WCLA MCLE 8-10-11

• AMA Guides: Section 8.1b, Fundamentals & Case Study

• Wednesday August 10, 2011 from 11:45 am to 1:15 pm

• Dr. David Fetter, M.D.• James R. Thompson Center Auditorium,

Chicago, IL• 1.5 Hours General MCLE Credit

PA97-0276Added to Section 5

(effective immediately 8-8-11)• Notwithstanding any other defense, accidental injuries incurred while the employee is

engaged in the active commission of and as a proximate result of the active commission of (a) a forcible felony, (b) aggravated driving under the influence of alcohol, other drug or drugs, or intoxicating compound or compounds, or any combination thereof, or (c) reckless homicide and for which the employee was convicted do not arise out of and in the course of employment if the commission of that forcible felony, aggravated driving under the influence, or reckless homicide caused an accident resulting in the death or severe injury of another person. If an employee is acquitted of a forcible felony, aggravated driving under the influence, or reckless homicide that caused an accident resulting in the death or severe injury of another person or if these charges are dismissed, there shall be no presumption that the employee is eligible for benefits under this Act. No employee shall be entitled to additional compensation under Sections 19(k) or 19(l) of this Act or attorney's fees under Section 16 of this Act when the employee has been charged with a forcible felony, aggravated driving under the influence, or reckless homicide that caused an accident resulting in the death or severe injury of another person and the employer terminates benefits or refuses to pay benefits to the employee until the termination of any pending criminal proceedings.

New Section 8.1b 820 ILCS 305/8.1b

• Sec. 8.1b. Determination of permanent partial disability. For accidental injuries that occur on or after September 1, 2011, permanent partial disability shall be established using the following criteria: (a) A physician licensed to practice medicine in all of its branches preparing a permanent partial disability impairment report shall report the level of impairment in writing. The report shall include an evaluation of medically defined and professionally appropriate measurements of impairment that include, but are not limited to: loss of range of motion; loss of strength; measured atrophy of tissue mass consistent with the injury; and any other measurements that establish the nature and extent of the impairment. The most current edition of the American Medical Association's "Guides to the Evaluation of Permanent Impairment" shall be used by the physician in determining the level of impairment. (b) In determining the level of permanent partial disability, the Commission shall base its determination on the following factors: (i) the reported level of impairment pursuant to subsection (a); (ii) the occupation of the injured employee; (iii) the age of the employee at the time of the injury; (iv) the employee's future earning capacity; and (v) evidence of disability corroborated by the treating medical records. No single enumerated factor shall be the sole determinant of disability. In determining the level of disability, the relevance and weight of any factors used in addition to the level of impairment as reported by the physician must be explained in a written order.

Title & Applicability Date• Sec. 8.1b. Determination of permanent partial disability. For accidental

injuries that occur on or after September 1, 2011, permanent partial disability shall be established using the following criteria:…

• “Guides to the Evaluation of Permanent IMPAIRMENT”• Guides: “The relationship between impairment and disability remains

both complex and difficult, if not impossible to predict…In disability evaluation, the impairment rating is one of several determinants of disablement.” (pgs. 5 & 6).

• “For purposes of the Guides, the following operational definitions and disclaimer apply: Impairment: a significant deviation, loss, or loss of use of any body structure or body function in an individual with a health condition, disorder or disease; Disability: activity limitations and/or participation restrictions in an individual with a health condition, disorder, or disease.” (pg.5)

Physician• (a) A physician licensed to practice medicine in all of its branches preparing a permanent partial disability

impairment report shall report the level of impairment in writing.• “A physician”; Not all physicians, not every physician; not treating physicians. • Guides: “Although treating physicians may perform impairment ratings on their patients, it is recognized that

these are not independent and may be subject to greater scrutiny…requires expertise and judgment.” (pg. 23)• Medical Practice Act of 1987: “10. ‘Physician’ means a person licensed under the Medical Practice Act to practice

medicine in all of its branches or a chiropractic physician licensed to treat human ailments without the use of drugs and without operative surgery.” 225 ILCS 60/2.

• “In the current version of the Medical Practice Act of 1987, the legislature's definition of ‘physician’ expressly includes both medical doctors and chiropractors, describing a ‘physician’ as ‘a person licensed to practice medicine in all of its branches or a chiropractic physician licensed to treat human ailments without the use of drugs and without operative surgery’.” Montes v. Mai, 398 Ill.App.3d 424 (2010).

• Strunk & White: “The position of the words in a sentence is the principal means of showing their relationship… Modifiers should come, if possible next to the word they modify.” This is an IMPAIRMENT report.

Impairment Report• The report shall include an evaluation of medically defined and

professionally appropriate measurements of impairment that include, but are not limited to: loss of range of motion; loss of strength; measured atrophy of tissue mass consistent with the injury; and any other measurements that establish the nature and extent of the impairment. The most current edition of the American Medical Association's "Guides to the Evaluation of Permanent Impairment" shall be used by the physician in determining the level of impairment.

• Notice legislatures’s distinction between impairment vs. disability• “Loss of range of motion”? Is this in Guides? • “Any other measurements that establish nature & extent”? Does “any

other” include measurements not in Guides? Must evaluator go outside of Guides to comply with this requirement?

• “Most current” is 6th Edition, Second printing

Factors

• (b) In determining the level of permanent partial disability, the Commission shall base its determination on the following factors:

• Notice legislature’s distinction between impairment and disability

• Notice seemingly mandatory language: “shall base”

• Notice use of word “factors”: one of five elements in ultimate determination of PPD

FactorsImpairment

• “(i) the reported level of impairment pursuant to subsection (a)”• What if no “reported” impairment? Guides cannot be considered:

decisions “shall be based exclusively on evidence in the record.” New(?) standards of conduct.

• Must comply with paragraph (a); done under AMA Guides• Are Impairment Reports (IR) automatically admissible? No! Blatant

hearsay at least; no exception made for IR; legislature knows how to make things automatically admissible; See Section 16

• Section 16: “does not apply to reports prepared by treating providers for use in litigation.” IR’s are just this!

• Section 12? 48 hour rule?

FactorsOccupation; Age; Earning Capacity• “(ii) the occupation of the injured employee”

When? DA or later? • (iii) age of the employee at the time of the

injury” Why at the time of the injury? Cuts both ways: young live with it longer; old recover poorly

• “(iv) the employee’s future earning capacity” Consider 8(d)1 wage differential or 8(d)2 PAW

FactorsEvidence of Disability

• “and: evidence of disability corroborated by the treating medical records.”

• “Corroborated by”: supported by; credibility• “Treating medical records”: who cares what

IME says about evidence of disability?• “Evidence of disability”: PPD shall be based on

disability! Still!• What is evidence of disability?

FactorsEvidence of Disability

• Commission decisions: “conclusions of law set out in such decisions shall be regarded as precedents by Arbitrators” Section 19(e)

• 81 IIC 1: “evaluate the effect of a disability on the life of the particular worker before it. Several factors are relevant…”

• “Occupation; age; inability to engage in certain kinds of work or activities; loss of income; skill; training; pain; stiffness; weakness; cramps; numbness; inflammation; spasms; limitation of motion; tenderness; atrophy; lack of coordination; soreness; diminished reflexes; the need for assistance devices such as braces, orthotics and glasses; the need for medication and ongoing medical care.”

• Still a question of fact for reviewing courts

FactorsNo Sole Determinant

• “No single enumerated factor shall be the sole determinant of disability.”

• “No single”: one alone• “enumerated”: (i) through and including (v)• “shall be the sole”: contrary to law if violated• “determinant”: decisive factor• “of disability”: Still PPD! Get it yet?!

Factors Weight

• “In determining the level of disability, the relevance and weight of any factors used in addition to the level of impairment as reported by the physician must be explained in writing.”

• Notice disability v. impairment• Notice no special weight given to any one factor (i) through (v)• Notice relevance: irrelevant evidence in record?• Notice weight: “ Arbitrator assigns great weight to Petitioner’s

credible complaints of pain as corroborated by the treating medical records.”

• Written order: Decision

Is This Right?• Compare to previous versions (See SB 1349 McCarter: (c) In determining

the level of disability, the Commission shall base their determination on the level of impairment as certified by the physician. The Commission may deviate from the level of impairment only using the following additional factors…)

• “Illinois will not be a strict AMA Guides state”• Positions of interested parties: labor, ITLA, Chamber, CAT• No change in minimum permanency compensation (amputations, organs

etc.)• New carpal tunnel provision: recognition that disability is different from

impairment• NCCI: No premium reduction for this provision because, “PPD award is

based on determination of disability by the WCC using other subjective factors.” (8.8% reduction altogether)

AMA AMA Guides, 6Guides, 6thth Edition Edition It’s Changed It’s Changed

Coming SOON Coming SOON to to Illinois Workers’ CompensationIllinois Workers’ Compensation

Why are you listening to me??

• 820 ILCS 305/8.1B (NEW)– For accidental injuries that occurs on or after

September 1, 2011, permanent partial impairment shall be established by the following criteria:

a. A Physician licensed to practice medicine in all of its branches preparing a permanent partial disability disability report shall report the level of impairment in writing. …. The most current edition of the American Medical most current edition of the American Medical Association’s “GuidesAssociation’s “Guides to the Evaluation of Permanent Impairment: shall be used shall be used by the physician in determining the level of impairment.

Why are you listening to me??• 820 ILCS 305/8.1B (NEW)

– b. In determining the level of permanent partial disability, the Commission shall base its determination of the following factors:

– (i) the reported level of impairment pursuant to subsection (a)– (ii) the occupation of the injured employee– (iii) the age of the employee at the time of the injury– (iv) the employee’s future earning capacity– (v) evidence of disability corroborated by the treating medical

records.• In determining the level of disability, the relevance and

weight of any factors used in addition to the level of impairment as reported by the physician must be must be explained in a written order.explained in a written order.

18

JAMA Feb 15, 1958The Musculoskeletal System

12 other “Guides” published over the next 12 years in Issues of JAMA.

19

AMA Guides – Work in ProgressGradual, Incremental Change

20

History of the AMA Guides• 1956 - ad hoc committee• 1958-1970 - 13 publications in JAMA• 1971 - First Edition• 1981 - established 12 expert panels• 1984 - Second Edition• 1988 - Third Edition• 1990 - Third Edition-Revised• 1993 - Fourth Edition (4 printings)• 2000 – Fifth Edition (November 2000)• 2007 (December) – Sixth Edition

– Radical paradigm shift

SAME MethodologyRefined and Improved Over time

21

The Color: Purple

Date of publicationDecember 24, 2007Merry Christmas

Axiom 1:Axiom 1:• The AMA The AMA GuidesGuides must adopt must adopt

the terminology and the terminology and conceptual framework of conceptual framework of disablement as put forward disablement as put forward by the International by the International Classification of Functioning, Classification of Functioning, Disability and Health (ICF). Disability and Health (ICF).

(WHO, 2001)(WHO, 2001)

23

24

We are all to some degree DISABLED ?

ICF Model is INTENDED to blur CAUSATION, so we focus on the individual’s handicap,NOT on Causation.

Traditional ICIDH model Traditional ICIDH model (WHO, 1980)(WHO, 1980)

New ICF model New ICF model (WHO, 2001)(WHO, 2001)

No Activity Limitation

Complete Activity Limitation

No Participation Restriction

Complete Participation Restriction

Contextual Factors

Body Functions and Structures

Activity Participation

Environmental Personal

Normal Variation

Complete Impairment

Health Condition, Disorder or Disease

ICF TerminologyICF Terminology

• Body functionsBody functions – physiological/psychological – physiological/psychological functions of body systemsfunctions of body systems

• Body structuresBody structures – anatomical parts (organs, – anatomical parts (organs, limbs, & components)limbs, & components)

• ActivityActivity – execution of a task or action by an – execution of a task or action by an individualindividual

• ParticipationParticipation – involvement in a life situation – involvement in a life situation

ICF Terminology (2)ICF Terminology (2)

• ImpairmentImpairment – problem in body function or – problem in body function or structure as a significant deviation/lossstructure as a significant deviation/loss

• Activity limitationActivity limitation – difficulty an individual has – difficulty an individual has in executing an activityin executing an activity

• Participation restrictionParticipation restriction – problem – problem experienced in involvement in a life situationexperienced in involvement in a life situation

29

AMA Guides Growth in Size

0

100

200

300

400

500

600

700

Pages

Pages 245 254 262 339 613 634

Second ThirdThird Rev.

Fourth Fifth Sixth

Sixth Edition Fifth Edition

Fourth Edition

Chapter Title Length Chapter Length Chapter Length

1 Concepts and Philosophy 18 1 15 1 6

2 Practical Application 12 2 8 2 6

3 Pain 16 18 28 15 12

4 Cardiovascular system 30 3&4 62 6 32

5 Pulmonary system 24 5 30 5 16

6 Digestive system 28 6 26 10 14

7 Urinary & reproductive system 30 7 30 11 14

8 Skin 24 8 18 13 14

9 Hematopoietic system 30 9 22 7 8

10 Endocrine system 34 10 34 12 14

11 Ear, nose, & throat 34 11 32 9 12

12 Visual system 40 12 28 8 14

13 Central and Peripheral Nervous System 26 13 52 4 14

14 Mental and Behavioral Disorders 36 14 16 14 12

15 Upper Extremities 110 16 90 3.1 60

16 Lower Extremities 64 17 42 3.2 19

17 Spine 46 15 60 3.3 42

602 593 309

32

Impairment Rating Does NOT• Determine Medical Care• Comment on causation • “Impairment evaluations are usually performed not to

establish academic facts or to make treatment decisions but, rather, to establish the financial obligations of payers to individuals, or, conversely, the entitlement of individuals to monetary rewards. – Guides, 5th Edition page 569

33

Impairment Rating: 6th Edition• “… to translate objective clinical findings into a

percentage of the whole person. Typically this number is used to measure the residual deficit, a loss – a number that is then then converted to a monetary converted to a monetary awardaward to the injured party.” – page 20

• The Guides is not intended to be used for direct estimates of work participation restrictions. Impairment percentages derived according to the Guides criteria do NOT directly measure work participation restrictions.”– Page 6, 6th Edition– Page 13, 5th Edition

34

AMA GuidesCOMPARE 5TH & 6th Editions

• “For purposes of the Guides” (6th Edition) the following operational definitions and disclaimers apply.” - page 5

– 6th Edition: Impairment; a significant deviation, loss, or loss of use, of any body structure or body function in an individual with a health condition, disorder, or disease. – page 5

- 5th Edition: Impairment is “A loss, loss of use, or derangement of any body part, organ system, or organ function.”

Definitions are essentially the same

35

AMA GuidesCOMPARE 5TH & 6th Editions

• “For purposes of the Guides” (6th Edition) the following operational definitions and disclaimers apply.” - page 5– 6th Edition: Disability; activity limitations and/or

participation restrictions in an individual with a health condition, disorder, or disease. – page 5

– 5th Edition: Disability; “An alteration of an individual’s capacity to meet personal, social, or occupational demands because of an impairment.”

Definitions are essentially the same

36

AMA Guides, 6th Edition• Definition: Maximal Medical Improvement

– “Maximum Medical Improvement (MMI) refers to a status where the person is as good as he/she is the person is as good as he/she is going to get from the medical and surgical going to get from the medical and surgical treatment available to him/hertreatment available to him/her. It can also be conceptualized as a date from which further recovery or deterioration is not anticipated, although over time (beyond twelve months) there may be some expected change.”

- Chapter 2.5e, page 26

Words are somewhat different, but the concept is UNCHANGED.

37

KEY POINT• Physicians rate impairment

– Medical determination– Medical training required (Anatomy, Physiology)

• Judges rate disability– Judge “factors in” NON-medical factors– In Workers’ Compensation, the

philosophical basis for the Lump Sum cash settlement is the loss of earning ability, and NOT “pain and suffering”.

• Doctor: “DoDoctor: “Do NOTNOT think aboutthink about the ability to do his/her job, availability of similar jobs in the local economy, etc., as that is the judge’s task, NOT your task.”

38

Impairment DOES NOT equal Disability• Example: both a lawyer and a pianist sustain

an amputation of the non-dominant little finger.– Both have the same impairment

• 100% of the digit, 10% of the hand, 9% of the upper extremity, 5% whole person

– The lawyer has no disability– The pianist is unable to perform his occupation

• Totally disabled for his occupation• Fully capable of many jobs

• Physician’s role: Determine IMPAIRMENT

39

Impairment is NOT Disability

• “In disability evaluation, the impairment rating is ONE of several determinants of disablement. Impairment rating is the determinant most amenable to physician assessment; it must be further integrated with contextual information typically provided by nonphysician sources regarding psychological, social, vocational, and avocational issues.” – page 6

Unless otherwise specified page numbers refer to the Guides, 6th Edition

40

AMA Guides Philosophy• Ratings reflect the severity and limitations of the

organ/body system impairment and resulting functional limitations

• Ratings in whole person, or converted to whole person

• 0% whole person rating – No significant organ or body system functional

consequences– Does not limit the performance of common activities of

daily living• 90% - 100% whole person rating

– Very severe organ or body system impairment– Requires the individual to be fully dependent on others

for self-care, approaching death (page 19)

41

AMA Guides, 6th EditionPhilosophy

• “Impairment rating: consensus derived percentage estimate of loss of activity reflectingreflecting severity for a given health condition, and the degree of associated limitations in degree of associated limitations in ADLsADLs.” – page 5–ADLs = Activities of Daily Living

42

Self- Care

1. Conceptual Foundations and Philosophy

Activities of Daily Living (ADLs):•Bathing, showering

•Dressing

•Eating

•Feeding

•Functional mobility

•Personal device care

•Personal hygiene and grooming

•Sexual activity

•Sleep/rest

•Toilet hygiene

43

Self- Care

1. Conceptual Foundations and Philosophy

Instrumental Activities of Daily Living (IADLs)•Care of others (including selecting and supervising caregivers)

•Care of pets

•Child rearing

•Communication device use

•Community mobility

•Financial management

•Health management and maintenance

•Home establishment and maintenance

•Meal preparation and cleanup

•Safety procedures and emergency responses

•Shopping

44

Identical to Table 15-10 in the Upper ExtremitySimilar to Table 17-10 in the SpineSimilar to Table 4-4 in the Cardiovascular SystemSimilar to Table 5-3 in the Pulmonary SystemSimilar to Table 6-3 in the Digestive SystemSimilar to Table 7-1 in the Urinary and Reproductive SystemEtc.

Lower Limb Chapter

Essential Elements of Physician Assessment & Reporting:

ORHow one Doctor talks to another about a case

• What is the clinical problem (diagnosis)?• What difficulties does the patient report

(symptoms; functional loss)?• What are the physical examination findings?• What are the results of clinical studies?• These same steps are involved in rating

impairment using the 6th Edition methodology.

Spine Example:Spine Example:Steps to Determine Diagnosis-Based Impairment (Steps to Determine Diagnosis-Based Impairment (DBI)DBI)

1) Perform Hx & P/E and determine 1) Perform Hx & P/E and determine MMIMMI2) Establish appropriate Spine 2) Establish appropriate Spine diagnosisdiagnosis3) Use regional “DBI grid” 3) Use regional “DBI grid”

(Cervical/Thoracic/Lumbar/Pelvis) to determine (Cervical/Thoracic/Lumbar/Pelvis) to determine Impairment ClassImpairment Class

4) Use “adjustment grid4) Use “adjustment grid” grade modifiers ” grade modifiers to to determine Final determine Final Impairment GradeImpairment Grade within-class within-class

5) Assign Spine 5) Assign Spine Impairment Rating Impairment Rating (IR)(IR) according to according to diagnosis-specific diagnosis-specific IC/IG IC/IG

Cervical Spine Regional GridCervical Spine Regional Grid

Cervical Spine Regional Grid (2)Cervical Spine Regional Grid (2)

Methodology for Grade Determination Within-Methodology for Grade Determination Within-Class:Class:

Adjustment Grid SummaryAdjustment Grid Summary

Functional History Adjustment: SpineFunctional History Adjustment: Spine

Physical Examination Adjustment: SpinePhysical Examination Adjustment: Spine

Physical Examination Adjustment: Spine (2)Physical Examination Adjustment: Spine (2)

Clinical Studies Adjustment: SpineClinical Studies Adjustment: Spine

Net Adjustment Formula:Net Adjustment Formula:

Example: Cervical RadiculopathyExample: Cervical Radiculopathy• History: 23 y.o. right handed male sustained blow History: 23 y.o. right handed male sustained blow

to posterior aspect of neck from machine support to posterior aspect of neck from machine support that slipped. Studies revealed that slipped. Studies revealed C7-T1 disk C7-T1 disk herniationherniation. Patient managed conservatively and . Patient managed conservatively and refused surgery in spite of continued symptoms. refused surgery in spite of continued symptoms. Evaluated 1 year post injuryEvaluated 1 year post injury

• Functional History: Neck pain radiating to ulnar Functional History: Neck pain radiating to ulnar aspect of left hand with numbness of ring and aspect of left hand with numbness of ring and

little fingers. little fingers. Increased symptoms with minimal Increased symptoms with minimal activityactivity. . PDQ score of 105 PDQ score of 105 (~severe disability)(~severe disability)

• PE: Decreased neck ROM; + cervical compression PE: Decreased neck ROM; + cervical compression with C8 radicular pain; decreased C8 sensation with C8 radicular pain; decreased C8 sensation and motor weakness (3/5)and motor weakness (3/5)

• Clinical Tests: Clinical Tests: MRI posterolateral HNP C7-T1MRI posterolateral HNP C7-T1; ; EMG left C8 fibrillation potentials.EMG left C8 fibrillation potentials.

Example 1: Example 1: (cont’d)(cont’d)

• Diagnosis: Diagnosis: C7-T1 disk herniation C7-T1 disk herniation with with chronic chronic left C8 radiculopathyleft C8 radiculopathy

• Impairment Rating: Regional impairment Impairment Rating: Regional impairment Class 2 (“default” Grade C = 11% WP)Class 2 (“default” Grade C = 11% WP)

Cervical Spine Regional GridCervical Spine Regional Grid

Example 1: Example 1: (cont’d)(cont’d)

• FH: (Grade 3)FH: (Grade 3) PE: (Grade 2) (sensory & motor)PE: (Grade 2) (sensory & motor) CS: (Grade 2) CS: (Grade 2) • Net adjustment (3-2) + (2-2) + (2-2) = +1Net adjustment (3-2) + (2-2) + (2-2) = +1• Diagnosis: C7-T1 HNP with chronic left C8 Diagnosis: C7-T1 HNP with chronic left C8

radiculopathyradiculopathy• Final Impairment Rating: Final Impairment Rating:

– Class 2, Grade D = 12% WPIClass 2, Grade D = 12% WPI

Cervical Spine Regional GridCervical Spine Regional Grid

61

Example 16-9 p 526

• Subject: 52 year old man• History: Twisting injury

– s/p ACL reconstruction and medial meniscal repair– Severe pain and “nearly total functional loss of his

extremity”

62

Example 16-9 p 526• Physical Exam:

– “Mild laxity of the ACL”– 5° loss of terminal extension

• 5° flexion contracture– Normal flexion– No effusion– Severe limp in the exam room.– NORMAL gait when exiting the exam room.

63

Example 16-9 p 526

• Clinical Studies: MRI had confirmed torn ACL and “Bucket handle tear of medial meniscus”.– Pre-Op study

• Clinical Studies: Current weight-bearing X rays show bioabsorbable fixation of the ACL in good position with a normal 5 mm joint space in all 3 compartments.

64

Example 16-9 p 526

• "The methodology requires the examiner to pick one diagnosis for the region. • The anterior instability diagnosis was

chosen, and the effect of the meniscal tear is reflected in the adjustments."

65

Errata• "Diagnosis: "cruciate or collateral ligament injury"

with mild instability assigned to class 1 with a default value of 10% LEI.

• Functional History judged unreliable in the presence of only mild instability and no atrophy, and thus not used in rating.

• Physical exam instability not used as a grade modifier since stability was used in class assignment. No atrophy would be grade 0, but 5° flexion contracture would be rated at 10% LEI by table 16-23, and table 16-25 indicates a 10% LEI rating would be a mild degree of problem, or a grade 1 modifier from table 16-7.

66

Text for Example 16-9• Clinical Studies: The anterior cruciate

reconstruction in good position without joint space narrowing on current weight bearing x-rays by itself would be a grade 1, mild pathology adjustment. The presence of the meniscal tear and subsequent repair (documented in the operation report) would justify moving up a grade to grade 2 for the final clinical studies adjustment.

• The net adjustment is +1, so class 1, grade D, or 12% LEI is the final rating."

67

Example 16-9 p 526• Diagnosis: ACL “mild laxity”

– Class 1• Diagnosis: Meniscal injury

– Class 1• FH = grade 4, but not utilized [INVALID]• PE = grade 1 Flexion contracture• CS = grade 2

– [Move up because of meniscal tear/repair]• Net Adjustment = + 1, and grade D is used for ACL.

Class1, Grade D = 12% LEI

Features of AMA Features of AMA Guides 6Guides 6thth ed ed::

• ICF Model of Disablement (WHO 2001) ICF Model of Disablement (WHO 2001) replaces outdated ICIDH model (WHO replaces outdated ICIDH model (WHO 1980)1980)

• AMA AMA GuidesGuides is regularly updated with is regularly updated with latest, evidence-based diagnostic latest, evidence-based diagnostic information information

• AMA AMA GuidesGuides is increasingly diagnosis- is increasingly diagnosis-based, hence physician-friendly and easy to based, hence physician-friendly and easy to learn and to uselearn and to use

Features of AMA Features of AMA Guides 6Guides 6thth ed: ed: (2) (2)

• AMA AMA GuidesGuides is internally-consistent, hence is internally-consistent, hence easy to apply across multiple organ systemseasy to apply across multiple organ systems

• AMA AMA GuidesGuides is functionally-based to help is functionally-based to help capture impact of impairment upon ADLscapture impact of impairment upon ADLs

• AMA AMA GuidesGuides has high precision and resolution has high precision and resolution of impairment ratingsof impairment ratings

• AMA AMA GuidesGuides is transparent and promotes is transparent and promotes • greater inter-rater reliability and agreementgreater inter-rater reliability and agreement

Conclusions• Many of the more meaningful changes

were for spine-related diagnoses that resulted in surgery.

• Diagnoses not previously ratable (e.g. soft tissue) may result in small impairments.

• Consistent process should result in improved inter-rater reliability.

7171

ThanksFor Your Attention