How to Request Authorization for Treatment

If you are a medical professional working in California workers’ compensation, then you will probably need to prescribe treatment or diagnostic testing for your patients.

When you’re working in California work comp, all treatment, testing, and other medical services must be authorized by the employer’s insurance administrator. To request authorization, you need to submit a Request for Authorization (or RFA). The RFA is a written request for treatment, diagnostic testing or other medical services for the injured worker.

Anybody can fill out a form. But it takes a true professional to complete an RFA form with all the information that insurance administrators need.

If you don’t complete an RFA form correctly, then your treatment authorization may be delayed, or not approved at all.

But you can easily submit a RFA that will give insurance administrators all of the information they need. You just need to cover all the bases by following a few simple steps.

How to Correctly Submit a Complete RFA in 8 Easy Steps

  1. Get the correct RFA form from the DWC website, here: https://www.dir.ca.gov/dwc/DWCPropRegs/IMR/IMRFormRFAClean.pdf

  2. In the top box of the form, check the reason for the RFA.

    • Check “New Request” for all treatment that you have not previously requested.
    • Check “Resubmission – Change in Material Facts” if new information is available about the employee’s medical condition.
    • Check “Expedited Review: Check box if employee faces an imminent and serious threat to his or her health” if the request is urgent–but not life threatening. (If the request is life threatening, and the employee requires hospitalization or emergency surgery, then submit a concurrent RFA.)
    • Check the “Check box if request is a written confirmation of a prior oral request.” if you have spoken with the claims adjuster, and you have agreed that the employee needs care and that the treatment will be approved. For example, if the employee requires immediate surgery or medication, and the adjuster verbally approves the treatment, you will still need to submit an RFA.

     

  3. Complete the rest of the form by providing basic information about the injured worker.

  4. In the “Requested Treatment” section, ensure that you give all details about the treatment you’re requesting in the “Other” column. For example, if you’re requesting physical therapy, then make sure that you indicate the amount of treatments; if you’re prescribing medication, then specify the dosage and refills.

  1. If you’re the treating physician, then sign the RFA. If you’re not the treating physician, make sure you get his or her signature.

  2. Submit the Request For Authorization form with the visit report (the Doctor’s First Report, PR-2 report, etc.) via fax or email. If you don’t submit the RFA with the visit report, then the RFA will likely be returned to you.

  3. You should receive your approved or denied RFA within 14 calendar days after you submit it. If you don’t, then contact the insurance administrator.

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What is the technical definition of disability?

Whether you’re a doctor, an attorney, or an insurance adjuster, a precise definition of disability is essential in impairment rating. However, for such an important term its technical definition often goes unexamined.

What You Need to Know About Disability

  1. Disability is an inability to meet social, occupational, personal, or statutory requirements because of impairment.
  2. Disability is different than impairment.
  3. Someone may have disability at home but not at work. Likewise, an individual may have disability at work, but not at home.
  4. A physician may provide an opinion on disability if he/she has expertise and is acquainted with the individual’s work activities and activities of daily living.
  5. An impairment evaluation is only one aspect of determining disability. A disability evaluation includes information about skill, education, job history, adaptability, age, environment requirements and modifications.

Time for an Example

Consider this: a 43 year old man performs sedentary clerical work. He has a permanent impairment from an amputation of the right leg below the knee. He cannot climb stairs in his home. Is he disabled from occupational demands? No. He performs clerical work that doesn’t require him to walk around. Is he disabled from personal demands? Yes! His activities of daily living are affected. Feel free to email us if you have any questions about disability and impairment rating.

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What is the technical definition of ‘Impairment’?

impair (v.) l, from Old French empeirier, from Latin impeiorare “make worse.” In reference to driving under the influence of alcohol, first recorded 1951 in Canadian English.

Okay…. But what does Impairment mean in the world of Workers’ Compensation?

If you’re a medical professional who examines injured employees, then impairment means “a loss, loss of use, or derangement.” (That’s straight out of the in the AMA Guides 5th Edition, Chapter 1, page 2.)

An injured worker’s impairment is considered permanent when the injury reaches “maximum medical improvement” or “MMI”.

Maximal medical improvement means the patient’s condition is unlikely to change in one year.

The AMA Guides 5th edition refers to impairment as permanent impairment. Permanent impairment requires evaluation of a physician.

Remember, loss, loss of use, or derangement means a change from normal.

So, let’s take this example: imagine a 27-year-old construction worker who has injured her right shoulder. At MMI, you as a doctor, measure the injured shoulder, which flexes to 160°, and then you measure the uninjured shoulder, which comes out to 180°. Does this patient have impairment?

The answer yes, because the employee has lost 20° of use.

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Understanding Exacerbation versus Aggravation

Exacerbation: from exacerbate. ex·ac·er·bate. iɡˈzasərˌbāt/
verb 1. make (a problem, bad situation, or negative feeling) worse.

Aggravation: from aggravate. ag·gra·vate ˈaɡrəˌvāt/
verb 1. make (a problem, injury, or offense) worse or more serious.

The difference… is confusing. That’s why we’re here to help! In a workers’ compensation context, the difference between exacerbation and aggravation is very significant.
  • Aggravation is a worsening of a pre-existing condition or impairment.
  • Exacerbation is a temporary or transient worsening of a prior condition.
  • The determination between aggravation and exacerbation can only be judged correctly when the employee’s work-related injury is at MMI (maximal medical improvement).

Problem Solving: A 34-year-old female has pre-existing chronic low back pain 5/10. Then, a work injury occurs, and the pain in her back increases to 8/10. Conservative care is provided, and at maximal medical improvement the pain returns to a 5/10.

Has an aggravation or exacerbation occurred?

The answer: Exacerbation, because the employee has returned to her pre-existing condition baseline.

Next time you need to look up this pesky but important difference, simply remember that the determination between aggravation or exacerbation can only be made at MMI.

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What are Activities of Daily Living in the AMA Guides 5th Edition?

An impairment report without an inventory of the patient’s Activities of Daily Living (or ADLs, as we like to say) is like trying to drive to an unknown destination without a map. After all, how can you determine the severity of an injured worker’s impairment without understanding how his or her daily life is (or isn’t) affected?

If you’re a provider writing an impairment report such as a PR-4 report, then asking your patient about his or her activities of daily living is essential. If you’re a claims adjuster or an attorney reviewing an impairment report, keep an eye out for whether or not the physician has made note of the ADLs.

What You Should Know About Activities of Daily Living

  • In the the AMA Guides 5th Edition, the Activities of Daily Living (ADLs) are an inventory of 34 activity measurements that show how an injury affects the life of the individual (page 4).
  • The activities of daily living include basic functions such as eating, speaking, personal hygiene, and moving around.
  •  The doctor’s description of ADLs serves as objective support when adjusting the final injury value (Whole Person Impairment WPI) up or down.
  • Once determined, the ADL value may serve this function for multiple impairments being calculated. For example, a shoulder injury may not even consider ADL, while a skin injury requires the ADLs to place the condition in a primary category. Other conditions use ADLs somewhere in between, such as determining the influence of pain on a nerve function.

Attention Medical Providers!

If you are examining a worker who has injured multiple body parts, then a separate ADL inventory must be performed on each injured body part. For example, if the worker has injured both her knee and her shoulder, then you should check to see how both her shoulder injury and her knee injury affect each activity.

It’s a lot of work, but it’s necessary. Here’s why:

  1. A complete ADL inventory tells the person who reads the report (such as an insurance administrator) that you invested additional time and effort into understanding the employee’s level of disability.
  2. A complete survey of the activities of daily living is a set of data that further supports the conclusions and final calculations of the reports impairment rating.

For example…

If you, as a medical provider, assign a worker’s injury a very high impairment rating—such as 90% whole person impairment—then the claims adjuster for the claim needs to understand why. If you demonstrate that the injury has disrupted all of the worker’s activities of daily living, then the impairment rating is supported. But if you don’t mention the activities of daily living at all, then you might very well receive a phone call from the insurance company in short order.

Reports that lack mention of the complete ADL inventory should be carefully considered before the conclusions are accepted as valid.

If a reader of an impairment report is unable to understand how much an injury affects the individual’s daily life, understanding the reasons for arriving at the final whole person impairment (WPI) are nearly impossible.

Bottom line: If you create impairment reports, include a complete ADL inventory. If you’re a RateFast user, then you already know that our PR-4 report-writing system  ensures that you ask about each activity for all body parts.

If you review impairment reports, insist that activities of daily living inventories are provided.

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Do you have all the tools you need to perform an impairment exam?

Doctors can’t calculate an accurate impairment rating without the proper tools. Here at RateFast, we’ve reviewed a lot (a lot) of impairment ratings, and in our experience, one reason why doctors produce incorrect unjustifiable ratings is because they did not take the necessary measurements.

Accurate impairment ratings require accurate measurements, and to get the right measurements, you need the right tools.

Tools to Calculate Impairment Ratings

  1. Height and weight scale and blood pressure cuff — You need basic measurements and the worker’s basic vital signs.
  2. Tape measure — Made of flexible material, like fabric.
  3. Goniometer — Used for measuring joint ranges of motion. We prefer using goniometer apps on our phones. If you have an Android phone, you can download the RateFast Simple Goniometer for free from the Google Play store. If you have an iPhone, check the Apple App Store soon!
  4. Inclinometer — An inclinometer is used to measure the spine ranges of motion. You can also use use two phone goniometers, or one digital master/slave inclinometer.
  5. Grip dynomometer — Here in California, this is only for pain-free cases, greater than one year from date of injury or surgery.
  6. Pinch dynomometer — Like the grip dynomometer, this is only for pain-free cases, greater than one year from date of injury or surgery.
  7. Monofilament set — Be sure to have a 10 gram member in the set.
  8. Two point nerve discriminator — You can use a bent paperclip measured to 6 mm distance.

That does it. Once you get these tools, you’ll be ready to gather the correct measurements for your impairment ratings like a pro.

What about the rating itself?

Of course, to actually calculate the impairment rating in California (and many other states), you’ll also need the A.M.A. Guides 5th Edition. Then, you’ll need some time to plow through all the tables, diagrams, and charts.

Alternatively, you can join RateFast, and let our impairment rating specialists calculate the rating for you.

How to Measure and Report Ratable Atrophy According to the AMA Guides, 5th Edition

If you’re a medical provider, then at some point in your career you will probably observe atrophy in one of your workers’ compensation cases. We hope this post is useful for you if one of your patients has atrophy that is related to a work injury.

Muscle atrophy is a medical term that is used to describe the loss of muscle size or mass when concerning orthopedic injuries or conditions. For more on the definition of atrophy, click here.

Today, we’re discussing ratable atrophy, as defined by the AMA Guides, 5th Edition.

According to Chapter 15, The Spine (page 382), ratable atrophy in the spine requires a 1 centimeter (cm) difference or greater in the arm, forearm or leg (calf), and 2 cm or greater in the thigh.

Chapter 17, The Lower Extremities, page 530 Table 17-6 allows rating values to be assigned for 1 cm or grater for the thigh or calf.

Make sure muscle atrophy measurements are reported in centimeters. If they are entered in inches, convert and round the value to the nearest centimeter (cm).

Make sure that ratings assigned for muscle atrophy are reported and provided for the injured side.

Make sure that you’re using the correct chapter (Chapter 15, The Spine or Chapter 17, The Lower Extremities) when impairment values for thigh muscle atrophy are being assigned. If you don’t use the correct chapter of the AMA Guides when assigning ratable atrophy, then the impairment rating will be wrong!

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How to Calculate an Impairment Rating for a Skin Condition

Does Impairment Rating Get Under Your Skin?

Today we Chapter 8 in the AMA Guides 5th Edition: “The Skin.” Specifically, we want to make sure that you place a skin condition in the appropriate class for impairment rating.

The rating table, found on page 178 of the Guides, represents the rating strategy for the entire “Skin” chapter. The rating method is a class based rating system comprised of 5 classes. The whole person impairment range for the chapter is 0-95%.

The rating method in this chapter is primarily driven by the impact of the skin condition on activities of daily living (ADL;Table 1-2 Page 4).

Inventory the Activities of Daily Living!

Initial classification of the skin condition is based on determining how many ADLs (activities of daily living) are “limited.” The ADLs that are considered to be limited by the industrial injury or condition are then grouped into the following categories:

  1. No (none)
  2. Few
  3. Many
  4. Most

Classes 3 and 4 are differentiated by “intermittent confinement at home or domicile.”

Summary

When creating or reviewing an impairment rating for the injured employee’s skin, make certain the ADLs have been properly reviewed. It is necessary that those ADLs used to classify the rating category clearly are indicated as “limited.” When “Many” ADLs are reported as “limited,” a statement should be included if the condition results in the individual being confined to his or her home.

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The Department of Transportation Gets Mobile App Support

We recently came across another reporting application. 3bExam is a web application developed by Bit by Bit in New York. Although 3bExam doesn’t have much to do with workers’ compensation, it is a platform designed for use by medical professionals to streamline a government-required examination: the DOT exam.

    • 3bExam aims to streamline the medical certification process for the Department of Transportation (DOT) driver physical exams.
    • This app allows medical providers to perform the DOT certifying exam using a mobile device or personal computer. The goal is to eliminate the old paper system and improve the guidance of the examiner while minimizing completion errors.
    • Designed for the cloud, this app allows users to access files across multiple devices.
    • 3bexam contains a menu driven dashboard which allows medical staff and provider to work as a team in collecting medical history and exam findings on the driver being examined.
      Report signatures are obtained while in the app. When the doctor completes the exam, the document is submitted to the electronic FMCSA database (currently a manual, and time-consuming process for the medical provider)
    • It is supported on all major browsers including Firefox, Chrome, Internet Explorer, and Safari.
    • Bit by Bit plans to release the app in the Apple App store in the near future. However, a 3bExam app is available for custom download by the developers.

For up to 25 exams per month, the cost is $49. If you perform more than 25 exams in a month, then the price is $99 per month. Payment method is credit card on file and monthly invoicing.

We did not get a guest account for actual trial report writing, so we are unable to make a recommendation on the utility and functionality aspects of the 3bExam app.

The Bottom Line

If you perform multiple DOT exams in your medical practice, then 3bExam might be worth a try—or at least worth a free demo.

If you have used 3bExam, or work in relation to the DOT exam, then share your experiences in the comments section.

If you have an occupational medicine related mobile app you would like us to review, please contact us.

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How To Determine Muscle Atrophy in a Workers’ Compensation Exam

What is muscle atrophy?

Muscle atrophy is a medical term which is used to describe the loss of muscle size or mass when concerning orthopedic injuries or conditions.

Atrophy may occur in any orthopedic area, but for the purposes of impairment rating in the the AMA Guides 5th Edition, the term is usually applied to describe muscle loss in the arms or legs.

It’s important to note that the AMA Guides 5th Edition does not formally define the term “atrophy” anywhere in the formal text, glossary or the errata papers.

What causes muscle atrophy?

Muscle atrophy may be caused by disuse of muscles, injury to the central or peripheral nervous system, or a primary disease of the muscle itself. In the context of injury, muscle atrophy is most often caused by pain limiting the exercise of muscles or nerve damage which decreases the signal allowing the muscle to contract and exercise normally.

How To Determine Muscle Atrophy in a Workers’ Compensation Exam

Muscle atrophy in the limbs are objectively measured (limb circumference) with a flexible tape measure. For impairment rating purposes it’s reported in centimeters (if you’re using the AMA Guides 5th Edition—which you should be, if you’re in California).

Muscle Atrophy in the Arms

When measuring the arms, measure at the biceps and forearms. You can look it up for yourself in Chapter 15, The Spine, which instructs the medical evaluator to measure the injured worker’s arms “at the same distance above or below the elbow;” (page 392).

Strangely, there is no rating provided for muscle atrophy in Chapter 16, The Upper Extremities.

Muscle Atrophy in the Legs

In the legs, measure at the thigh and calf. Chapter 17, The Lower Extremities, instructs the medical examiner to measure the leg “at equal distances from above the joint line or another palpable anatomical structure.”

You might notice that Table 17-16 specifically states that the thigh “is measured 10 cm above the patella with the knee fully extended and the muscles relaxed.” Also, it says the calf “is compared with the circumference at the same level on the affected side.”

Note: Nowhere in the AMA Guides does it mention the position for measuring atrophy e.g. sitting, standing, or prone.

Summary

  • Muscle atrophy may be caused by disuse of muscles, injury to the central or peripheral nervous system, or a primary disease of the muscle itself.
  • The AMA Guides 5th Edition does not formally define the term “atrophy” anywhere in the formal text, glossary or the errata papers.
  • Muscle atrophy is a ratable finding in only two chapters of the AMA Guides 5th Edition, Chapter 15, The Spine, and Chapter 17, The Lower Extremities. (A ratable finding is a condition that affects the impairment rating.)
  • Chapter 15, The Spine, instructs the evaluator to measure arms “at the same distance above or below the elbow;” (page 392). Chapter 17, The Lower Extremities, instructs the evaluator to measure the leg “at equal distances from above the joint line or another palpable anatomical structure.”

Impairment Reporting Tips

  • Always define or look at the evaluators note for a description of where measurement for the assessment of muscle atrophy is performed e.g. Mid biceps or 10 cm above the knee joint line.
  • Make sure muscle atrophy measurements are reported in centimeters. If they are entered in inches, convert the value to centimeters (cm) and round up to the nearest cm for 0.5 or greater values and down to the nearest cm for 0.4 or less values.
  • Make sure that ratings assigned for muscle atrophy are reported and provided for the injured side.

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