I have worked with impairment ratings for more than 35 years. Their original purpose was to create an objective starting point for discussing indemnity benefits and compensation. Unfortunately, there are problems with this process. However, there are several proactive steps to be taken to ameliorate any issues that could lead to lengthy and expensive disputes.
Common Issues With Impairment Ratings
The first issue is whether this individual is truly at maximum medical improvement. Have all the disputes been resolved? Has the exact extent of the compensable injury sustained been thoroughly resolved, to avoid providing inflated impairment ratings that become a golden ring for some individuals? When this golden ring is not granted, it becomes the basis for contested findings.
Variability in Medical Opinions
One must also consider the variability of medical opinions relative to the sequelae of the compensable injury. There are some providers who feel a simple myofascial strain is significantly and permanently compromising the overall functionality of the injured individual, while others look at this particular clinical scenario and minimize the impairment rating based on their assessment of the severity of the injury.
Claim handlers should clearly explain the extent of injury and the statutory basis for maximum medical improvement. Clear communication reduces disputes and confusion.
Pain Complaints and Maximum Medical Improvement
Ongoing complaints of pain. There are those jurisdictions that have ruled that pain is not an inhibitor to reaching maximum medical improvement, and as such does not interfere with the attempt to provide an impairment rating. However, asking the injured employee who believes he still is in significant pain to participate in an impairment rating noting that this is the beginning of the end of additional benefits could negatively affect the veracity of the impairment rating assigned.
The next question would be how do these pain complaints affect and elevate the actual award. Was there a full and maximal effort on the range of motion testing? Is the injured employee who believes he is still in pain providing an accurate history which can modify the impairment rating?
Accuracy of Impairment Rating Calculations
Impairment rating calculations still create problems, even after decades of using the Guides. In some instances, individual providers will use the instructions from a later version of the Guides and apply those tasks to an earlier edition of the Guides, creating an impairment rating that is not consistent with the statutorily mandated version of the Guides.
Another issue is how these specific instructions are interpreted by that provider? Following each of these instructions in terms of calculating the impairment rating can be confusing. The English language can be challenging at times in terms of describing the actual intent.
Additional considerations in terms of accuracy come down to completing the mathematical calculation and knowing when to add certain values or when to combine certain values in calculating the final impairment rating.
Make no mistake about it, the earlier versions (3rd, 4th & 5th editions) of the Guides can be somewhat convoluted in their approach to the impairment rating calculation. Additionally, the exact intent is not always clear. While not particularly difficult, the convoluted nature of this process creates inaccuracies in the impairment rating process.
Compliance and Range of Motion Testing
Another significant issue is compliance by the injured employee. While rehabilitating that elbow injury and wanting to show the physical therapist just how well they are doing, the injured employee will demonstrate a significant range of motion actively. However, when forwarded to another provider to calculate the impairment rating, the injured employee may think if I only do this, the amount of benefits I receive will be significantly improved. Understanding there are some safeguards, such as if the range of motion reported is more than a grade different than previous range of motion assessments the entirety of the range of motion impairment is excluded. However, this particular criterion is not always applied in the impairment rating process.
The next issue is the active versus passive range of motion. As an example, in the 4th edition of the Guides, upper extremity range of motion impairment is based on the best active effort. Active effort completely relies on the intent of the injured employee. This intent may compromise the true range of motion, and that is an issue to be resolved.
Subjectivity in Impairment Evaluations
Different evaluators may interpret the same condition differently. As a result, they may apply the Guides using different methods. These examiners may take into consideration the effect this impairment rating assessment will have on the compensation being awarded to the injured individual.
Conclusion
To be clear, the purpose of impairment is to establish a starting point, somewhat arbitrarily, but in theory based on competent, objective, and independent medical evidence to start the discussion. Over time, several tangential compromises have been noted, making this process more convoluted and probably less accurate.
The impairment rating process is based on, and perhaps an overemphasis is applied to, the physical aspect of the injury and does not take into consideration any psychiatric issues, emotional issues, or other similar comorbidities that should be incorporated into the discussion of the functional deficits that are thought to be reasonably presumed to be permanent relative to the compensable injury sustained.
As noted, there is a rather large disconnect between medical recovery and functional capacity. There are several difficulties when attempting to address each of these issues, and as the statutory requirement is that the impairment rating must be based on the compensable injury alone, this places an even greater emphasis on the adjudication of the extent of the injury and the accepted compensable diagnoses before the impairment rating assessment.
While noting that a majority of the compensable injury sustained can be assigned and acceptable impairment rating, and most often is a function of the range of motion of the upper extremity, the diagnosis related to the lower extremity, or the cervical, thoracic and lumbar spine; if there is a third or outside party asked complete the impairment rating, there are many questions should be resolved before completing any impairment rating. Having a resource to assist with the determination of the accuracy is always a handy tool to maintain.
