Dept. of Labor & Industries DOCTORS WORKSHEET FOR RATING PO Box 44239 Olympia WA 98504-4239 DORSO-LUMBAR & LUMBO-SACRAL IMPAIRMENT Dear Doctor: This worksheet has been designed to help the attending physician perform impairment rating on their patients with permanent partial disability of the Dorso-Lumbar or Lumbo-Sacral spine. By performing this rating yourself, you can help prevent the need for Independent Medical Exams. You are also uniquely capable of accurately evaluating and explaining this evaluation to your own patient. This worksheet has been developed through the efforts of the medical, osteopathic and chiropractic communities. It has been reviewed by the business and labor communities, by the Department of Labor and Industries and by the legal community. It conforms to the rating requirement described in WAC 296-20-280. We hope this helps simplify the rating process for both you and the patient. Please contact me or your Claim Manager listed below with questions or comments. Sincerely, Hal Stockbridge, MD, MPH Associate Medical Director Department of Labor and Industries (360) 902-5022 Dear Doctor: The purpose of this worksheet is to encourage attending physicians to perform impairment ratings on their own patients. Patients are often grateful to attending physicians who perform the rating, since it frequently eliminates the need for an Independent Medical Examination (IME). This worksheet is all you need to send to the claim manager if you are the attending physician (assuming that you have provided all the required documentation - chart notes, history and physical, etc.). For sending the worksheet, use billing code 1190M (See Medical Aid Rules and Fee Schedules for current reimbursement). Simply use this code on the usual billing form (HCFA 1500 - L&I version F245-127-000). Mail the HCFA 1500 to the usual address (PO Box 44269, Olympia, WA 98504-4269). NOTE - To return completed copy: Tear back page off at the perforation. For your convenience fold page 4 so the address will show through a window envelope and mail. (Alternatively, use a regular envelope addressed to PO Box 44239, Olympia WA 98504-4239). Keep this front sheet for your reference and copy page 3 for your records. If you wish assistance with the impairment rating, you may contact the Office of the Medical Director at L&I, (360) 902-5022, 902-5028 or FAX (360) 902-4249. Sincerely, This WORKSHEET was developed jointly by representatives of the medical, osteopathic, and chiropractic communities, and has been reviewed by representatives of business, labor and the legal community. It is based on WAC 296-20-280. F252-006-000 worksheet/dorso-lumbar & lumbo sacral 9-00 Page 1>>>> 2Department of Labor & Industries Doctors Worksheet for Rating Dorso-Lumbar & Lumbo-Sacral Impairment Claimants Claim # name Step 1. (a) Has the workers condition reached maximum medical improvement? Yes No If No, do not rate. Please provide treatment recommendations. (b) If there is a pre-existing condition, was it permanently aggravated by the industrial injury? No N/AYes If Yes, attach explanation.Step 2. Is there any permanent impairment? NoYes Step 3. Circle one box in each column A through D below. Give brief explanation below (REQUIRED). Your entries should reflect the patients current A B C D Muscle Weakness Reflex loss Imaging and X-ray findings Other Findings AND: (In general only EXAMPLES: Degenerative disk disease, EXAMPLES: Dermatomal sensory loss, decreased EITHER Atrophy Asymmetric fracture disrupting the spinal canal, bulging discrange-of-motion, muscle guarding, +SLR (Only include or EMG losses are (Only include findings which are consistent findings which are consistent with the clinical picture.) abnormalities significant.) with clinical picture.) NOT TO BE CONSIDERED: OSWESTRY OR OTHER (See "notes" below.) PAIN SCALES Circle one Circle one Circle one Explain: Circle one Explain: none (1) none (1) none (1) none (1) mild intermittent (2) mild knee yes continuous or ankle yes (3) moderate intermittent (3) mild but mild but significant (4) significant (4) moderate moderate (5) continuous or marked ear on perforated lineT intermittent (5) moderate (6) marked (6) marked (7) marked continuous (7) essentially Give muscle group total loss of and specific low back abnormalities: functions (8) Box number circled Step 4: Calculate Rating (If you want in Column A: L&I to do the calculation, copy the numbers Box number circled into the 1st 4 boxes and go to Step 5.) in Column B: Box number circled Notes: Column A: Mild Weakness = 4/5 (Complete motion against gravity and less than full resistance); in Column C: Moderate = 3/5 (Barely complete motion against gravity); Box number circled Marked = 2/5 - 0/5 (Complete motion with gravity eliminated to no evidence of contractility). in Column D: Pain is considered in the rating, but must be reflected in findings described on this worksheet Total (for example, decreased range-of-motion). Average (total divided by 4) Enter the average rounded to nearest whole number (1.1=1, 1.5=2, etc.) This is the rating: I certify that I have examined the patient within the last 8 weeks and that the above report truly and correctly sets forth my findings and opinion. Step 5: Doctors address ZIP+4 Provider No. Certification Print Drs name Todays date Doctors signature The Physician should photocopy this worksheet for their medical records. Doctors should refer to the Medical Examiners Handbook for instructions on the use of this worksheet. Developed jointly by representatives of the medical, osteopathic and chiropractic communities with input from Labor and Business; based on WAC 296-20-280 Page 3 F252-006-000 worksheet/dorso-lumbar & lumbo sacral 9-00 >>>> 3 Definitions and Instructions The Fixed and Stable Concept Impairment is fixed and stable when it is reasonably certain that further medical treatment will not predictably alter the course of the illness or medical condition, i.e., there is no significant probability that the level of impairment will be decreased by the treatment. Fixed does not mean healed or static; rather, it means the worker has reached a stable plateau from which further recovery is not expected, though the passage of time may produce some benefit. The accepted condition can be rated when it has reached a peak of possible recovery, given the workers total medical condition. For example, the background of the workers total med