• Understanding the California Workers’ Compensation Language

    05 June 2012 / California Workers Compensation / Comments Off on Understanding the California Workers’ Compensation Language

    Understanding the California workers’ compensation language was like earning a badge of courage. This was something that medical school had completely overlooked.


    There were phrases, definitions, labor codes, and things like pr2, pr3, p and s, vocational retraining, and even words that sounded simple enough, but in actuality, meant things completely different, like “mild”, “moderate” and “severe”. It was pretty impressive. I remember the interviews that grilled new doctors to assess their understanding of this twisted and seemingly bizarre parallel universe. It went something like this: “So if his pain is slightly moderate, then increased to moderate severe with very prolonged and sustained grasping, how would you assess the loss of pre-injury capacity on the open labor market?” I quickly began to realize why most primary care clinics did not accept occupational injuries.


    What’s more, this learning curve did not take place in a single book, with a single patient, carrier, adjuster, lawyer, or even doctor, but was rather was scattered all about me like an endless treasure hunt to put all of the concepts together and try to make sense of it all. Forget the medicine, that was pretty straight forward, but try to decipher an attorney letter! It was all I could do to not embarrass myself. Many of my patients even understood the system better than me. It was a very humbling beginning.

  • The Pieces Finally Start to Fit -- Diary of an Impairment Rater

    31 May 2012 / Impairment Rating Specialists / Comments Off on The Pieces Finally Start to Fit -- Diary of an Impairment Rater

    Overtime the pieces finally started to fit. The other doctors would be kind enough to take me aside and give me amazing mini lectures on the medical legal paring of the specialty. The phrases they used, the words they placed in their exams (later to be “unleashed” if necessary during a deposition), and the verbal “jujitsu” of the daily report writing. The doctors I always admired the most were the ones who had an answer for everything, every situation, every possible employer call or scenario. They were brilliant. How did they come up with this stuff? I would try to pose my best attempt at tripping them up with yet another “hypothetical situation” (actually my last patient in the room with a question I could not answer), only to have it turned inside out like a sock.


    This was the beginning of my occupational medicine addiction. Sure, I would stray from the calling here and there with a stint in a primary care clinic for a year or two, but there was always the calling to return to the work comp clinic. And this is where our story begins.


    From the very onset, the words “California Workers’ Comp” strikes fear into the hearts of nearly every physician. It strikes fear because we as physicians are suppose to have, for some reason, a firm grasp of not only medicine, but in general every topic or problem that our patients might encounter in the course of their care (or life). A patient even asked me once where the best place in town was to have their car brakes repaired!


    Imagine being put on the spot to generate a medical legal document using words and ideas that are completely foreign to you. Not to mention that if the report is not correct or complete, your patient may be denied or delayed benefits they may be entitled to this system. And just like that steak knife ad…there’s more! You may even get deposed if your report is ambiguous or unclear in anyway. How does that sound? Kind of makes you want to jump up and down saying, “Pick me! Pick me!” or maybe not.

  • Neurological Focused Exams

    10 May 2012 / Impairment Physical Exam / Comments Off on Neurological Focused Exams

    Neurological Focused Exams should include documentation of cranial nerves 2-12, and vision screening corrected with lenses or pin hole if appropriate.

    Comment on:

    • facial symmetry,
    • light and sharp touch,
    • cold and warm perception,
    • motor grade testing (0-5 Grade Testing, page 484, Table 16-11, Chapter 16 Upper Extremity, AMA Guides 5th Edition, AMA Press, 2004),
    • deep tendon reflexes, long tract findings (clonus and plantar reflexes),
    • in addition to coordination (finger to nose, heel to shin motions), and
    • testing for ataxia (tandem gait testing and Romberg testing).
  • The Neurological Sensory Exam

    01 May 2012 / Impairment Physical Exam / Comments Off on The Neurological Sensory Exam

    Light touch sensory documentation is adequate if there are no sensory complaints, however, if “numbness” or “tingling” is noted in the history, it is advised to objectively document sensory complaint levels by using the Seims-Weinstein monofilament sets.


    I begin with the lightest weight in my set which is 0.07gm. Be certain the employee understands what the testing is looking for and how a positive sensation is registered.


    I do this by showing the employee the set, letting them apply the monofilament themselves (which has been mis understood as a needle by many an employee) and confirming they can relay a positive pre-examination test before closing their eyes and having the testing performed, right vs. left sides.


    A Seims-Weinstein filament weight is exercised properly when the filament is applied perpendicular and the body of the filament is bent. Do not drag or tickle the filament across the skin area being tested. Also, on hands and feet where there may be callus, apply the filament testing on the flexor creases for best testing results.

  • What Is Included in the Impairment Physical Exam

    26 April 2012 / Impairment Physical Exam / Comments Off on What Is Included in the Impairment Physical Exam

    In general, each orthopedic body location is examined in the same sequence order to include the following:


    Inspection: scars, atrophy, right left asymmetry, deformity, joint contractures, asymmetric gross motion, joint misalignment and muscle fasciculation.


    Palpation: tenderness, spasm, crepitus, masses, guarding.


    Range of motion: Use the goiniometer for measurements. “Measurments of active motion take precedence in the Guides. The actual measured goiniometer readings or linear measurements are recorded”. (page 451, Chapter 16, The Upper Extremities, AMA Guides 5th Edition, AMA Press, 2004)Active motion is the motion the employee can do on his/her own.


    The most common convention is to list right over left side in reporting the measurements, and a minimum of two measurements must be obtained to verify accuracy and reproducibility for rating purposes. The AMA Guides state, "Two measurements made by the same examiner using the Guides that involve an individual or an individual's functions would be consistent if they fall within 10% of each other." (page 20, Chapter 2, Practical Application of the Guides, AMA Guides 5th Edition, AMA Press, 2004).


    I list the measurement set as “Valid” or “Invalid” based on the 10% reproducibility requirement. This practice helps assists the reader in identifying ratable vs. unratable findings early on in the report.

  • Spine Examination in an Impairment Rating Exam

    24 April 2012 / Impairment Physical Exam / Comments Off on Spine Examination in an Impairment Rating Exam

    Doing the exam, I prefer to work from the top of the body down, the same format that is followed in the report dictation. This serves two purposes, it allows the examiner to again have a predictable format to minimize the chance of missed examination data, and, it helps the reader move logically through the findings.


    Spine Examination

    I use a bubble inclinometer for all measurements on the spine regardless of the DRE or Range of Motion Method being used. This is also helpful to insure accurate measurements, and validate asymmetric motion rating on Box 15-1 (page 382, Chapter 15, The Spine, AMA Guides 5th Edition, AMA Press, 2004). Become familiar with bony land marks to use the bubble inclinometer correctly. Use Chapter 15 Spine, AMA Guides 5th Edition, AMA Press, 2004 for full instructional details.


    Examine both right and left sides on all extremity exams, as this is critical for subtracting the employee’s normal (if any) impairment baseline findings from the injured side when arcs are separated and subtracted in the rating calculations. "If a contra-lateral "normal" joint has less than average mobility, the impairment value(s) corresponding to the uninvolved joint can serve as a baseline and are subtracted from the calculated impairment for the involved joint". (page 453, Chapter 16, The Upper Extremities, AMA Guides 5th Edition, AMA Press, 2004).

  • Measuring Atrophy in The Impairment Physical Exam

    10 April 2012 / Impairment Physical Exam / Comments Off on Measuring Atrophy in The Impairment Physical Exam

    “Atrophy is measured with a tape measure at identical levels on both limbs. For reasons of reproducibility, the difference in circumference should be 2 cm or greater in the thigh and 1 cm or greater in the arm, forearm or leg.” (page 382, Box 15-1, Chapter 15, The Spine, AMA Guides 5th Edition, AMA Press, 2004)


    For neck and upper extremity injuries measure right and left side circumferences for comparison. For the upper extremities measure mid bicep, mid forearm and wrists. If rating specifically elbows, also include the elbow measurements here.


    Likewise, for lower extremity cases, measure mid thigh, calf and ankle. The thigh is measured 10 cm above the patella, and the calf is measured at the maximum level bilaterally (page 530, Chapter 17, The Lower Extremities, AMA Guides 5th Edition, AMA Press, 2004).If rating the knee, also include the knee measurements.


    29 March 2012 / Impairment Rating Specialists / Comments Off on NOT FOUND

  • Henry DeGroot, MD - Program Director of Dermatologic Disease and Surgery

    27 March 2012 / Impairment Rating Specialists / Comments Off on Henry DeGroot, MD - Program Director of Dermatologic Disease and Surgery

    Henry DeGroot MD, Program Director of Dermatologic Disease & SurgeryDr. Henry DeGroot is the Program Director of Dermatologic Disease and Surgery for Impairment Rating Specialists.

    Dr. DeGroot began practicing Dermatology in 1998, and is a Diplomate of the American Board of Dermatology. He has experience as an Occupational Medicine Dermatology consultant, and currently is the CEO and Medical Director of NorCal Skin Disease and Surgery. He has clinics in Santa Rosa and Ukiah in Northern California.

    After high school he served in the United States Marine Corps both in the States and abroad. He finished his military service in Hawaii and stayed there for his initial undergraduate work at the University of Hawaii. Dr. DeGroot received his Medical Degree with Distinction at Indiana University, where he received numerous awards and scholarships. After completing his Residency at UC San Diego, where he also served as Chief Resident, Dr. DeGroot worked at Kaiser Permanente for 10 years before pursuing private practice. Dr. DeGroot has remained active in teaching and holds academic appointments with both UC Davis and UC San Francisco.

    Dr. DeGroot has experience in Occupational Dermatology and serves as both as a consultant and secondary treating physician. Visit Dr. DeGroot at the Impairment Rating Specialists website to learn more about his practice.

  • Why Our Impairment Reports Are So Different

    22 March 2012 / Impairment Rating Specialists / Comments Off on Why Our Impairment Reports Are So Different

    Impairment reports and impairment ratings are critical to the correct and timely closure of a workers’ compensation claim. In California, when the treating doctor needs to summarize the claim, he/she needs to write a PR4 Report to review the essential elements of the claim, and perform an AMA Guides 5th Edition impairment rating, required by law.


    The impairment rating report is a multi-use document used by doctors, lawyers, judges, insurance companies, and employees. The writing of an impairment report must be exceedingly clear and focused.


    Our experts help doctors and adjuster improve the quality of reports. We understand the time and expertise that goes into writing a correct summary report (PR4, QME, AME and IME) because we have written and reviewed thousands! Collectively, our associates have over 90 years of medical and legal practice experience. We place high value on accurate and reproducible evaluations. Our report formats are constantly reviewed and updated to insure they meet the highest standards of clarity, organization and opinions that are consistent with the AMA Guides to the evaluation of permanent impairment rating.


    Why Our Reports Are So Different

    We have done the research. We have reviewed thousands of impairment reports and incorporated only the “best of the best” in our report delivery design. We know that an excellent report demonstrates the examiner’s competency in five basic skill sets.


    1. Subjective History:

    The history is the employee’s opportunity to have their story told. Every claim is unique and we bring a high level of personalization to each narrative so the reader can best understand the employee’s recall and decisions he/she made in the course of their care. We tell that story in a strictly non-judgmental voice, including quotations direct whenever possible and written in the “employee’s voice”.


    2. Chart Review:

    Chart reviews are important as they serve as a parallel check to the history provided by the employee. Our review notes are specially coded and summarized in a format that highlights important information in the opinions and impairment calculation that follow. Charts are also voluminous at times. We understand that this poses a threat to losing the reader’s interest while they try to discern what is and what is not relevant.


    3. Physical Exam:

    Our exams are adhere to the highest standards of impairment rating. All orthopedic exams include measurements obtained by goniometer or dual bubble inclinometer, bilateral extremity comparisons, and a set of three trials to confirm that motion is reproduced and validated within 10% variability. Our founder, Dr. John Alchemy, MD, leads the group’s standards and expectations for the exams. Dr. Alchemy is additionally credentialed as a Certified Independent Medical Examiners (CIME) by The American Board of Independent Examiners (ABIME). The ABIME is an international organization which independently certifies examiners for competency in the correct use of the AMA Guides by proctored written examination.


    4. Certified Impairment Ratings:

    Specialized certified impairment rating sets us apart as leaders and what has made us an innovator in the industry. Each and every one of our reports are reviewed by a Certified Independent Medical Examiners (CIME) and verified as correct with the AMA Guides 5th edition prior to the report being signed and served to the requesting party. Our requirement of using CIMEs demonstrates our commitment to excellence and detail.


    5. Summarized Discussion Review:

    We integrate the entire above essential exam elements into an organized discussion review that outlines the internal consistency and conflict of the data. Opinions are considered on objective and reproducible documentation. The discussion summarizes the key findings and presents it in a usable and understandable format based on claim facts.

Back to top