Whether you’re a medical provider, an injured worker, a claims adjuster, or an attorney, this article is relevant to you if you’ve encountered a 0% whole person impairment rating in a California PR-4 or QME report.
If you receive a report—or are writing a report—with 0% WPI (whole person impairment), this number should raise some flags.
Because, when it comes to the AMA Guides and impairment rating, a 0% WPI is a very special number.
If a report claims that a patient has 0% impairment, then it needs to meet some specific requirements. If it doesn’t meet those requirements, then the number is inaccurate—and as we all know, an inaccurate impairment rating can lead to unnecessary delay, litigation, and expense for all stakeholders.
Here are three key questions to determine if a 0% WPI value is accurate and supported by the AMA Guides.
Is the chapter rating truly 0% WPI? The evaluator who calculates the impairment rating must have a solid command of the chapter material, or use an impairment rating tool such as RateFast, to properly organize and review the report for accuracy and completeness of ratable data. Remember, ratable data includes key history questions, specific physical exam measurements, and diagnostic testing results. If the chapter rating in the AMA Guides still delivers a 0% WPI, move on to step two.
Does the report include a complete inventory of the individual’s Activities of Daily Living (ADLs)? The activities of daily living must be included in the report. Here’s what the AMA Guides 5th edition has to say: “Impairment percentages or ratings developed by medical specialists are consensus-derived estimates that reflect the severity of the medical condition and the degree to which the impairment decreases an individuals ability to perform common activities of daily living (ADL), excluding work.” (AMA Guides, 5th Ed. Section 1.2 Page 4.)
Are any of the ADLs limited? If an activity of daily living is limited in some way, then the impairment rating for that body part cannot be zero. “A 0% whole person rating (WP) impairment is assigned to an individual with an impairment if the impairment has no significant organ or body system functional consequence and does not limit the performance of the common activities of daily living indicated in Table 1-2.” (AMA Guides, 5th ed. Section 1.2, Page 5)
As you can see, a body part that has been given a whole person impairment rating of 0% actually requires a higher level of documentation than other WPI values, such as 5% WPI or 1% WPI. The medical examiner really needs to work to prove that the activities of daily living are in no way restricted, and that the AMA Guides chapter related to that body part supports a 0%.
If you’re reviewing somebody else’s report and the 0% WPI is not fully supported by documentation, the report should be sent back to the evaluator for clarification.
If you’re a medical provider and you’re about to give a patient a 0% WPI in your report, check and make sure that your examination and your documentation justify the number.
Got questions? Don’t quite believe us? Reach out. We love to talk impairment rating. Contact us at firstname.lastname@example.org.