ERRONEOUS RATINGS STUDY: PART VI

Saturday, May 20, 2006 | 0

In the previous installments we examined some of the common reasons for erroneous ratings, in this issue we will look at errors in the rating process itself.

The Guides criteria must be applied appropriately. Section 2.5b Combining Impairment Ratings explains "Begin with an estimate of the individual's most significant (primary) impairment and evaluate other impairments in relation to it. Related but separate conditions are rated separately and impairment ratings are combined unless criteria for the second impairments are included in the primary impairment." It is important to assure that the impairment is adequately rated without duplicative rating, i.e. "double dipping".

Spinal impairment ratings are often erroneous. Common errors include basing the data on unreliable data, using the wrong method, misapplying a method, and rating for non-existent corticospinal tract damage. Chapter 15, The Spine, explains there are two methods, the Diagnosis-Related Estimates (DRE) Method and the Range-of-Motion (ROM) Method, and three spinal regions, cervical, thoracic, and lumbar. The Fifth Edition states in Section 15.2, Determining the Appropriate Method for Assessment on page 379 "The DRE method is the principal methodology used to evaluate an individual who has had a distinct injury". Typically, the ROM Method will result in a higher rating than the DRE Method, with the notable exception of spinal fusions. (With spinal fusions, a single-level fusion is rated using the DRE Method and typically this results in a higher rating than with a multiple-level fusion that is rated using the ROM Method.) A common inappropriate excuse for this is multiple level degenerative disease, a finding associated with aging and genetics. Section 15.2 Determining the Appropriate Method for Assessment (379-381) stipulates specific situations when the ROM method is used. It is used if there is radiculopathy at multiple levels, however not merely on the basis of degenerative changes. The Guides explains on page 383:

The DRE method recommends that physicians document physiologic and structural impairments relating to injuries or diseases other than common developmental findings, such as (1) spondylolysis, found normally in 7% of adults; (2) spondylolisthesis, found in 3% of adults; (3) herniated disk without radiculopathy, found in approximately 30% of individuals by age 40 years; and (4) aging changes, present in 40% of adults after age 35 years and in almost all individuals after age 50. As previously noted, the presence of these abnormalities on imaging studies does not necessarily mean the individual has an impairment due to an injury.

Therefore, first determine if the appropriate method was applied. Once the appropriate method is selected, it is important to determine the correct rating based on reliable examination findings. The Guides provide detailed standards for the physical examination in Section 15.1 Principles of Assessment (374-378) and for assessing motion in Section 15.8 Range-of-Motion Method (398-403); this is also excellent content for cross-examination. If the Diagnosis-Related Estimates (DRE) Method is used, the physician must select one of five categories based on specific, reliable findings and within each category choose an appropriate numeric rating within a 3% range. A common error is to assign a patient to the wrong category. With the Range-of-Motion Method, a rating is based on the combination of diagnostic criteria as well as examination findings. An unreliable examination will result in an erroneous rating, and nearly always this erroneous rating will be higher than is appropriate.

In the next issue of the ezine we will examine some of the common errors in the rating process itself, i.e. the use of Guides criteria.

Brigham Walker provides training for Claims Professionals, Attorneys, and Medical Professionals on apportionment, use of the AMA Guides, California's new PD Rating System, and all of the areas noted above.

Please contact Mindy Brigham for further information on training and resources. Call 619-299-7377 or mbrigham@brighamassociates.com.

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