RateFast’s Roadmap to Apportionment

Apportionment is one of the top three decisions which can delay a WorkComp claim from closing. This is understandable, as it’s a tricky subject. Nearly all medical providers have a different idea about how apportionment should be arrived at. Insurance companies want to pay the injured worker the right price, the injured worker needs to be adequately compensated… And the employer only wants to be responsible for the part of the injury which was caused at work.

Bottom Line: There are no clear rules with apportionment. Although the law defines that only “permanent disability” is to be apportioned, there are no instructions on how the medical provider is to actually do it. Is it functional disability (eg. could lift 20 pounds before the injury and now lifts only 10 pounds)? Is it “permanent disability” from a permanent disability rating (PDR) that results from an impairment measurement (eg. %Whole person impairment, which may or may not result in true permanent functional disability). Or, is it a change in treatment burden such as medications, therapy, and or other measurable medical support that is now needed, new, or increased from a pre-injury condition to maintain the new level of function? Which one is a correct method? They can all be used clinically with equal defensibility when correctly explained and supported.

There are a few things which can be referenced when deciding apportionment, in order to keep consistent, objective impairment reports.

Let’s start with some definitions.

  • Apportionment is one of the subsets of the PR-4 report.
  • It’s a section where the medical provider is asked to make a determination if the permanent disability that results from the work injury may be attributed medically to any other conditions.

Now time for a real-world example.

A gentleman who is 25 y/o is lifting a box at work. He injures his back and receives treatment. At the conclusion of the report the doctor is going throught the case history and it turns out that the worker had a pre-existing injury to his back. This placed him on a restriction from listing more than 20 pounds. After this new injury he can only lift 10 pounds.

Is apportionment present and if so, what %?

The answer is yes. He is 50 % apportioned to his permanent disability from the old, unrelated event when he hurt his back.

In this case we’re lucky enough to have a clear a baseline of pre-existing disability, we know the worker is at MMI, and now there’s a new level of permanent disability. This makes the apportionment determination much simpler, and helps with the timely closure of the claim. Remember apportionment is no walk in the park, so if you’re looking for any advice feel free to Submit a PR-4 report for review today!

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What is a PR-4 Permanent & Stationary Report? (for patients)

What is a PR-4 report? What is a permanent and stationary report?

The significance of a PR-4 report can be confusing to patients. This video below explains the significance of PR-4 reports for injured workers. This video introduces the topic of PR-4 reports. I’ve shown it to a few of my patients before the actual PR-4 examination takes place. It answers about 80% of the common questions that patients have about the report and the exam—a real time saver for everybody.

If you’re a patient and you have a work injury, then this video will cast some light on how your work injury is going to be evaluated and rated.

If you’re a medical provider or office manager at a medical clinic, please feel free to use the video to help explain the significance of the permanent and stationary report to injured workers that you are going to examine. Send your patients the link to this post via email, and they can watch it on their home computer—or on their cell phones while they’re in the waiting room.

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Automatic billing for your PR-4 reports! How to use the RateFast Billing Calculator

Update for 2021: RateFast Express is an even easier alternative to the wonderful RateFast software. Try RateFast Express today!

Accurately sending your bill for a PR-4 report can be a time consuming process, but it doesn’t need to be.

The RateFast PR-4 Billing Calculator counts the amount of pages in your PR-4 report, asks some basic questions, and then prints out a bill at the end of your report.

This article describes how to turn on the billing calculator and how to use it correctly.
Continue reading Automatic billing for your PR-4 reports! How to use the RateFast Billing Calculator

The fastest occupational medicine exam ever

Hi, my name’s Dr. John Alchemy—I’m a physician, a QME, as well as the CEO and founder of RateFast.

If your outpatient/office based clinic does occupational medicine, then I’d like to share a recent experience that could benefit your workplace and speed up your workday.

Using nothing but my iPhone and my laptop, I recently gave my fastest work-injury examination ever. The crazy part is that neither my patient or myself had to leave our homes.

Here’s the story: I was at home on a Saturday when I got a phone call. It was from a patient who had recently sustained a knee injury while he was at work. I had seen him recently, ordered some basic treatment, and completed a Doctor’s First report for his claim. But now he was experiencing some new symptoms: his knee was locked. He couldn’t bend it at all. Understandably, he was pretty alarmed.

If I had received this phone call 10 years ago, then my patient would have needed somebody to drive him to the emergency room, or else wait until Monday when my clinic was open. Once he got to the clinic or hospital, he would have needed to wait until somebody was available to see him. The odds of him quickly getting an appointment with me or another provider who was already familiar with his claim and work restrictions would have been pretty slim.

But that’s all in the past. Here’s what we did:

  1. We converted the phone call to a video chat.
  2. Using his phone’s camera, I examined his knee and remotely performed a physical.
  3. I determined that he had a possible bucket handle tear.
  4. While we were on the phone, I logged into RateFast on my laptop and created a PR-2 report. All the information about his injury and his employer from his Doctor’s First report imported into the PR-2 automatically, so I didn’t need to rewrite anything. Instead, I simply added some information about his new symptoms, and updated his treatment plan—specifically, I directed my patient to go to the ER or an orthopedic consultation.
  5. Then, I placed a call for sign-out to the ER. I gave them my potential diagnosis and treatment plan, which prepped them to help my patient when he arrived at the hospital.
  6. My patient’s wife drove him to the ER. But between the time they hung up the phone and the time they got into the car, I had already updated his work restrictions in RateFast and printed out the PR-2 report. It was ready to send to his employers’ insurance carrier.
  7. The whole thing—the exam, the phone call to the ER, and the PR-2 report—was over in less than 15 minutes.

Without telemedicine, this sort of visit might have easily cost my patient more than an hour—15 minutes of driving to the clinic (assuming the clinic is open), 15 minutes in the waiting room, 15 minutes of examination, and then another drive to emergency room. Without RateFast, I would’ve needed to spend extra time refreshing myself on the details of the case and filling out the PR-2 report.

Here are some of the positive outcomes of the whole business:

  1. My patient was able to get an examination without leaving his home or waiting until Monday.
  2. I essentially extended my medical practice’s office hours without losing more than few minutes of my own weekend.
  3. I was able to examine this patient without impacting the schedules of other patients who had appointments at the clinic on Monday.
  4. Since my patient didn’t need to drive as much, the employer and insurance company saved on travel expenses.
  5. My patient’s work restrictions and work status were updated sooner than they normally would’ve been, and the PR-2 was completed without a face-to-face visit.

The bottom line is that the whole claim moved forward faster, and everybody involved saved time and energy.

If you’re not already using telemedicine in your medical practice, then I can’t recommend it enough. Your patients might thank you for it.

If you’re not already on RateFast, now’s a great time to join: RateFast Express has more features than ever, and you get 2 free PR-2 and PR-4 reports (impairment ratings included!). Doctor’s First reports are completely free. Contact us at info@rate-fast.com for more information about how we can help your medical practice.

How to measure range of motion for a PR-4 report

If your patient has injured a joint, then you (the medical provider) should be sure to measure the range of motion (ROM) of that joint. It’s particularly important to report the range of motion of an injured joint in a PR-4 Report (or the PRIMARY TREATING PHYSICIAN’S PERMANENT AND STATIONARY REPORT).

Why?

Measuring the range of motion for an injured joint is essential for calculating an accurate impairment rating.

If you don’t know how much motion your patient has lost, then you can’t tell how much the work injury impaired him or her.

4 Steps to taking accurate range of motion (ROM) measurements for work comp

1. Have your patient warm up by stretching for two minutes

If your patient warms up before measuring, then your measurements  will be more accurate and consistent, with greater reproducibility.

Reproducibility of measurements within 10% is necessary for measurements to be considered valid by the AMA guides.

2. Use the proper tool

If the joint is in the upper or lower extremity (arm or leg), then use a goniometer.

If the injured joint is in the spine, then use an inclinometer.

3. Measure both sides

Notice that the PR-4 report says “Include bilateral measurements – injured/uninjured – for injuries of the extremities.”

So, if your patient has injured her right shoulder, then measure the range of motion of both shoulders. This shows the contrast between the injured body joint and the uninjured joint.

Unless, of course, both sides are injured! But in this case, you should still measure both sides and report your measurements.

4. Measure multiple times!

If the injured joint is in the upper extremity, then take two measurements across each plane (flexion, extension, etc.).

If the injured joint is in the lower extremity or the spine, then take three measurements across each plane.

5. Report your results in the “Physical Examination” section of the PR-4 report

You will find the “Physical Examination” section on the second page of the PR-4 report form that’s currently on the California Department of Industrial Relation’s website.

Make sure that you present your measurements clearly so that it’s easy to read for a claims adjuster, employer, or another doctor. Indicate the plane of motion and the side of the measurement.

We like to show our measurements in a table. This is how the new version of RateFast, our PR-4 reporting web app, displays the range of motion of a body part:

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Spine Specialist Vs. Primary Care Provider: What’s the Difference?

Dr. Christian Athanassious, a recent guest on the California Work Comp Report Podcast and a trained spine expert, gave us the lowdown on spine exams in workers’ compensation. If you’ve ever wondered how a spine exam might differ from a regular trip to the doctor, then look no further.

Spine specialists look at the exam from the point-of-view of what they can treat and what they can fix: something objective that the spine specialist can take care of. This doesn’t necessarily mean they are looking for something to operate on using surgery. Rather, a spine specialist will search for a structural cause that the specialist can give an answer to, and more than likely predict the outcome for the patient.

Depending on where along the spine the patient is experiencing pain (neck, mid-back, and/or low-back) and how that motion relates to his or her disability, the spine specialist can create a plan for medical care.

The spine specialists also considers how back pain is related to the motion of the upper or lower extremities.

Every spine exam measures the patient’s sensory function, reflex function, and motor strength. This is measured using a system of dermatomes which is how nerves map throughout the body and gives it sensation, and myotomes, which is how the nerves connect to the different muscles within the body.

Once the specialist gets an idea of where the disease or pain is coming from, then he or she can determine the specific nerves that are related to the patient’s pain or disability.

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One Simple Tip to Improve How Your Practice Organizes Work Comp Claims

Currently when patients come into a clinic, whether the clinic uses an EMR or paper charts, a chart is created. Notes are written- that works fine, as long as there’s only one injury being managed. The real problem comes up when patients get a second injury.

What can easily happen is that the notes for the two different dates of injury get shuffled together. Incorrect documents given to the provider can then further confuse the patient’s examination, and delay the claim being closed.

This is the problem with administering multiple claims in the clinic. So what’s the solution?

Patient’s injuries need to be organized around the date of the event. Unfortunately that’s not the way that we’ve created healthcare records. Traditionally you have a chart that is organized chronologically.

To solve this problem we have to re-organize the way we write and create our EMRs for Work Comp. Because in Workers’ Comp, each claim has it’s own universe, it’s own set of unique information. These need to be the drivers of the organization in the chart. All you really need to know is what date of injury is this patient here for? Once you know that then you know what the injured body parts are, and you can put your finger on the last, correct, and appropriate notes.

Once you’re working in a system that’s correctly organized by date of injury, it now presents an opportunity for everyone in the clinic to start contributing to the creation of the correct visit note. Now the front office has the opportunity to prepare the patient for an exam based on that specific date of injury. A medical assistant can open the EMR, verify the date of injury, and check-in about pending actions and RFAs.

This allows the doctor to focus on making medical decisions instead of doing clerical research. The patient’s visit goes really smoothly and the patient feels that the doctors are informed and the clinic cares about moving their claim forward.

Take a good look at how different members of the clinical team are helping as injured workers come into the office. It says a lot about the quality of care perceived by the injured worker.

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Understanding Disability: For Insurance Adjusters

Question: Dr. Alchemy, Based on limited range of motion for the neck in the PR-4 exam, can the injured worker return to usual and customary work duties? (This worker was provided an impairment rating WPI value, but no work limitations were clinically indicated).  Sincerely, DS

Answer: Dear DS, Impairment and disability are two independent concepts. Impairment value is a loss of an organ system or function to which a number value is assigned, whereas, “disability” is an ability to meet social or occupational demands. An individual may have impairment but no disability, or the reverse may be true.

A great example here is a knee injury with a meniscus tear. If I choose to not have surgery, but have range of motion above the ratable guidelines, I have a non-ratable knee, BUT I may not be able to stand, squat or lift to the requirements of the job. So, no impairment, but disability (eg. work limitation).

Same knee example as above, but I have surgery this time and a partial meniscus debridement is performed. My knee is perfect post operatively and no pain. I return work no problems. My impairment, however, is 1% WPI based on DBE table rating in Chapter 17, Lower Extremity Table 17-33 etc.

Summary, when an impairment value is incorporated into the California Permanent Disability Rating  (PDR) calculation, true “disability” may or may not be present.

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Adjuster’s Corner: For Insurance Adjusters

Introducing the RateFast “Adjuster’s Corner”.

Adjuster’s Corner is brought to you by, well, adjusters. This series of newsletters are based on real life letters and questions from insurance carrier adjusters seeking clarity and knowledge of the AMA Guides 5th Edition impairment rating situation in California.

Our responses are provided by Dr. John Alchemy, MD, DABFP, QME, CIME. Dr. Alchemy’s credentials include:

A) A current Qualified Medical Examiner (QME) for the State of CA

B) A certified educational provider for the State of CA DWC Medical Unit, specifically approved for content in the AMA Guides 5th Edition, Chapters 1,2,15, 16 and 17, in addition to advanced impairment report writing (12 hrs CME).

C) Currently certified by the American Board of Independent Medical Examiners (ABIME) as a Certified Independent Medical Evaluator (CIME) and have successfully passed a proctored written exam demonstrating competency in the AMA Guides 5th Edition rating system.

Got a great rating question? Send it in (info email link here)!  We love questions almost as much as answers.

Case Study #1 Submitted by adjuster DS:

Question: Dr. Alchemy, why did the cervical spine rating come out so high for a non-surgical neck?

Answer: Dear DS, Do not fall into the trap of responding to impairment values based on the result value. If one reads the rating criteria, surgery is only a subset of the DRE categories, and in no way, a single gateway for rating inclusion etc. Additionally, surgery plays only a subset in the rating determination when using the ROM spine rating.

Rather, I would urge you to focus on the data set that is presented, the validity of the measurements, and the application of the results to the tables and figures. The goal in providing AMA ratings is to provide the stakeholders a numeric value  based on statistical rigor, objectivity, and reproducibility.

If you have specific questions as to the validity of a number or the application of a table/figure, please let me know specifically which part of the data set is appears inconsistent and let’s have learning opportunity.

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