• Complexities of PI Assessment by a senior Certified Independent Medical Examiner (CIME).

    5 October at 20:49 from atlas

    The evaluation of  permanent impairment (PI) is complex in itself, but there are differing requirements and is based on different schedules , or tables from not only jurisdictions in various countries, but depending on the time of injury(TOI).Some jurisdictions have their own tables or guides that adopt, or are utilised alongside the  various AMA (American Medical Association) Guides to the evaluation of PI. These guides were fist utilised in 1971 and are administered and published by the American Board of Independent Medical Examiners (ABIME).The ABIME trains & assesses candidates who must pass a written examination covering ALL aspects of assessment of the human body ,including terminology & method of combining injuries as well as the requirements for performance of a PI independent  report with awarding of the title CIME.

    Assessing PI involves clinical assessment on the day of assessment and determining:

    (i)whether the claimant's condition has resulted in impairment

    (ii)whether the condition has reached Maximum medical Improvement (MMI)

    (iii)whether the resultant is permanent

    (iv) the degree of impairment that results from the injury

    (v) the proportion of impairment sure to any previous injury, pre-existing condition or abnormality , if any.

    By the time an assessment of PI is required , the question of liability for the primary , or index, condition would normally have been determined legally between the various parties.The exceptions to this could include those conditions of slow onset.The person who makes the referral for an assessment of PI is required to make clear to the assessor  the work injury for which an assessment is being sought , as  well as fully briefing the assessor with all documentation including all statements, contemporaneous and continuing medical records, imaging and other ancillary investigations and which jurisdictional 'guide or table' of injury / or which Edition of the AMA Guides ( there are 6 Editions :1-6)  is to be utilised. These vary from State to State)and for the TOI,as well!) in Australia-as is also the case in other countries.

    Assessments are only to be conducted when the medical assessor considers that the degree of PI of the injured worker is fully ascertainable-in general has reached MMI.This is generally considered to be the case when the worker's condition has been medically stable for the previous 3 months and is unlikely to change by more than 3 % WPI in the ensuing 12 months with or without further medical treatment i.e. further recovery or deterioration is not anticipated).

    If , however, the assessor considers that treatment has been adequate and MMI has NOT been reached , the assessment should take place at a deferred time and comment should be made on the value of additional / different treatment and/or rehabilitation.

    If the claimant has been offered , but refused, additional or alternative  treatment that the assessor feels is likely to improve the claimant's condition, the assessor should evaluate the current condition, without consideration of potential changes that could flow from the further treatment.The assessor may note the potential for improvement in the evaluation report, and the reasons for refusal by the claimant, but should NOT adjust the PI on the basis of the claimant's decision.

    Similarly, if an assessor considers that although stable for the present, but is expected to deteriorate in the long term, the assessor should make NO ALLOWANCE for this possible deterioration in the long term, but again, note its likelihood in the evaluation report.If the claimant's condition deteriorates in the future ,the claimant may re-apply depending on jurisdictional allowances for a re-evaluation.

    On referral, the medical assessor should be provided with ALL relevant medical &allied health material, including results of all clinical investigations related to the index injury.

    AMA 5 indicates the information and investigations that are required to arrive at a diagnosis and to measure PI.Assessors can only give the most accurate evaluations when referrers provide all material from the TOI to allow a contemporaneous continuum of independent & objective clinical documentation.Provision of a brief summary, some certificates is UNACCEPTABLE. The assessor is unable to arrive at a diagnosis without viewing all the medical & allied health records from the time of injury& before the TOI if there is consideration& request to assess pre-existing condition & performing the complex Apportionment.

    Assessors have an obligation to act in an ethical, professional &considerate matter when assessing and examining claimants for the determination of PI.

    Effective communication is vital to ensure that the claimant is well-informed &able to maximally co-operate in the process.Assessors should ensure: the claimant understands who the assessor is & the assessor's role in the evaluation, the claimant understands how the evaluation will proceed, take steps to preserve the privacy& modesty of the claimant during the evaluation & NOT provide ANY OPINION to the claimant about their claim.I  always introduce myself, explain my qualifications & involvement in the assessment, show the claimant all material that is before me & obtain consent to proceed.

    In circumstances where the treatment of a condition leads to a further secondary  impairment, other than a secondary psychological impairment, the assessor should use appropriate parts of the relevant Guide to evaluate the effects of the particular treatment /s, and the utilise the Combined Values Chart ( in each AMA Gude e.g. pp 604-606 in AMA 5-not just adding-I have seen WPIs. 100% !) to arrive at the final WPI,

    Where an effective treatment has resulted in an apparent substantial or TOTAL elimination of the claimant's PI , but the claimant is likely to revert to the original level of impairment if the treatment is withdrawn, the assessor may INCREASE the % of WPI by 1, 2 or 3 % WPI, and this should be COMBINED(not numerically ADDED) with any other PI, again using the complex Combined Values Chart of the relevant AMA guide Edition requested by the referrer.NOTE: this does NOT apply to the use of analgesics or anti-inflammatory medications.As previously stated, where a claimant has declined assessor opined beneficial treatment/s , the PI rating should be NEITHER INCREASED OR DECREASED.

    Regarding the ordering of additional investigations, the assessor should not order such tests purely for the purpose of assessing PI. He/she MAY order them as apart of a workman's compensation IME&R to assist in diagnosis and management planning , but in general not for Pi assessments.If however the assessor feels that inadequate, inappropriate tests have been performed ,and considers that a different test is needed, he/she can consider the deferral of assessment ,providing the claimant and  referrer  give approval and there is no undue risk to the claimant.

    The degree of PI from a pre-existing condition should NOT be included within the index injury PI.In assessing the PI from the index injury , the assessor is to indicate the degree of impairment due to previous injury or condition&this proportion is known as "the deductible proportion".The DP is deducted from the finalPI determined by the assessor. It is surprising how frequent one sees reports of PI at Court proceedings where neither assessor, legal representatives for both parties & judicial/determining officer do not address the DP from the PI in awarding damages for the effects of the index injury, & utilise the entire WPI (injury+pre-existing!).

    Inconsistent presentation is a major issue in this adversarial system.AMA5 (page 19) states:"Consistency tests  are designed to ensure reproducibility and greater accuracy.These measurements, such as one that checks the individual's range of motion are good but imperfect indicators of people's efforts.The physician must use the entire range of clinical skill and judgement when assessing whether the measurements or test results are plausible and consistent with the impairment being evaluated.If ,in spite of an observation or test result, the medical evidence appears insufficient to verify that an impairment of a certain magnitude exists, the physician may modify the impairment rating accordingly and then describe and explain the reason for the modification in writing."This paragraph applies to inconsistent presentation ONLY.

    Rounding is used in the AMA guides.All Pis must be rounded to the nearest whole number before leaving to the next level i.e.finger to hand, or from regional to Whole of Person Impairment. Figures should also be rounded BEFORE using the complex Combined Values table in each AMA guide Edition.The convention is , or equal to 0.4 rounded down & values of & above 0.5 are rounded up to the next whole number.

    Some tables in the AMA guides require the medical specialist to consider the impact on ADLs in determining the precise PI value.The impact on ADLs should be verified wherever possible by reference to objective measurements e.g. physio / OT reports.

    A report of the evaluation of PI should be accurate, comprehensive and fair.It should address clearly the question being asked of the assessor, including : current clinical status and the basis for determining MMI; the degree of PI that results from a specific ('index') injury ; and the proportion of that assessed PI due to any previous injury, pre-existing condition or abnormality, if any.The report should contain factual information based on the assessor's own history taking and clinical examination.If other reports or investigations are relied upon they should be noted.Regional PIs are converted to WPI%.

    If the assessor felt that the assessment was made without pertinent records, tests etc the assessor should point this out ,IN WRITING.

    ASSISTANT PROFESSOR MICHAEL CORONEOS CIME MASE

    SENIOR NEUROSURGEON

    TRIPLE PI CERTIFIED PI ASSESSOR-CIME by ABIME.