This article is a transcription of an episode of the RateFast podcast, which you can listen to by searching “RateFast” in iTunes or the iOS podcast store.
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Doctors in workers’ compensation must issue impairment ratings for their patients when they sustain an injury at work. These ratings must be consistent with the AMA guidelines. The impairment rating percentage ranges from 0 to 100, and the number describes the patient’s range of motion and activities that they’re able to perform after becoming injured.
An impairment rating of 0% is somewhat rare in workers’ comp. In fact, Dr. John Alchemy finds that it often means a doctor did not know how to rate it correctly and perhaps skipped a chapter in the AMA Guides. But when the 0 is correct, it means that the patient did not suffer any loss to their daily activities. Read more to find out about impairment ratings and zero-percent impairment.
Activities of daily living (noun) – (ADL) routine activities that people perform every day without assistance.
Impairment (noun) – a percentage estimate of how much normal use of your injured body parts you’ve lost. This number is determined by the standards set in the AMA Guides.
WPI (noun) – whole person impairment. It is a final value that communicates to the reader what the final measurement loss is in the claim. 0% means that there’s no measurable loss, and 100% means that the individual is nearing requiring support for everything that they do.
Zero-percent impairment (noun) – this means that the patient has no measurable loss of motion in a body part or any inability to perform their ADL’s. They may still be in pain, but they are able to perform all of the activities they did before.
Claire Williams: Hello, welcome to the California Workers’ Compensation Report. I’m Claire Williams, here today with Dr. John Alchemy. Hi John, how are you doing today?
Dr. John Alchemy: I’m doing great, thanks Claire. How are you?
Claire Williams: Doing well, I’m pretty excited today. We’re talking about zero, and zero is a really interesting mathematical concept. If you want, you can check out our blog post about it on the RateFast Blog. But, what does it mean in particular to workers’ compensation, and specifically in this concept of whole person impairment? So John, do you want to start us off – what do we mean by whole person impairment, or WPI?
Dr. John Alchemy: So, the AMA Guides, which is the text we use in California, 5th Edition, for doing impairment rating, scores injuries and residuals of the injuries, rates measurable findings on a range of 0 to 100. The whole person impairment is a final value that communicates to the reader what the final measurement loss is in the claim. So for example, a zero means that there’s no measurable loss, and 100% means that the individual is nearing requiring support for everything that they do – feeding, toileting themselves, dressing, et cetera. So it’s just a range between 0 and 100% that they came up with by convention, and it’s what everyone looks for in these impairment reports, is delivering that whole person impairment, and doing it in an accurate and a substantiated way.
Claire Williams: Okay. And would you say that this is a frequent value that you’ve seen assigned to workers’ compensation injuries?
Dr. John Alchemy: Well, I’ve looked over a fair amount of reports, and I obviously do the impairment reports myself, and I would say that zero does come up frequently in reports. The number, however, is supported variably in the reports. Once you really read through the AMA Guides, and as we’ll discuss a little bit later on about what it really means to have a zero percent impairment rating, I often find zeros are attached to reports where the doctor didn’t really find anything in the chapter that they could rate, or at least in the parts of the chapter that they were familiar with. And that’s sort of another discussion, but people who are marginally familiar with the AMA Guides tend to become really comfortable with certain sections of the AMA Guides, and they focus their rating and their data collection based on only that part of the chapter. So for the purposes of our discussion, we’ll just say that the chapter didn’t offer any rateable findings, and therefore a zero was assigned by the provider.
Claire Williams: Mhm. And would you say that this is accurate? In these reports that you are reviewing, do you find that that it’s really the case? That it should be a zero percent WPI?
Dr. John Alchemy: Well, the issue is that, in order to have a zero percent whole person impairment, the provider needs to do the full ADL (Activities of Daily Living) inventory, and make sure that the ADL’s are not limited. So that’s the first step. The second step, then, is to go ahead and do your exam and your measurements and run them through the tables and charts, and make sure that there is no rateable loss based on the measurements themselves. So it’s really a two-step process. And I would say, in my experience looking at the reports that I’ve looked at, of those that contain a zero percent WPI, probably 75% of those reports do not substantiate that 0 percent to that degree of detail.
Claire Williams: Okay. So, let’s say I’m an insurance adjuster, or even an attorney or an injured worker or a fellow doctor reviewing the report. What do I look for to substantiate that claim?
Dr. John Alchemy: So the first thing that you need to do is pick up the report and go straight to the Activities of Daily Living section. And you may be surprised as to the number of reports out there that do not inventory the ADL’s.
Claire Williams: Mhm.
Dr. John Alchemy: There, you’re going to find basically that some reports just don’t mention ADL’s at all, or they’ll talk about certain activities that cause pain but it’s not really clear if the pain is actually limiting the activity or not, or if the activities described are actually one of the 34 ADL’s. So that’s step one. Make sure that it has a complete ADL inventory. And if it does, make sure that it’s clear that the ADL’s are limited, and don’t just cause pain, but the injured worker can actually do the activity. Because the book is pretty clear, it says it needs to be limited. Step two is to go through the data set then, under the physical exam findings in the diagnostic testing, and make sure that all of the data is there, and that the data has been properly validated for measurements, and properly described so it can be interpreted on the tables. So those are the two big steps that stakeholders need to look at when they receive a report with a zero percent impairment.
Claire Williams: Okay. So a complete ADL inventory. And how many activities are included in that, according to the AMA Guides?
Dr. John Alchemy: The AMA Guides, in the 5th Edition, lists 34. And that goes all the way from personal hygiene, communication, non-specific hand activities, sitting, standing, walking, transportation, which includes driving a vehicle, being a passenger, also flying, it includes sexual activity, and also sleep. So are you sleeping through the night? Are you well-rested in the morning? Those types of concepts are supported or reviewing in the ADL’s.
Claire Williams: And so the injury needs to be limiting the injured workers’ ability to complete these activities. If it’s just causing them pain but they can still do everything, then that does not affect the WPI. Is that correct?
Dr. John Alchemy: That’s correct, the book is very clear that it has to be limited.
Claire Williams: Okay.
Dr. John Alchemy: So that’s another level of detail that one should look for in these reports, to see how detailed – when an activity of daily living is disturbed, they really need to drill down and explore that comment for the reader.
Claire Williams: Okay. And with 34 ADL’s and doctors on a pretty tight schedule, are there any tools you can recommend to help providers ensure that their inventories are complete?
Dr. John Alchemy: In the product that we’ve developed, RateFast, there is a dedicated section of the report, a tab, if you will, that opens up and makes that review quite quickly. So you can ask someone very quickly, “Hey, do you have any problems bathing, toileting yourself, preparing food, eating? Are any of those an issue?” Yes, no, if no you can simply move on to the next step. So if someone truly has no impact on their ADL’s, you can move through that list of 34 quite competently in probably five minutes or less. Now, if they are having some challenges, it’s important that you slow down and you ask about these ADL’s, particularly if you’re doing an impairment rating on two or more body parts. Because you can imagine, for instance, that if you have a knee problem, lifting is going to be a problem. But if you also have a skin claim, lifting may or may not be a problem. So it’s important that the doctor or provider clearly delineates a set of activities of daily living for each body part in a claim that’s being rated.
Claire Williams: Great. Yes, that seems super important. And are there any other thoughts you have about how providers, or also people reviewing these reports, can ensure — What happens, let’s say if I do get a report with a zero percent impairment rating and I don’t see these claims substantiated — what should I do next?
Dr. John Alchemy: Well, the great thing about have a systematic approach to doing an evaluation is that when you have that, you’re able to clearly outline in a letter back to the provider about what’s missing. Lots of times, I see letters that either other doctors bring back to me, or letters of insurance adjusters, and they’re just not really clear what it is in the report they’re unhappy with. But when a doctor gets a report or a letter of request from a stakeholder that’s very clear, saying “Hey, you didn’t comment on the ADL’s, can you please return us a list of the 34 ADL’s, and if there’s a limitation in any of those activities?” Now, that’s a very constructive and simple and helpful letter. The letters that are less helpful are the ones that say, “We think your rating is high.” Or “We think your rating is too low. Please comment further.” That is not really a very helpful letter for anyone to get, any of the stakeholders, because it’s very vague and it’s unclear as to what the reader is unhappy with. So again, the more specific you can be in the requests to the provider, the more valuable and the more timely it is, [laughs] and likely, to be honest, that the letter is going to get a response.
Claire Williams: Okay, great. And any closing thoughts on zero whole person impairment rating here?
Dr. John Alchemy: Sure. So, the closing thought is this: When a stakeholder sees a zero percent WPI, they need to understand that that is held to the highest level of substantiation in impairment rating.
Claire Williams: Uh-huh.
Dr. John Alchemy: Now, if you find a loss of motion, strength loss, sensory loss, et cetera, that’s rateable. If you’re really going to be delivering a zero to the stakeholders, you have to make sure that that report clearly delineates all 34 ADL’s for the body part being provided as zero percent, and the data set of the measurements is complete, and it’s been correctly validated and applied to the tables. So those two steps are the keys to ensuring that the zero percent WPI is accurate.
Claire Williams: Mhm. Wonderful. Well, this seems like it will be really helpful for people to hear, and thanks so much for joining us today.
Dr. John Alchemy: Thanks again.
Claire Williams: Alright, talk to you next time.
Dr. John Alchemy: Bye now.
Narrator: Thank you for joining us for this episode of the California Work Comp Report. We look forward to next week in continuing our discussion of work comp claims in California. Questions or comments? Got a great workers’ compensation story to share? Find us on Twitter at @ratefast, or at rate-fast.com.