Bradford & Barthel believes “double dipping” should be limited to visits to Baskin-Robbins!
Unfortunately many QMEs, PTPs, and even AMEs are attempting to get applicants “a little something extra” when applying the DRE method to the spine!
Tables 15-3 (page 384), 15-4 (page 389) and 15-5 (page 392) of the AMA Guides provide the criteria for rating spinal impairments for the lumbar, thoracic, and cervical spine respectively. Each of these tables has five categories (I-V). Categories II, III, IV and V each provide a range of Whole Person Impairment (WPI). For example, Table 15-3 (lumbar spine), provides 5% to 8% WPI for Category II, 10% to 13% WPI for Category III, 20% to 23% WPI for Category IV, and 25% to 28% for Category V.
How is the examiner to place an applicant within any one of these 4% ranges? “If residual symptoms or objective findings impact the ability to perform [activities of daily living] despite treatment, the higher percentage in each range should be assigned,” ( AMA Guides, page 381). Thus, for a physician to move an applicant in Category II from a 5% to an 8% WPI, the physician must provide “explicit documentation” of the impact on activities of daily living.
Although the foregoing appears simple, it becomes complicated when the doctor then wants to provide value for pain. Recall that, per Chapter 18 (the “Pain” chapter), the doctor can increase the WPI percentage by up to 3% in certain well-established situations if pain has “increased the burden” of the applicant’s condition. What is the primary method by which the doctor is to determine whether the burden of the applicant’s condition has been increased by pain? Answer: Assess how the pain impacts the ADLs!
In short, in order for the doctor to first take the applicant higher in the range of any one DRE category, the doctor must do an ADL analysis. Generally speaking, if the doctor finds that the applicant’s ADLs have been impacted, this, by itself, is a reflection of pain. After all, if an injured individual stops performing an activity; or stops performing an activity as frequently as prior to his injury, and/or discontinues performing the particular activity as proficiently as prior to the injury, the typical reason for this is pain.
If pain impacting the ADLs is the justification for increasing the person within DRE range (for example, for a 5% to 8% WPI), it would clearly be “double dipping” for the doctor to then add an additional 1%, 2% or 3% for “pain” pursuant to Chapter 18.
For insight as to how the editors of the AMA Guides themselves view this issue, review Example 18-3 on page 588, as well as the corrections to the answer found in the Errata Sheet published in March, 2002. (The Errata Sheet was included in copies of the AMA Guides, 5th Edition, printed after March, 2002. It can be downloaded from the American Medical Association‘s website.) In this example, the applicant was placed in DRE Category IV due to a moderately severe pain-related impairment (which included 10 flare-ups per year “during which he is confined to bed for several days,” severe limitations in sitting, standing, walking and lifting, and the fact that he is “often unable to travel by car”). Because of the ADL problems, applicant’s impairment was increased within a range from 20% to 23% WPI. In short, this applicant received the maximum WPI within DRE Category IV. Per the Errata Sheet, although the pain itself was also “ratable” it was deemed that the pain had been “adequately compensated in the relatively high impairment for his lumbar spine DRE Category IV rating.”
Donald R. Barthel is a founding partner of Bradford & Barthel, LLP.
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