How to Calculate an Impairment Rating for a Skin Condition

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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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What exams are included in the RateFast application?

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In order to guarantee accurate impairment ratings and truly complete work-comp reports, the Ratefast app guides users through various medical examinations according to the requirements of the AMA Guides.

RateFast asks questions, prompts you to indicate abnormalities, and requests that you take measurements based on your patient’s injury. A set of these questions and prompts for measurements are called exams.

 

RateFast currently has customized exams for injuries to the following body parts:

  • AMA Guides 5th edition cervical spine exam
  • AMA Guides 5th edition thoracic spine exam
  • AMA Guides 5th edition lumbar spine exam
  • AMA Guides 5th edition shoulder exam
  • AMA Guides 5th edition elbow exam
  • AMA Guides 5th edition wrist exam
  • AMA Guides 5th edition thumb exam
  • AMA Guides 5th edition index finger exam
  • AMA Guides 5th edition middle finger exam
  • AMA Guides 5th edition ring finger exam
  • AMA Guides 5th edition little finger exam
  • AMA Guides 5th edition pelvis/hip exam
  • AMA Guides 5th edition shoulder exam
  • AMA Guides 5th edition knee exam
  • AMA Guides 5th edition ankle/foot exam
  • AMA Guides 5th edition toe exam
  • AMA Guides 5th edition skin exam (for various skin areas)

Related Reading

If you’re a current RateFast user and you want to learn how to access the body part exams, then check out this article in the How to Use RateFast – Basic Tasks section.

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The Department of Transportation Gets Mobile App Support

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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

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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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The Twisted Story of Asymmetric Spinal Motion and Your PR-4 Report

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What is Asymmetric Spinal Motion?

Asymmetric means not symmetric, or unequal. Asymmetry of spinal motion means more movement in some directions than others.

A physical exam finding of asymmetric spinal motion is a gateway to a Diagnosis-Related Estimate (DRE) class II rating in the AMA Guides 5th Edition.

The AMA Guides 5th Edition in Chapter 15 The Spine on page 382 defines asymmetry of spinal motion as “Asymmetric motion of the spine in one of the three principle planes.”

But the AMA Guides goes to a little more effort here to help the medical examiner by stating: “To qualify as true asymmetric motion, the finding must be reproducible and consistent and the examiner must be convinced that the individual is cooperative and giving full effort.”

How to Document Asymmetric Spinal Motion in Your Report

When documenting asymmetry of spinal motion in an impairment report for rating purposes, it is helpful to the reader of your impairment report if you provide comments on muscle spasm, muscle guarding and employee cooperation. These comments also makes the observation more compelling.

When reading a report that includes the finding of asymmetry of spinal motion look for comments on muscle spasm, muscle guarding and employee cooperation.

California PR-4 Reports are about reproducible observations and findings. Reports that are minimally supported may be more confusing than helpful, and lead to costly delay for the medical examiner, the insurance administrator, and, of course, the injured worker and the employer.

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Muscle Guarding

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Muscle guarding is simply the body trying to avoid a painful stimulus. When irritable muscles are touched, they don’t like it and try to pull away.

A physical exam finding of muscle guarding is a gateway to a Diagnosis-Related Estimate (DRE) class II rating in the AMA Guides 5th Edition.

The AMA Guides 5th Edition in Chapter 15, The Spine, on page 382 defines “Muscle Guarding” as “a contraction of of muscle to minimize motion or agitation of the injured or diseased tissue.” Don’t confuse this with muscle spasm, which is an “involuntary contraction of a muscle or group of muscles.”

Associated finding may include loss of the low back contour (lordosis) and may have “reproducible loss of spinal motion.”

If you’re writing a PR-4 report

When documenting muscle guarding in an impairment report for rating purposes, it is helpful to the reader if comments on lordosis and actual measured spinal motion are provided. These comments also makes the observation more compelling.

If you’re reading a PR-4 report

When reading a report which includes the finding of muscle spam look for comments on lordosis and evidence of loss of spinal range of motion.

California PR-4 Reports are about reproducible observations and findings. Reports that are minimally supported may be more confusing than helpful, and lead to costly delay.

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What Is Muscle Spasm Anyway?

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Muscle spasm is probably the most elusive and non-reproducible exam finding on spine examination. It is difficult to assess because it is ambiguous and a continuum between examiners.

For example, a spasm on your examination may not be considered a spasm on mine. If findings are suppose to be reproducible between two examiners, you can see how this might pose a problem.

A physical exam finding of muscle spasm is a gateway to a Diagnosis-Related Estimate (DRE) class II rating in the AMA Guides 5th Edition.

The AMA Guides 5th Edition in Chapter 15 The Spine on page 382 defines muscle spasm as “involuntary contraction of a muscle or group of muscles.” It is a diagnosis made by feeling “a hard muscle”. Is should be present in both the standing and lying position, and “frequently” causes a scoliosis.

How To Document Muscle Spasm in Your Impairment Report

When documenting muscle spasm in an impairment report for rating purposes, it is helpful to the reader if the side, and spine level of the spasm is documented. Additional comments on persistence with positional change and influence on spinal alignment is useful and makes the observation more compelling.

When reading a report which includes the finding of muscle spasm, look for the associated findings positional persistence and scoliosis.

California PR-4 Reports are about reproducible observations and findings. Reports that are minimally supported may be more confusing than helpful, and lead to costly delay.

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Work Restriction Management: The 300 Level Course

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Imagine This

An injured worker has a chemical exposure on the job to the left eye which results in redness burning of the eye with minor changes in vision acuity which corrected to normal (20/20) with lenses. Skin examination is clear. The employee is placed off work for three days for rest, prescription treatment and recovery.

In the interval of the following 72 hours, the employee develops a blistering rash limited to the 2nd branch (V2) of the trigeminal nerve, and is diagnosed with “shingles” by her primary care doctor, and placed off work for a week. The employee is not able to appear for follow up and a status check because the primary care doctor instructed her not to drive.

The employer’s insurance adjuster wants to know the work status at 73 hours. How does the managing industrial provider respond?

Answer

The correct response to the insurance adjuster is “Work status is unknown, pending additional clinical evaluation.”

The above scenario is difficult to navigate because an industrial event has a non-industrial overlay, making opinions on work status confusing. The key is to clearly separate the two events, and simply report the objective information available to the industrial medical provider to comment on the ability to work.

Remember, the answers to work status, when given limited medical information and clinical exam information is yes, no, or I don’t know. All are acceptable answers if the circumstances are clearly communicated to the employer and the insurance adjuster.

All three parties (employee, adjuster and employer) are anxious to understand their responsibilities in a situation such as this. Is the employee to be compensated with workers’ comp benefits or sick leave on a non-industrial basis? It’s an excellent question.

Epilogue

This particular case resulted in a follow up call to the employee from the industrial medical provider. At this discussion it was determined that the symptoms from the original chemical work exposure had not improved, and now additional overlay of the shingles causes a new set of symptoms and pain. It was carefully determined that the original symptoms have persisted, and the symptoms of shingles have now added an additional set of problems. The industrial medical provider outlined to the employer that the employee has persistent baseline symptoms that continue, despite the complication of the shingles. The employee was referred to an ophthalmologist on an industrial basis to investigate the ongoing complaints of the pain and redness, and to see the health plan ophthalmologist for shingles treatment recommendation.

Keeping a clear separation between industrial injury circumstances and non-industrial conditions is essential for clear and well reasoned management of work restrictions. Remember, everyone has a vested interest in honoring work restrictions and making reasonable accommodations available for the injured worker.

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How to Correctly Document Your Patient’s Job Description

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Getting A Job Description Is A Hassle

Yes it is.

Imagine This

Adjuster M.A. from a major insurance carrier writes in today after reviewing a RateFast PR-4 report created on one of her injured workers. The worker is a firefighter who has been provided shoulder limitations precluding lifting and carrying more than 10 pounds, no pushing or pulling more than 11-25 pounds, no climbing ladders and no crawling. The report comments that, “Ability to return to her usual occupation is deferred pending the carrier providing a formal job description (RU 91 Format)”.

It’s obvious this injured worker cannot return to their job… Or is it?

When we talk about job activities, what people are expected to do, and what they don’t do all the time is casually listed in the clinic, but it’s what written down in the official job description that counts.

The Real Question

An accurate job description is actually a pretty rare event in the impairment report writing business. Probably less than 5% of claims have a usable job description. This is frustrating because one of the most important questions to be answered in a medical legal report or PR-4 report is, “Can the employee return to their job?”

Employees Don’t Know What Their Jobs Are

An employee’s understanding of his or her job is often very different than the official job description. A job description may include an activity that is rarely required, but is considered essential to perform the job safety and correctly.

…And Employers Don’t Either

To cause further frustration, the employer will sometimes provide the carrier an “administrative” job description and not an actual physical activity job description (RU 91). An administrative job description talks about job requirements such as personal temperament, educational requirements, and ability to concentrate, complete tasks etc. For orthopedic injuries, an administrative job description doesn’t cut it.

Get the RU 91

The RU 91 format is a systematic, standardized review of physical activities, specific weights and endurance requirements that guide the medical examiner. It should also be signed by both the employee and employer to confirm agreement.

And let’s not forget the Americans with Disability Act. Here it is required for an employer to make “reasonable accommodations” for employees with disability for the essential activities of the job. Think about this… How can we do that without looking at an actual job description? The answer: we can’t.

So, let’s get back to our adjuster’s question. The most correct approach for return to work opinion is based on a job description review. It may or may not change the opinions of the medical examiner, but everyone will have a better understanding of the final determination about return to work if there is a firm guideline cited in the report (RU91). Yep, we need the job description to give a correct and complete opinion on the return to work evaluation.

This simple systematic approach to thinking about the job description will pay dividends in the way of avoiding legal delay and confusion in the management of claim.

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What You Need to Know About Percentages in Work Comp

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The AMA Guides are full of percentages and a strong conceptual understanding of “percentage” is essential. We know there may be those of you among us who don’t care for math or who downright don’t like it. Not to worry, the concept of percentage is a fun and easy topic when introduced properly.

There is a hierarchy of percentage values in the AMA Guides 5th Edition. For example the AMA guides are calculated in digits impairment, hand impairment, upper extremity impairment, whole person impairment. Likewise foot impairment, and lower extremity impairment. We would like to untap the sometimes confusing concepts of percentages.

On behalf of Rate Fast we have today Steve Williams who is a science and math educator at Santa Rosa Accelerated Charter School. Sit back, relax, and take a front row seat in the class as we explore a better understanding of percentage.

Listen to our special lecture by clicking the link below:
https://dl.dropboxusercontent.com/u/40853549/LowDownOnPercentages.m4a