July 2021 Update

Medical Examiners' Handbook July 2022 Update

Impairment Ratings and Independent Medical Examinations in Washington State Workers' Compensation For IME Examiners, Attending Doctors and Consultants

Free 3 Hours Category 1 CME Credit

The Department of Labor & Industries (L&I) is accredited by the Washington State Medical Association to provide continuing medical education for physicians. L&I designates this type of enduring material for a maximum of 3 AMA PRA Category 1 Credit(s)TM. Physicians should claim only the credit commensurate with the extent of their participation in the activity. This activity meets the criteria for up to 3 hours of Category 1 CME credit to satisfy the relicensure requirements of the Washington State Medical Quality Assurance Commission. Accreditation: Original Activity Date -- July 1, 2018

Renewal Date -- July 1, 2021 Expiration Date -- June 30, 2024

This publication contains guidelines, sample reports, and billing procedures for preparing and conducting impairment ratings and independent medical exams (IME) in Washington's Workers' Compensation system. The activity was planned and produced in accordance with the WSMA Essential Elements, Criteria, and Standards of Accreditation of Continuing Medical Education. Disclosure: None of the faculty involved with developing this handbook or self assessment test online has any financial relationship to disclose nor do they financially benefit from this product.

First published April 1990 PUBLICATION F252-001-000 [07-2022]

About the July 2022 Updated Medical Examiners' Handbook

The July 2022 updated edition of the Medical Examiners' Handbook contains selected updates to the July 2021 edition. New or updated information is listed in the table below.

Updates and Additions to the Medical Examiners' Handbook, July 2022

Chapter Page Title

Comments

Cover

Handbook Cover Page Updated with current dates including CME accreditation dates

1

4

Reasons Why IMEs are Added new Case Progress WAC

Requested

2

15-16 Requirements for IME Firm Reformatted medical director responsibilities

Providers

2

18

Examiner Credentialing Clarification regarding maintaining board certification

Requirements

3

21

Interpreter Services

Updates and clarification

4

31

Details to Include in the Language added regarding contralateral range of motion

Report

4

35

Treatment Guidelines Updated list of Department Treatment Guidelines

4

36

Pain Management and Added language regarding opioid prescribing concerns

Opioid Prescribing

7

50-60 Mental Health IME Reports Clarifying edits added throughout the chapter

7

51

Diagnosis and Baseline Clarification added regarding "unspecified" diagnoses

7

53-54 Preparing for Your Mental Updates added regarding Somatic Symptom Disorder

Health Report

9

72-75 Providing Testimony

Minor edits and updates added throughout the chapter

12

113-118 Mental Health

Minor edits and updates added regarding Mental Health impairments

13

140-142 Billing Information

Minor edits and updates added throughout the chapter Fee Schedule updated, links to 2022 MARFS included

Append C 191

Relevant Laws and Regulations

Updated WAC 296-23-302 ? Definition for Case progress examination

Append C

Relevant Laws and Regulations

WAC Repealed 296-23-307 ? Why are independent medical examinations requested

Append C 193-194 Relevant Laws and Regulations

Append C 208

Relevant Laws and Regulations

Append D 212 Append D 214

Websites Glossary

Added new WACs; 296-23-308 ?Scheduling case progress examinations 296-23-309 ? How many examinations may be requested

Added new WACs; 296-23-401 ? Can the department schedule an examination or order a self-insured employer to schedule an examination after receipt of an appeal to the board of industrial insurance appeals (BIIA) 296-23-403 ? Independent medical examinations ? Department data reporting

Added link for Department of Health Resources for Healthcare Providers

Added additional terms

Table of Contents

Preface ........................................................................................................................... 1

CHAPTER 1 ............................................................................................... 2

Workers' Compensation in Washington State............................................................ 2

Background ........................................................................................................................................... 2 Legislative Intent & Department Role ................................................................................................... 2 Reasons Why IMEs are Requested...................................................................................................... 3 Additional Types of Examinations......................................................................................................... 4 Confidential Information ........................................................................................................................ 5 Claim Manager Role ............................................................................................................................. 6 Scheduling IMEs ................................................................................................................................... 7

CHAPTER 2 ............................................................................................. 10

The Independent Medical Examination Provider...................................................... 10

Types of Examiners ............................................................................................................................ 10 Application Process............................................................................................................................. 11 Examiner Credentialing Requirements ............................................................................................... 11 Additional Requirements for Specific Examiner Specialties: .............................................................. 12 Examiner Training Requirements and Opportunities .......................................................................... 14 Site Standards and Business Requirements ...................................................................................... 14 Independent Medical Examination Firms............................................................................................ 15 Requirements for IME Firm Providers................................................................................................. 15 Review of Applications ........................................................................................................................ 17 Reporting Changes to L&I................................................................................................................... 17

CHAPTER 3 ............................................................................................. 20

The Independent Medical Exam ................................................................................. 20

Preparing for the Examination / Scheduling ....................................................................................... 20 Missing Documents or Records .......................................................................................................... 20 Interpreter Services............................................................................................................................. 21 Who is Allowed to Attend an IME?...................................................................................................... 22 May the Worker Record the IME?....................................................................................................... 22 Examiner Responsibilities ................................................................................................................... 22 Discussing the Examination Results with the Worker......................................................................... 23 May I Offer to Provide Ongoing Treatment? ....................................................................................... 23 Ordering Diagnostic Tests .................................................................................................................. 24 Unable to Complete Examination ....................................................................................................... 24 Additional Examiner Needed .............................................................................................................. 24 No Show or Late Cancel ..................................................................................................................... 24 Releasing Information to Other Parties............................................................................................... 25 Medical Records - Maintenance and Disposal ................................................................................... 25 Worker's Questions About Their Claims ............................................................................................. 25 Telehealth/Telemedicine ..................................................................................................................... 26

Medical Examiners' Handbook 07-2022

CHAPTER 4 ............................................................................................. 28

The IME Report ............................................................................................................ 28

Unbiased, Accurate IME Reports Contribute to Equitable Treatment of Workers.............................. 28 Due Date for IME Reports................................................................................................................... 28 Late Reports........................................................................................................................................ 28 What to Include in an IME Report ....................................................................................................... 28 Details to Include in the Report ........................................................................................................... 30 Radiology Reporting Requirements for IMEs ..................................................................................... 31 When to Sign the IME Report ............................................................................................................. 32 Where to Send the IME Report........................................................................................................... 32 When Examiners Disagree on IME Conclusions ................................................................................ 33 Addendum Report ............................................................................................................................... 33 What is Meant by `more-probable-than-not' in an IME? ..................................................................... 33 Maximum Medical Improvement (MMI)............................................................................................... 33 Treatment Recommendations............................................................................................................. 34 Guidelines, Coverage Decisions, and Policies on Specific Medical Conditions and Treatment Recommendations .............................................................................................................................. 35 Pain Management and Opioid Prescribing ......................................................................................... 36 What to Avoid in the Examination or Report....................................................................................... 36 If the Injured Worker needs Treatment from a different provider........................................................ 37 Reopening a Closed Claim (worsening, objective findings) ............................................................... 38

CHAPTER 5 ............................................................................................. 40

Preexisting Conditions, Lighting Up, and Segregation ........................................... 40

When Does L&I Accept Full Responsibility for a Preexisting Condition? "Lighting Up" ..................... 41 When Does L&I Accept Limited Responsibility for a Preexisting Condition? "Segregation" .............. 41 When Does L&I Deny Responsibility for a Preexisting Condition?..................................................... 41 What Should I do to Address Preexisting Conditions? ....................................................................... 42

CHAPTER 6 ............................................................................................. 44

Occupational Diseases ............................................................................................... 44

The Occupational Disease Report ...................................................................................................... 44

CHAPTER 7 ............................................................................................. 50

Mental Health IME reports .......................................................................................... 50

Diagnosis and Baseline ...................................................................................................................... 50 Causation ............................................................................................................................................ 51 Ability to Work / Work Restrictions...................................................................................................... 51 Job Analysis ........................................................................................................................................ 52 Maximum Medical Improvement (MMI) or Treatment......................................................................... 52 Impairment Rating............................................................................................................................... 53 Preparing for Your Mental Health Report - Definitions, WACs, and Background............................... 53

CHAPTER 8 ............................................................................................. 62

Vocational Issues & Physical Restrictions ............................................................... 62

Job Analyses and/or Job Descriptions................................................................................................ 62 Reviewing a Job Analysis or Job Description ..................................................................................... 63

Medical Examiners' Handbook 07-2022

Addressing Current Physical Capabilities ........................................................................................... 63 Common Household/Work Items ........................................................................................................ 66 Job Analysis Form............................................................................................................................... 68

CHAPTER 9 ............................................................................................. 72

Providing Testimony................................................................................................... 72

Examiner Responsibility...................................................................................................................... 72 Deposition or Live Testimony.............................................................................................................. 73 Fee Schedule for Testimony ............................................................................................................... 73 Appeal Process ................................................................................................................................... 74

CHAPTER 10 ........................................................................................... 76

Complaints about the Independent Medical Exam................................................... 76

Complaints or Comments about an IME ............................................................................................. 76 Types of Complaints ........................................................................................................................... 76 Possible Department Actions .............................................................................................................. 77

CHAPTER 11 ........................................................................................... 78

Impairment Rating- General Information................................................................... 78

The Difference Between "impairment" and "disability," and Why it is Important................................. 78 Is an IME the Same as an Impairment Rating Examination? ............................................................. 78 Who May Rate Impairment? ............................................................................................................... 78 When to Rate Impairment ................................................................................................................... 79 The Five Required Components of ALL Impairment Reports............................................................. 79 Medical Judgment in the Rating Process ........................................................................................... 80 Objective Findings in the Rating Process for Physical and Mental Health Impairment...................... 80 What Rating Systems Should I Use?.................................................................................................. 80 How are Injuries Prior to October 1974 Handled? .............................................................................. 84 How is Pain Considered in an Impairment Rating? ............................................................................ 85 Does the Rating Process Include Consideration of the Worker's Financial Need?............................ 85

CHAPTER 12 ........................................................................................... 86

Impairment Rating - Detailed Instructions ................................................................ 86

Rating and Technical Assistance........................................................................................................ 86 Detailed Instructions for Rating Various Body Systems ..................................................................... 86 American Medical Association Guides - General Instructions ............................................................ 87

Back Impairment ......................................................................................................... 87

Cervical and Lumbo-Sacral Guidelines, Case Examples ................................................................... 87 Cervical and Cervico-Dorsal Spine ..................................................................................................... 87 Guidelines For Cervical and Cervico-Dorsal Impairment.................................................................... 89 Dorsal Spine........................................................................................................................................ 91 Dorso-Lumbar and Lumbo-Sacral Spine Impairment ......................................................................... 93 Guidelines For Dorso-Lumbar and Lumbo-Sacral Impairment .......................................................... 95

Pelvis............................................................................................................................ 98

Cardiac ......................................................................................................................... 99

Convulsive Neurologic Disorders (Seizure Disorders, Epilepsy) .......................... 99

Medical Examiners' Handbook 07-2022

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