• Alaraz/Guzman II Ratings and AMA Guides

    20 March 2012 / Impairment Rating Specialists / Comments Off on Alaraz/Guzman II Ratings and AMA Guides

    NEWSFLASH:  ALMARAZ/GUZMAN II RATINGS DO NOT PERMIT THE DOCTOR TO IGNORE THE AMA GUIDES.

    I take hundreds of doctor depositions under the AMA Guides across California.

    And here is one thing I can share with you:  most doctors believe that Almaraz/Guzman II says they can simply ignore the AMA Guides.

    THAT IS COMPLETELY INCORRECT.

    In Almaraz/Guzman II, the WCAB said there are 4 criteria which must be met for use of Almaraz/Guzman II for a rating:

    First, the doctor must do the rating specified by the Guides for the diagnosed condition correctly, following all instructions in the Guides that go with that rating.  (In 90% of the cases, doctors do not do this.)

    Second, the physician must then state that the specified rating in the Guides (which he has done correctly) does not adequately describe the Applicant's impairment.

    Third, the physician must indicate the case is extraordinary or complex.  (Many do not do this and use Almaraz/Guzman II in every case.  Wrong.)

    And fourth, and most important, the doctor must select another rating in the Guides, perform that rating correctly, and follow all instructions in the Guides relating to when and how that rating is to be done.  

    (This is the area where doctors simply try to pick and choose parts of a rating they like and ignore the rest.  In Almaraz/Guzman II, the WCAB specifically said that the Guides are an integrated document and that the doctor must follow the instructions relating to the rating.)

    So, don't let doctors tell you that they can simply do the rating anyway they want under Almaraz/Guzman II. This is not accurate.  When they ignore provisions of the Guides, file a Motion to Strike the report as not consistent with the AMA Guides and Almaraz/Guzman II.  

    Or, better yet, use a doctor who does the rating correctly.  You can find them at Impairment Rating Specialists or through my Doctor Accuracy List which you can get for free by emailing lizkennedy@askphilwalker.com.

  • Taking a Great Medical Legal History

    15 March 2012 / Impairment Physical Exam / Comments Off on Taking a Great Medical Legal History

    Know your historian.

    Before the doctor even begins the exam, he or she needs to assess the validity of the applicant. Is the applicant reliable? How clearly does the applicant recall the injury? Is there adequate understanding? Should and interpreter be present?

    These considerations are all too commonly overlooked. I cannot tell you the number of times I have had applicants bring their children as interpreters, sometimes as young as six years old!

    If dealing with a head injury and complaints of memory loss, bring in the spouse or adult children to help with the history. Lay ground rules regarding speaking in turn for the overly helpful spouse who want to talk for the applicant. Make it easy on yourself and the applicant.

    Set up the history for success, not failure, early on in the process. If the collection of the history is flawed from the beginning, how accurate do you think the conclusions will be?

  • Arthritis and the Impairment Physical Exam

    13 March 2012 / Impairment Physical Exam / Comments Off on Arthritis and the Impairment Physical Exam

    Arthritis:

    Arthritis is a term used to describe many forms of inflammation and degeneration of a joint and its components. The joint, made of bone and covered with cartilage, is constructed to allow smooth movement and minimal friction with motion.

    Arthritis has been found to have a genetic component, particularly in the spine.

    Individuals suffering from arthritis may have enlargement and swelling of the joint.

    The most common form, osteoarthritis, can result from trauma or fracture of the joint or simply the aging process. Septic arthritis is caused by joint infections from bacteria. Rheumatoid arthritis is linked to autoimmune conditions. Crystal disease such as gout or pseudogout may cause and/or aggravate arthritis.

    Treatment for arthritis ranges from conservative methods such as ice, anti-inflammatory medications, cortisone injections, or manufactured joint fluid supplements such as Synvisc. More aggressive treatments can include surgical intervention or total joint replacement.

    X-ray’s and CT scans are used in diagnoses. One should be aware that medical imaging does not always accurately indicate the severity of the symptoms.

     

    Review:

    *Some causes of arthritis are: normal aging process, underlying autoimmune conditions, metabolic conditions, or trauma.

    *Treatment for arthritis may include anti-inflammatory medications, injections, and possible surgical intervention for advanced conditions.

    *Medical imaging such as an X-ray and CT scan may aid in diagnosis.

     

    Rating Comment:

    The AMA Guides Fifth Edition provides rating for arthritis, particularly in the lower extremities, based on X-ray cartilage intervals. Rating for arthritis in the lower extremities should be obtained based on bilateral X-rays and weight bearing. When assessing arthritis of the kneecap and joint for impairment rating, it is best to obtain a Merchant's view with the knee flexed 45°.

  • Independent Medical Exam Results for Impairment Ratings

    08 March 2012 / Impairment Physical Exam, Impairment Rating Specialists / Comments Off on Independent Medical Exam Results for Impairment Ratings

    A treating physician who is not familiar with The AMA Guides can refer impairment evaluations to Impairment Rating Specialists. Our goal is to assign cases the correct and independent rating.

     

    Physicians: send us a case referral with our online form for treating doctors. Our staff will obtain authorization and schedule the patient.

  • Primary Treating Physicians Have an Option

    06 March 2012 / Impairment Physical Exam / Comments Off on Primary Treating Physicians Have an Option

    Our cases are ideally referred by the primary treating doctors who understand the value of the quality of our impairment reports. They also do not want to turn in an incorrect report or a report that can result in getting a letter-after-letter from the insurance carrier.

     

    Physicians: send us a case referral with our online form for treating doctors. Our staff will obtain authorization and schedule the patient.

  • What Is The Difference Between Exacerbation and Aggravation?

    01 March 2012 / Impairment Physical Exam, Medical History / Comments Off on What Is The Difference Between Exacerbation and Aggravation?

    A newer version of this article is
    posted at the RateFast Blog.

    Click here to read!

    A CASE STUDY FOR LEARNING.

    A 28 year old man injured his low back at work while doing repeated bending and lifting. He had a well documented pre-existing low back pain history with lumbar spine imaging that showed moderate to severe degenerative changes.

    His base line back pain was 2/10 and occasional. His work injury increased his symptoms to 8/10 and constant. The claim was accepted.

    Treatment consisted of anti-inflammatory medication and therapy. Repeat imaging confirmed his degenerative pre-existing low back pain condition.

    He was found to be a non surgical candidate. He was referred for impairment rating with the claim being nearly three years old at referral. He remained on light duty these entire three years.

    At impairment rating, he was obese, and his lumbar spine exam demonstrated no ratable findings (i.e. WPI =0%). It was discussed and agreed upon that the employee would perform a trial of full duty, although his pain was still above his pre-injury baseline.

    The employee was opined to be at maximal medical improvement (MMI). He was provided a provisional opinion that his pre-existing low back condition had been “aggravated” on an industrial basis. Future care was outlined, and it was asked he follow up in three months for an update on his clinical status.

    At four months, the carrier provided additional prior chart documentation for review, which contained no new contributory information.

    A symptom review update was carried out the employee, and it was learned that he was tolerating work at full duty without problems, and his back pain had entirely returned to his pre-injury baseline without the need of increased supportive treatment (i.e. more pain medications or an “increased burden of treatment”).

    A summary supplemental report was issued which documented the return of the employee to his pre-injury baseline. The opinion of causation was revised based on new and additional information which found the employee’s back pain to now be best described as an “exacerbation”.

    No further future care was indicated, the impairment rating remained WPI =0%, and no further treatment on an industrial basis was recommended. The employee was discharged as cured.

     

    Discussion:

    There is often confusion about the terms “exacerbation” and “aggravation”. This case nicely demonstrates these “words of art” and how they apply to clinical situations.

    The claim had been appropriately managed with conservative care, and the employee was a non surgical candidate. He had become MMI. He had not, however, been returned to a trial of full duty.

    If this were the end of the story, his condition would be considered an industrial “aggravation” of his pre-existing low back pain.

    The AMA Guides 5th Edition, Glossary, page 599, defines an “aggravation” as, “A factor(s) that adversely alters the course or progression of the medical impairment. Worsening of a preexisting medical condition or impairment”. More specifically, in clinical terms, a permanent “aggravation”.

    There was a clinical opportunity here, however, because the employee was very motivated to return to work. He was assured that after a thorough examination and review of his imaging studies, his pain was “not dangerous” and he should consider a trial of regular work, given that his current restrictions were based only on tolerance of symptoms, and not risk or capacity loss.

    He was furthermore reassured that if his symptoms worsened, he would simply return to clinic for replacement of his tolerance limitations. He agreed.

    The story ends happily, as the employee not only successfully returned to his usual and customary work, but the pain also returned to pre-injury baseline.

    An adequate trial of full duty for four months had been performed without “recurrence” of his low back symptoms. At this time, the opinion was revised to describe his condition as an “exacerbation” as that term is defined on Table 10-4, Chapter 10, Causation, of the AMA Disability, Second Edition, “Temporary worsening of a prior condition by an exposure/injury”.

     

    Keys of Review:
    • The AMA Guides 5th Edition, Glossary, page 599, defines an “aggravation” as, “A factor(s) that adversely alters the course or progression of the medical impairment. Worsening of a preexisting medical condition or impairment”.

    • This condition is best defined as an “exacerbation” as that term is defined on Table 10-4, Chapter 10, Causation, of the AMA Disability, Second Edition, “Temporary worsening of a prior condition by a exposure/injury”.

    • If the employee is motivated, and present restrictions are based only on tolerance, and not risk or capacity loss, consider a trial of full duty. Fear on behalf of the employee can be managed with adequate review of the physical exam findings and imaging if clinically appropriate. Agree on a clinical follow up plan to decide if future care management is still indicated in the claim, and further support your recommendations. This approach may minimize industrial morbidity and allow the employee to play a decisive role in the ultimate outcome of their injury.

  • Ligaments and The Impairment Physical Exam

    23 February 2012 / Impairment Physical Exam / Comments Off on Ligaments and The Impairment Physical Exam

    Ligament:

    A ligament is a soft, fibrous tissue structure that connects bone to bone to form a joint. A ligament differs from a tendon, which connects muscle to bone. Injury can occur when a ligament becomes stretched, partially torn, or completely disrupted. The injury can range from a minor strain to complete disruption of all fibrous tissue. Serious cases of injury may result in instability of the joint, significant bleeding, chronic pain, and swelling.

     

    Most ligament injuries can be diagnosed by an X-ray or MRI scan and treated with conservative measures such as ice, rest, compression, and limited bracing. When a ligament overlies a joint, it may become difficult to determine if pain and symptoms are due to a ligament injury or an underlying joint injury. In certain instances such as a knee injury, the tendon and joint cartilage may be injured at the same time. Injuries that do not respond to conservative care may require additional imaging by an MRI and/or referral to an orthopedic specialist.

     

    *A ligament connects bone to bone.
    *Treatment is usually conservative. If the condition fails to improve, additional imaging by an orthopedic specialist may be indicated.

     

    Review:
    * Caution must be taken when diagnosing an injury that involves a ligament overlying a joint. Consideration must be given for a possible deep joint or cartilage structure injury.

     

    Rating Comment: The AMA Guides Fifth Edition provides impairment rating for ligament instability in the wrist, chapter 16: Upper Extremities and in the knee, chapter 17: Lower Extremities. Additional impairment rating may also be assigned in some circumstances for ligament injuries that impair range of motion.

  • Bursa/Bursitis in Impairment Physical Exams

    21 February 2012 / Impairment Physical Exam / Comments Off on Bursa/Bursitis in Impairment Physical Exams

    Bursa/Bursitis:

    A bursa is a fluid-filled sac made of soft tissue that acts as a cushion to reduce friction between tendons and bones. Bursitis (inflammation of a bursa) occurs when the bursa becomes irritated from overuse or direct trauma. Symptoms include: pain, swelling, and even redness if infected. Shoulders, elbows, and knees are common areas prone to bursitis.

     

    This condition is often seen in trades where the employee is frequently on his/her knees such as carpet and floor industries. Treatment consists of ice, rest, physical therapy, and cortisone injections. Surgery, excision, and drainage are rarely recommended as treatment methods. Difficult cases should be referred to an orthopedist for further evaluation.

    Review:
    *Common locations: shoulder, elbow, and knees.
    *Common causes: repetitive use or trauma.
    *Bursitis usually responds well to conservative treatments such as cortisone injections. Orthopedic evaluation may be needed for difficult cases.

    Rating Comment: Per the AMA Guides Fifth Edition, bursitis alone is a non-ratable condition. Bursitis may qualify for rating if it interferes with range of motion of a joint.

  • Are Your IME Workers Comp Claims Managed Correctly?

    16 February 2012 / Impairment Rating Specialists / Comments Off on Are Your IME Workers Comp Claims Managed Correctly?

    Phil Walker, Esq with Impairment Rating Specialists goals include people getting well, going back to work, permanent impairments measured accurately, and getting paid promptly.

  • Phil Walker, Esquire & Impairment Rating Specialists

    14 February 2012 / Impairment Rating Specialists / Comments Off on Phil Walker, Esquire & Impairment Rating Specialists

    Phil Walker, Esq.Phil Walker, Esq. has over 25 years experience in representing California’s largest airlines, shipyards, steel companies, retailers, universities and insurers. He also specializes in Longshore claims and is a member of the bars of California, New York and the District of Columbia.

    Phil Walker, Esq. is an educator, professional speaker, author and AMA Guides expert well recognized in California. Phil Walker, Esq., owns Walker Companies, a California Law Corporation that offers AMA report review services to California’s largest businesses (Macy’s, UC California, Wal-Mart). Report review services insure physician rating reports are legally compliant with the AMA Guides. Mr. Walker is an expert in California employment and Worker's Compensation law. Walker Companies perform comprehensive legal services and consulting for employers, physician practices, and insurance carriers who want to improve their standards of care, and place high value on returning injured workers to their jobs. He is the author of The AMA Guides Made Simple and is a noted public speaker.

    Phil Walker is proud to be partnering with Dr. John Alchemy and Impairment Ratings Specialists to provide correct AMA reports and results for injured workers and the California Workers’ Compensation industry.

    Walker Companies and Impairment Ratings Specialists are innovators in the industry working tirelessly to meet this goal. The goal is simple: “Make California’s Workers’ Comp Work”.

Back to top