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Red Flags In Impairment Evaluations

Impairment evaluations should be performed and reviewed by physicians who are ex-perienced in the appropriate use of the AMA Guides to the Evaluation of Permanent Im-pairment, Fourth Edition. When risk managers or claims staff review a physician’s evaluation, they should be alert to certain red flags. While the presence of one or more of these warning signs does not necessarily mean that the final rating or other portions of the evaluation are erroneous, it does suggest a need for careful review.

In General

• Title of the AMA Guides to the Evaluation of Permanent Impairment is incorrectly referenced. (This error occurs very commonly and often reflects an evaluation per-formed by an inexperienced physician.)
• Wrong edition of the Guides is used or no edition is specified. (The physician needs to reference both the edition and the printing. With the fourth edition, there have been three printings, each correcting errors in the printing before it.)
• Evaluation is performed by a physician who has not demonstrated proficiency in using the Guides. (Within a given region, some physicians may be infamous for ratings that reflect either bias or a lack of knowledge and skill.)
• Report fails to clearly delineate the three steps: medical evaluation, medical analysis, and comparison to criteria.
• Rating is provided without indication that maximal medical improvement or permanency has been achieved. (The physician must first determine that the condition is permanent.)
• The word “disability” is used when “impairment” would be proper. (This can be correlated with inexperience.)
• Figures, tables, and page numbers in the Guides are not referenced. (This level of specificity is required.)
• Report is less than 3 pages long. (On occasion, brief reports are adequate. However, an appropriate evaluation often reflects hours of effort and results in a multiple-page report.)
• Subjective complaints that have no corroborating objective findings are rated. (Impairment must be based on objective findings, not merely complaints.)
• Psychological disorders are evaluated and a numeric value is provided. (Chapter 14, “Mental and Behavioral Disorders,” does not provide any numeric ratings. The contributors to this chapter felt that it wasn’t possible to assign numeric values to psychiatric conditions.)
• Pain is rated using Chapter 15. (The process of evaluating pain is discussed in Chapter 15; however, similar to Chapter 14, the chapter provides no numeric values.)
• Rating is qualified as an approximation, e.g., “about 10 percent.” (Specific criteria should result in specific impairment values.)

Upper Extremity Impairment Evaluations

• Figure 1, “Upper Extremity Impairment Evaluation Record,” is not completed. (There are many opportunities for error in assessing upper extremity impairments, particularly those of the hand. Using the form in Figure 1 decreases the likelihood of error.)
• Cumulative trauma disorder is rated. The Guides states: ̶A patient with wrist or hand pain or other symptoms may not have evidence of a permanent impairment. Alteration of the patient’s daily activities or work-related task may reduce the symptoms. Such an individual should not be considered to be permanently impaired under Guides criteria.” (4th ed., at 19.)
• Peripheral nerve motor impairment is greater than 25 percent of the maximum value for that component of the nerve. (It is rare for individuals to have this extent of muscle weakness.)
• Causalgia or reflex sympathetic dystrophy is rated. (This is a very problematic diagnosis, often incorrectly diagnosed and evaluated.)
• Table 16, “Entrapment Neuropathy,” is used. (Entrapment neuropathies refer to the compression of a nerve within a structure, as occurs in carpal tunnel syndrome. Table 16 is problematic since it does not provide definitions for rating the severity of the condition. Other approaches to defining neurological impairment are more thorough.)
• Section 3.1m, “Impairment Due to Other Disorders,” is used. (There is a special section in the Guides for assessing uncommon conditions. Because all of these conditions occur rarely, physicians are less likely to be familiar with them.)
• Loss of strength is rated. (There is a section in the Guides on “strength loss.” Physicians use instruments to determine the amount of strength an individual has lost and then may determine an impairment on the basis of this data. The Guides states this is used for the “rare” case and provides specific directions on how to obtain the data. The vast majority of the times physicians have used this approach to define impairment, they have been incorrect.)
• Impairment values are added. (They should only be added for the same joint, thumb motion deficits, and total-hand impairment derived from digits. Evaluating physicians often incorrectly add values that should have been combined, resulting in an elevated rating.)

Lower Extremity Impairment Evaluations

• Two or more methods are used and the ratings are combined or added. (For lower extremity impairment assessments, various models are presented. Typically, the evaluating physician should select a single model. Less experienced evaluators may use multiple models and combine or add the results.)
• Rating is based on Section 3.2a, “Limb Length Discrepancy,” Section 3.2b, “Gait Derangement,” Section 3.2g, “Arthritis,” or Section 3.2l, “Causalgia and Reflex Sympathetic Dystrophy.” (These approaches are used infrequently.)
• Range of motion (ROM) deficits for the same joint are added or combined. (In the lower extremity, the value resulting in the greatest impairment is selected rather than added to other values, which occurs with the upper extremity.)
• Values from Table 68, “Impairment from Nerve Deficits,” are used directly without complete nerve deficit. (These values should first be modified by grading the extent of motor and sensory loss.)

Spine

• The Range of Motion Model is used. (The final rating in the fourth edition must come from the Injury Model if the condition was induced by an injury.)
• Subjective complaints without objective findings are rated higher than 0 percent. (For example, an individual with complaints of low-back pain who has no objective findings has no ratable impairment.)
• Nonradicular spinal pain with objective findings is not rated as a 5 percent whole-person impairment. (Localized, nonspecific neck or low-back pain, supported by objective findings of “guarding,” results in a 5 percent whole-person impairment.
• Cervical radiculopathy is not rated as a 15 percent whole-person impairment. (If there is a cervical injury with objective findings of nerve-root-involvement radiculopathy, the rating is 15 percent, unless there is multilevel involvement.)
• Lumbar radiculopathy is not rated as a 10 percent whole-person impairment. (If there is a low-back injury with objective findings of nerve-root-involvement radiculopathy, the rating is 10 percent.)
• Recurrent radiculopathy is not rated as 0 percent. (A person can only be assigned a rating once. If an individual had a previous radiculopathy and now has a new one, there is no change in the classification, e.g., there is no incremental impairment.)
• Diagnosis Related Estimate (DRE) is higher than Category III. (Higher categories are uncommon.)
• Rating is based on “Loss of Motion Segment Integrity.” (This is a very rare condition. The Guides provides specific criteria for its determination.)
• Multiple areas of the spine are rated for single-region injury. (It is important to determine what portions of the spine are causally related to the injury.)

ABOUT THE AUTHOR

The Journal of Workers Compensation is a quarterly review of risk management and cost containment strategies published by Standard Publishing in Boston, Massachusetts. For more information, please visit standard-pub.com, or contact the editor at 800-682-5759, extension 222, or subscription services at extension 228.

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July 2000