6 Preparing Reports, 22)

r Described the residual function and impact of the medical impairment(s) on the examinee's ability (or lack thereof) to perform activities of daily living.

2.6a.8 (2.6 Preparing Reports, 22)

r Listed the types of affected activities of daily living (Table 1-2, 4) and identified any medical consequences for performing activities of daily living.
 

2.6a.8 (2.6 Preparing Reports, 22)

Maximum Medical Improvement

r Discussed the medical basis for determining whether or not the examinee is at maximum medical improvement, or when the examinee should be expected to reach MMI.
 

2.6a.5 (2.6 Preparing Reports, 21)

Impairment Evaluation

r Report documented evaluation performed by the AMA Guides to the Evaluation of Permanent Impairment, Fifth Edition (or other Edition if required).

“it is strongly recommended that physicians use this latest edition, the fifth edition” (1.1 History, 1)

r Chapter used where the problems originated or where the dysfunction was the greatest.  

“generally, the organ system where the problems originate or where the dysfunction is greatest is the chapter to be used for evaluating the impairment” (2.4 When Are Impairment Ratings Performed?, 19)

r Compared the medical findings with the impairment criteria within the Guides and calculated the appropriate impairment rating.

2.6b (2.6 Preparing Reports, 22)

r Discussed how specific findings relate to and compare with the criteria described in the Guides.
 

2.6b (2.6 Preparing Reports, 22)

r Began with provided rating of the most significant impairment and evaluated other impairments in relation to it.  

“begin with an estimate of the individual’s most significant (primary) impairment and evaluate other impairments in relation to it.” (2.5b Combining Impairment Ratings, 19)

r Included an explanation of each impairment value with reference to the applicable criteria of the AMA Guides.

2.6c.1 (2.6 Preparing Reports, 22)

r All criteria considered in placing an individual’s impairment rating within a range which includes performing activities of daily living.
 

“consider all the criteria in placing an individual’s impairment rating within a range which includes performing activities of daily living” (2.5d Interpolating, Measuring, and Rounding Off”, 20)

r Referred to and explained the absence of any pertinent data and how the physician determined the impairment rating with limited data.
 

2.6b (2.6 Preparing Reports, 22)

r Adjusted ratings for inconsistent findings and explained rational.  

“may modify the impairment rating accordingly and then describe and explain the reason for the modification in writing.” (2.5 Consistency, 19)

r Impairment rating not altered if a patient declines treatment.

“A patient may decline surgical, pharmacologic, or therapeutic treatment of an impairment” (2.5g Adjustments for Effects of Treatment or Lack of Treatment, 20)

r Combined, and not simply added, separate conditions using the Combined Values Chart.

“related but separate conditions are rated separately and impairment ratings are combined” (2.5b Combining Impairment Ratings, 19)

r Did not combine impairment of secondary impairment if already included in the primary impairment.

“unless criteria for the second impairment are included in the primary impairment” (2.5b Combining Impairment Ratings, 19)

r Did not combine separate, yet unrelated conditions at the whole person level.

“each impairment rating is calculated separately, converted or expressed as a whole person impairment, then combined” (2.5b Combining Impairment Ratings, 19)

r Additional impairment for chronic pain, if appropriate, per guidelines in Chapter 18.

“The impairment ratings in the body organ system make allowance for any accompanying pain.” (2.5e Pain, 20) , however, Chapter 18 makes allowances for a "qualitative method for evaluating permanent impairment due to chronic pain" (p 565)

r Final rating rounded to the nearest whole person.

“final calculated whole person impairment rating . . . should be rounded to the nearest whole number” (2.5d Interpolating, Measuring, and Rounding Off”, 20)

r Rated permanent impairment, not disability.

“Impairment percentages derived according to the Guides criteria do not measure work disability” (1.2b Disability, 9)

r Apportionment derived from rating current state of impairment and subtracting prior impairment using current edition of the Guides, providing an explanation of the medical basis for all conclusions and opinions. 

“If an individual received an impairment rating from an earlier edition  . . the individual is evaluated according to the latest information.  . . . The value for the preexisting impairment rating can be subtracted from the present rating to account for the effects of the intervening injury or disease” (2.5h Changes in Impairment from Prior Ratings, 21)

r Included a summary list of impairments and impairment ratings by percentage, including calculation of the whole person impairment.

2.6c.2 (2.6 Preparing Reports, 22)