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Headline: DRE v. ROM: Which Rating Method Applies?

by Tim Mussack, (April 2, 2020)

One of the most frequent questions we see in workers’ compensation defense is whether the Diagnosis-Related-Estimate (DRE) or Range-of-Motion (ROM) permanent disability ratings apply to the spine.

Although state administrators have offered regular review, the misuse of the ROM method to evaluate the spine continues to be one of the common issues and errors that arises in rating permanent disability. Use of the ROM method in the absence of surgery, fracture, or confirmed radiculopathy is likely not the correct method for evaluating the spine.

Where do we start with our analysis? First and foremost, one must look to Chapter 15 of the 5th Edition of the AMA Guides to the Evaluation of Permanent Impairment, which addresses this topic.

Fortunately, the Disability Evaluation Unit (DEU) has also offered their interpretation of the use of the ROM Method for the Spine for California Permanent Disability Ratings at multiple DWC Annual Educational Conferences.

In 2014, the DEU reviewed “Ten Common Issues and Errors in Ratings.” The most common mistake the DEU found is incorrectly using the ROM method instead of the DRE method, in a section they called:

The #1 Error: “Incorrect Use of Spine Method”

When ROM Method is used:

– Multi-level or bilateral radiculopathy
– Multi-level fracture
– Multi-level fusion
– Recurrent radiculopathy

On pages 373-374 of the AMA Guides Fifth Edition, the Introduction to Chapter 15, discusses revision in the Fifth Edition from the Fourth Edition.

There are evaluators that would like to offer the ROM method based on the wording from page 374:

Use the ROM method when the impairment is not caused by an injury or when an individual’s condition is not well represented by a DRE category.

Review of the entirety of Chapter 15 allows a complete understanding of the message regarding the use of the DRE or ROM method.

Chapter 15 of The AMA Guides 5th Edition includes detailed instructions for use of the ROM Method, on pages 373-374, in the Introduction, and on pages 379-381, Section 15.2,

Determining the Appropriate Method for Assessment. For instance, check out these excerpts:

  • “…the DRE method is the primary method used to evaluate individuals with an injury”; (p. 374).
  • “The DRE Method is the principle methodology used to evaluate an individual who has had a distinct injury”; (p. 379)
  • On page 383, the Guides indicates that most conditions are well represented by a DRE category. They wrote: “Although there are five categories, almost all individuals will fall into one of the first three DRE categories.”

The DEU, at the Annual DWC Educational Conferences, has further addressed the use/misuse of the ROM Method. At the 2013 DWC Educational Conference, the DEU highlighted the following text from the Guides:

“The DRE Method is the principle methodology used to evaluate an individual who has had a distinct injury” (p. 379.)

From review of the AMA Guides, and additional clarification from the DWC Annual Educational Conferences, there are several situations in which the ROM may be utilized instead of the DRE.

            1. When an impairment is not caused by an injury (p. 379):

              As expressed in Example 15-7, page 389 of the Guides, and consistent with California LC 3208.1, a cumulative trauma injury is an injury.

            2. When there is multilevel involvement in the same spinal region (eg, fracture at multiple levels, disc herniation, or stenosis with radiculopathy at multiple levels or bilaterally)” (p. 380):

              The AMA Guides on pages 379-381 indicates that the multilevel changes must be significant. The DEU has further discussed “multilevel involvement”. It does not include multilevel degenerative disc disease, multilevel bulges and/or multilevel herniation without a history of radiculopathy. This point was expressed by the DEU at the 80th Annual Meeting at the State Bar on 9/29/07, when it was addressed that multilevel bulges, multilevel degenerative changes and/or multilevel herniation—standing alone do not give rise to the ROM method.

              At the 15th Annual DWC Educational Conference, in 2008, the DEU reviewed page 380 of the AMA Guides, and again expressed “multi-level bulges, degenerative changes, or herniations are not sufficient by themselves to invoke the ROM method. There must be multi-level (or bilateral) radiculopathy”.

              In 2019, the DEU reviewed a Spine Rating Example: “Physician finds degenerative disk bulging at L2-3, L3-4, L4-5 and L5-S1 following lumbar injury”, and used the ROM Method to assign 12% WPI. The DEU instructed that the ROM method is NOT applicable, as “there is no multi-level radiculopathy, surgery, and fracture to qualify to ROM method”.

              For this example, the DEU indicated DRE Category II (5-8% WPI) would apply, for findings of “muscle guarding”.

            3. Where there is alteration of motion segment integrity (eg, fusions) at multiple levels in the same spinal region… (p. 380)
            4. Where there is recurrent radiculopathy caused by a new (recurrent) disk herniation or a recurrent injury in the same spinal region. (page 380)

              At the 15th Annual DWC Educational Conference, in 2008, the DEU also expressed “a second injury to the same spinal region by itself is not sufficient to invoke ROM. There must be recurrent radiculopathy”.

              In 2015, the DEU again noted that there must be “recurrent radiculopathy” to be a qualifying ‘recurrent injury’.

            5. Where there are multiple episodes of other pathology producing alteration of motion segment integrity and/or radiculopathy. (page 380)

    The DEU has also reminded us, including in 2013:

    “If more than one spinal region is impaired and both regions meet the criteria for ROM, then only one can be rated using ROM and the other using DRE. (pg. 381)”

    CONCLUSION

    So when a doctor or applicant’s attorney argues that the ROM method is the most accurate method of rating an applicant’s permanent disability, you’ll want to remember that use of the ROM method in the absence of surgery, fracture, or confirmed radiculopathy is probably incorrect.

    Tim Mussack has been in the workers’ compensation industry since 1988. His background includes training and auditing of claims handling in over 30 jurisdictions, with most of his experience in California. Tim has been an instructor of Permanent Disability rating since 1991, teaching rating using the 1988, 1997, and 2005 PD rating schedules. If you have any questions about rating PD, please feel free to reach out to Tim at tmussack@bradfordbarthel.com or 916.569.0790.

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