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Luis Pérez-Cordero PD
Rating Specialist |
California
Permanent Disability Ratings WWW.PDRATINGS.COM Voice:
(415)-861-4040 |
Craig
A. Lange Administrator/Med
Report Tech |
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Southern California Fax #: (619) 374-7334 / Sacramento/Central
California Fax #: (916) 848-3582 Bay Area Fax #: (415)
276-3741 |
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Permanent & Stationary Comprehensive
Medical Report Common Report Errors And How To Fix Them |
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I
Speaking The Same Language:
Defining Permanent Disability (PD)
A
Permanent Disability (PD) – LC Section § 4660 & (8 CCR 10151) Workers Compensation (WC) represents a compromise between the
interests of both employer and employee. The physician plays a critical role
in helping all concerned parties in their ‘good faith’ effort to quantify
disability to arrive at appropriate compensation for work-related injuries. PD is the benefit segment of WC that deals with the residual effects
of an industrial injury (partial
or total loss as compared to its previous level of functioning). PD (%) is the degree to which the
permanent effects of the injury have diminished the capacity of an employee
to compete for/maintain employment. 1. When
determining PD we consider: (LC § 4660) a.
The
nature of the physical injury/disfigurement, b.
The
occupation and age when injured, c.
The
diminished ability to compete in an open labor market. 2.
A rating can range from 0% to
100%. Presumptions of Total
Disability: (a) Loss of Both Eyes or sight (b) Loss of Both Hands
or their use thereof. (c) Total Paralysis (d) Insanity/Imbecility. All others
are determined in accordance with the facts. (LC § 4662) 3.
We rate medically evaluated residuals of an industrial injury by
the use of The Schedule of Rating Permanent Disabilities. The Schedule creates an arrangement of disabilities and values, which
stand in relationship to one another.
It provides the structure necessary to assign a standard to a
non-scheduled disability according to its seriousness. The medical
findings and conclusions translate into a Permanent Disability Rating
Formula which can be based on: a.
Objective
Physical Findings - amputation/motion
loss/orthopedic appliances b.
Subjective
Factors - disabling when
they affect function c.
Loss
of functional capacity -
expressed as a % of loss and/or a work restriction for a specific function or
group of functions. II
Indexes of Disability (Functional Loss) A
OBJECTIVE MEASURABLE PHYSICAL
FACTORS: Physical/Operational Loss. Two
correlating Indexes (and/or their components) are used to assist in the
numeric rendering of equitable, predictable determination of PD. Either Index or both can be used to
describe a particular condition. Each generates its own disability rating
formulation. When both are used, the
Index producing the higher rating is taken. Clear and logical reasoning
must support the evaluator’s opinion of functional loss under either
index. No level of residual permanent disability is immune from these
requirements. Page
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Luis Pérez-Cordero PD
Rating Specialist |
California
Permanent Disability Ratings WWW.PDRATINGS.COM Voice:
(415)-861-4040 |
Craig
A. Lange Administrator/Med
Report Tech |
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Permanent & Stationary Comprehensive
Medical Report Common Report Errors And How To Fix Them |
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The
Schedule provides standard ratings for much impairment, frequently at their
most disabling extremes. Most
scheduled objective factors of disability are for total loss of motion or
amputation at a joint. However, residuals from injuries are
more often partial impairments. The rating should reflect the proportional
amount of loss appropriate to the condition.
This is achieved by taking a fractional portion of the age adjusted
rating [formula] for complete loss. The use of Orthopedic Appliances is also given consideration, when
medically prescribed. Reporting
Measurable Findings: Physician must report
measurable physical elements of disability in accordance with the standard
method as described in the book - Evaluation
of Industrial Disability. (Packard Thurber, MD)- California
Code of Regulations 8 CCR 46 & 9725
"Packard
Thurber defines how the evaluator should measure the physical elements of
disability; Packard discusses what should be measured.” –Industrial Medical Council 1. Reporting includes: 1 a.
Relevant
description of body habitus and any general observations such as obvious
discomfort while sitting, standing, limping, etc. Example of Clear Reporting Language: “Dexterity
and hand strength were intact for handling papers and when opening the
examination room door.” b.
Circumferential
measurements & comments of the involved muscle groups and supporting
tissues. c.
Evaluation
of all joints on an injured extremity, including the inhibited arc of
motion as well as comments on rhythm/pattern (progression pace) of any given
joint. d.
The
Notes & the Reasons for any limitations and/or discrepancies in formally
measured vs. casually observed range of motion. If measurements or observations are normal, simply state ‘normal.’ Example of Clear Reporting Language: “Pain was experienced with range on motion in all directions.
Range appeared more restricted during the formal aspects of the examination,
than during the interview. Range of
motion was limited in a standing posture that was not commensurate with his
ability to sit unsupported on an examination table. The loss or range of motion doesn’t represent a factor of
medical impairment. “ (Dr.
Alan Kimelman, PQME) e. Grasping
power measurements - 3
successive tests of the right and left grips
(with the wrist in moderate dorsiflexion); reporting all test results;
commenting on exerted effort during testing; providing complete measurements
of both upper extremities; giving a reasoned opinion logically explaining the
causation for the grip loss, if any. Example of Clear
Reporting Language: “Examination of
the hands reveals no masses, deformities or scars. There is no intrinsic
thenar or hypothenar atrophy, swelling, signs of disuse atrophy or areas of
tenderness. The patient is able to make full grip, whereby all fingertips
touch the midpalm crease and the patient extends all fingers fully. The patient is able to touch the fifth
metacarpal head with the respective thumb.
Carpal compression test, Phalen and Tinel are negative for median
nerve entrapment in the carpal tunnel.
There is excellent strength of opposition, without intrinsic
tightness. There is no collateral ligament laxity in any of the digits, with
all flexors/extensor tendons fully functional, without any extensor lag.” Dr. R.G. Ghazal
– PQME Example of Clear
Reporting Language: “In the Primary Treating
Physician (PTP) P&S evaluation, (PTP) states that the patient is in need of
a non-scheduled work preclusion of being able to sit or stand or otherwise
move about to change position at will. She did not complain to me about
problems with sitting. During my Evaluation, she sat for approximately 45
minutes during the history-taking portion of examination. I do not feel that
she needs any work preclusion in that regard. Regarding standing, she describes no pain or impairment with
her standing. Her primary pain aggravators are lifting, to a lesser
extent repetitive bending, and twisting.”
Ross Chiropractic: Douglas Kyle, DC,
D.A.B.C.O. 1 For A More
Complete Outline: Refer To Evaluation of Measurable Factors at http://www.pdratings.com/MeasurableObjectiveFactors.htm Page
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Luis Pérez-Cordero PD
Rating Specialist |
California
Permanent Disability Ratings WWW.PDRATINGS.COM Voice:
(415)-861-4040 |
Craig
A. Lange Administrator/Med
Report Tech |
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Permanent & Stationary Comprehensive
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2.
The Impact of Under-Reporting: a.
Medical Legal Report must be capable of
proving/disproving a disputed medical fact. In determining whether a report meets
requirements, a WCAB Judge considers the substance, as well as ‘form’ of the
report, as required by applicable statutes and regulations. (LC§ 4620) Comprehensive Medical-Legal Evaluation: Evaluation of an employee, which results in the preparation of a
narrative medical report prepared and attested to in accordance with
LC§ 4628. Follows any applicable
procedures promulgated under LC§ 139.2 and the requirements of 8 CCR § 10606.
Is either performed by a (QME), (AME), or (PTP). (8 CCR § 9793
{c}.) b.
Substantial
Medical Evidence Is:
i.
The complete and thorough
evaluation of objective measurable and clinical factors.
ii.
The complete description of
Subjective Disability Factors and its relationship to the underlying
pathological processes, while distinguishing the difference between
‘complaints’ and ‘subjective disability’ and it affects function.
iii.
The foundation of Labor Code §
4660’s ‘implementing tool’ - The Schedule for Rating Permanent
Disabilities.
iv.
The support for the
reasoned/rational medical opinion requirements of 8 CCR WCAB §
10606(f)(h)(i)(k)(m)(n) as to the nature, extent and duration of disability
and work limitations.
v.
The validation for addressing
the diminished ability to compete in an open labor market. (Need for job modifications) (LC § 4660 [a]) 3.
Example: Under-Reporting Grip: No Comment On Readings or
Effort
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Luis Pérez-Cordero PD
Rating Specialist |
California
Permanent Disability Ratings WWW.PDRATINGS.COM Voice:
(415)-861-4040 |
Craig
A. Lange Administrator/Med
Report Tech |
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4.
Example: Under-reporting Grip: Estimated Normal (en) Average Normal
are to be used in cases of bilateral injuries or pre-existing disabilities; the
individual characteristics are used to modify these figures, e.g. age,
stature, weight, range of motion of other body joints, anomalies, or other
abnormal conditions, etc.
B
Subjective Factors: (The Most Problematic
Reporting Area.) Subjective Disability is characterized in
terms of affected body part, intensity, frequency, and activity giving rise
to the pain. Disabling pain should be
described by the activity or activities that produces the pain. Other
subjective factors can include numbness, weakness, tenderness, paresthesias
and increased/decreased sensitivity. All
of these factors may or may not cause a degree of disability. They become disabling when they affect
function. List the employee’s
complaints at the time of examination. Describe any subjective complaints,
which the employee attributes to the industrial injury, and then give your
medical opinion regarding validity and the reasons for conclusions. Page
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Luis Pérez-Cordero PD
Rating Specialist |
California
Permanent Disability Ratings WWW.PDRATINGS.COM Voice:
(415)-861-4040 |
Craig
A. Lange Administrator/Med
Report Tech |
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Permanent & Stationary Comprehensive Medical
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1. Reporting of Subjective Disability Factors includes: a description of the
activity that produces the symptoms (heavy work, repetitive use, heavy
lifting, etc.), the duration or frequency of the symptoms (occasional,
intermittent, frequent, constant), the level (intensity) of the symptoms
(severe, moderate, slight, minimal), the activities precluded as well
as those that can be performed with the symptoms. Comment on the means necessary to relieve the symptoms
and all other subjectives whether they are pain, tenderness, sensitivity,
sensory disturbances, weakness, fatigue or neurogenic residuals.
(8 CCR 46, 9725, & 9727) 2.
Example: How Identifying Language Becomes Inconsistent Language: In the Same Medical Report
Physician describes the following conflicting levels of disability.
3.
Identify both Complaints
& Subjective Disability: a. Describe any complaints the patient
attributes to the injury and then give opinion regarding validity and the
reasons for conclusions. Describe the pain and report complaints of
radiating pain into other areas, using the injured worker’s own words,
particularly if this results in a separate physical impairment. Describe
collateral symptoms, such as itching, cramping, tingling, etc., in regards to
location, severity, and frequency in relation to motion, effort and activity.
Outline factors or treatments, which tend to relieve the pain or symptoms. Page
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Luis Pérez-Cordero PD
Rating Specialist |
California
Permanent Disability Ratings WWW.PDRATINGS.COM Voice:
(415)-861-4040 |
Craig
A. Lange Administrator/Med
Report Tech |
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Permanent & Stationary Comprehensive
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b.
Describe
how the symptoms affect performance/ability to work, rather than how
severely the injured worker perceives the symptoms. c.
Then, “translate” into ratable language in the Subjective
Factors of Disability Section.
i.
Disability cannot be based on the
complaints. Complaints are not ‘Subjective Disability’. Disability is based on the objective
medical opinion as to the subjective factors of disability after the
completion of the medical evaluation. The reasons supporting the subjective
disability must go beyond a listing of diagnoses or findings.
ii.
Example: “Once again, I do not feel
that any additional therapy and or intervention at this point would improve
this patient’s current pain complaints. For a person who complains of
moderate-to-severe pain subjectively, he has no pain guarding and/or evidence
of disuse atrophy, he appears very comfortable and is able to participate in
his physical exam without any complaints.” – Northern
California Rehabilitation Associates
4.
Complete Identifying Language: (Incomplete Language =
Assumptions/Conjecture) |
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C
Work Capacity Index:
Justifiable Limitations of Functional
Loss. The overall loss of pre-injury
capacity should be discussed, identified and explained with references to the
factors and functional tasks used in the formulation of the estimate. Functional loss is correlated
with work history, findings, & examination, and is indicated in terms of a
percentage loss of pre-injury capacity for the specific individual. A Scheduled or Analogized Work
Restriction (an
identifiable word description of functional loss for pre-determined values) can be an equivalent
counterpart. Page
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Luis Pérez-Cordero PD
Rating Specialist |
California
Permanent Disability Ratings WWW.PDRATINGS.COM Voice:
(415)-861-4040 |
Craig
A. Lange Administrator/Med
Report Tech |
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Permanent & Stationary Comprehensive
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Fix Them |
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D
Work Capacity Index:
Justifiable Limitations of Functional
Loss. The overall loss of pre-injury
capacity should be discussed, identified and explained with references to the
factors and functional tasks used in the formulation of the estimate. Functional loss is correlated
with work history, findings, & examination, and is indicated in terms of a
percentage loss of pre-injury capacity for the specific individual. A Scheduled or Analogized Work
Restriction (an
identifiable word description of functional loss for pre-determined values) can be an equivalent
counterpart. In order to
prevent further injury/disability (whether specifically relevant to the
current occupation), work restrictions establish limits of specific
activities or tasks due to a disability that impedes an activity, body
position & motion, to avoid an exposure such as to chemicals,
substances, heat, etc. 1.
Percentage Loss of Pre-injury Capacity: Based on a comparison of what
the worker could do before and after the injury. The loss of pre-injury
capacity is reported as a percentage. The medical evidence relied on must be
clearly described. (AD No. 4061-02-18899 – Rocha vs. C.C.I.) Loss of
pre-injury work capacity can be estimated broadly in four main levels
addressing the 25%, 50%, 75%, and 100% levels of functional loss. When sufficient information is
available, the physician should be able to estimate the overall level of
functional loss more precisely.
a. Integrating vs. Fragmenting Functional Loss in The Extremities: Upper Extremity Chart - http://pdratings.com/singleuec.htm Lower Extremities Chart - http://pdratings.com/lowerextremities.htm Joint function
doesn’t occur in total isolation, but rather as an integral component of the extremity’s kinetic
chain. For example, in an
upper extremity the elbow joint serves as the anatomic link between the
shoulder (arm) and hand, thereby allowing hand placement as well as upper
extremity force transmission and absorption. Keeping in mind the anatomy and biomechanics of the injured
extremity, the physician can express loss of pre-injury work capacity by
referring to the “loss of function” dealing with placement, movement,
manipulation, dexterity, pinching, grasping, gripping, torquing, pushing,
pulling, lifting, carrying, repetitive movements, fine manipulation, and/or
other activities involving comparable physical effort. For the lower extremities, the overall % loss of
pre-injury capacity should address the activities pertaining to the
anatomical functioning of the lower extremities as it pertains to weight bearing activities
derived from the primary anatomical function of the lower extremities, which
involves the support of the full weight of the body by the legs. Weight bearing preclusions include such activities
as standing, walking, squatting, kneeling, crouching, crawling, pivoting,
climbing, walking on uneven ground or other activities of comparable physical
effort, such as lifting, carrying, pushing/pulling, etc. b. General Examples For The
Extremities: 40% loss of pre-injury capacity for lifting, pushing-pulling, grasping, pinching, holding,
torquing, finger dexterity/manipulation and other activities of comparable
physical effort. 50% loss of ability for manipulation or repetitive tasks. 75% loss of ability for
forceful grasping. (Power gripping) (Sustained Grasping) 25% loss of pre-injury
capacity for weight bearing 50% loss of pre-injury capacity for knee
flexion and extension. Page
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Luis Pérez-Cordero PD
Rating Specialist |
California
Permanent Disability Ratings WWW.PDRATINGS.COM Voice:
(415)-861-4040 |
Craig
A. Lange Administrator/Med
Report Tech |
|
Permanent & Stationary Comprehensive
Medical Report Common Report Errors And How To Fix Them |
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2.
Preventive Work Restrictions (PWR): Stated in order to prevent further injury when an
injured worker cannot/should not perform a specific function or a similar
group of functions. Based on medical impairment, PWR are stated to prevent
undue pain or harmful symptoms. The type of limitations can be both
‘temporary’ (to allow employee to return to modify work during healing
process) and permanent. They
facilitate job or ergonomic modifications, helping to determine levels of PD
functional loss as well as job retraining plans for Vocational Rehabilitation
Benefits. PWR are always
based on a sound medical opinion that takes into account all aspects of the medical
evaluation, medical history and measurable
physical/clinical findings. They are imposed when warranted by the
findings and when the physician feels that further performance of a specific
work function or group of functions will lead to: (1) increased symptoms, (2)
excessive increase in the need for treatment, (3) excessive flare-ups, (4) a
greater level of residual permanent disability. If no work preclusions are
needed and the residual disability is best expressed by either the objective
or subjective factors alone, it should be so stated “Disability may be expre ssed in terms of
limitations of work activities. The
Schedule provides a framework of work capacity guidelines for individual
torso (i.e., neck, back, pelvis, abdomen, heart, chest and lungs), and
separate guidelines for lower extremity disabilities.” [Page 1-8 of The Schedule.] 3.
Paradoxical Use of The Word
Prophylactic:
The word prophylactic
means ‘to-guard-against’. When used
with a work restriction, it implies that without the work restriction, the
injured employee would be harmed.
III
Consonance: Between Discussion of Disability (PD) and The Need For
Job Modifications. A
The Job & Its
Functions: Your Descriptions as to
job duties and activities. There should be no
inconsistencies between statements addressing an
injured employee’s need for job modifications and the described levels of
functional loss under Permanent Disability. Understanding Scheduled
terminology and their corresponding levels of functional loss avoids
misunderstandings and inconsistencies when describing multiple factors of
disability: loss due to subjective factors, work restrictions and/or the
‘opinion’ on the need for job modifications or alternative work. A Job Description or Job Analysis helps with
the Medical Eligibility for Determination and the loss of functional
capacity. If not provided, ask the
employee to describe duties and incorporate the description in the report.
The description then becomes a qualifier for the physician’s
eligibility determination and description of functional loss. Correlation of functional
loss (PD) to the need for current modifications or job functions helps all
parties understand if the injured employee can return to the position they were
engaged at the time of the injury. Helpful identifiers of a
realistic level of functional capacity or loss: (1) actual deportment and bearing (prior, during
and after) the examination, (2) current job functions/duties (if now engaged in a different occupation). Like PD, the determination for job
modifications must include not only the conclusion, but also the rationale. 1.
Examples of Integrating Language
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