Free F252-006-000 Doctors Worksheet for rating Dorso-Lumbar and Lunbo-Sacral Impairment - Washington


File Size: 832.7 kB
Pages: 3
File Format: PDF
State: Washington
Category: Workers Compensation
Word Count: 1,159 Words, 7,496 Characters
Page Size: 573 x 753 pts
URL

http://www.lni.wa.gov/Forms/pdf/252006a0.pdf

Download F252-006-000 Doctors Worksheet for rating Dorso-Lumbar and Lunbo-Sacral Impairment ( 832.7 kB)


Preview F252-006-000 Doctors Worksheet for rating Dorso-Lumbar and Lunbo-Sacral Impairment
Dept. of Labor & Industries PO Box 44239 Olympia WA 98504-4239

DOCTOR'S WORKSHEET FOR RATING 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

Department of Labor & Industries

Doctor's Worksheet for Rating Dorso-Lumbar & Lumbo-Sacral Impairment
Claimant's name Claim #

Step 1. (a) Has the worker's 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? Yes No N/A If "Yes," attach explanation. Step 2. Is there any permanent impairment? Yes No Step 3. Circle one box in each column A through D below. Give brief explanation below (REQUIRED). Your entries should reflect the patient's current

A Muscle Weakness

AND:
EITHER Atrophy or EMG abnormalities
(See "notes" below.)

B Reflex loss (In general only Asymmetric losses are significant.) Circle one none (1)

C Imaging and X-ray findings EXAMPLES: Degenerative disk disease, fracture disrupting the spinal canal, bulging disc (Only include findings which are consistent with clinical picture.) Circle one none (1) Explain:

Circle one none (1)

knee ankle (3)
Tear on perforated line

yes yes

D Other Findings EXAMPLES: Dermatomal sensory loss, decreased range-of-motion, muscle guarding, +SLR (Only include findings which are consistent with the clinical picture.) NOT TO BE CONSIDERED: OSWESTRY OR OTHER PAIN SCALES Explain: Circle one none (1) mild intermittent (2) mild continuous or moderate intermittent (3)

mild but significant (4)

mild but significant (4) moderate (5)

moderate continuous or marked intermittent (5) marked continuous (7) essentially total loss of low back functions (8) Step 4: Calculate Rating (If you want L&I to do the calculation, copy the numbers into the 1st 4 boxes and go to Step 5.) Box number circled in Column A: Box number circled in Column B: Box number circled in Column C: Box number circled in Column D: Total

moderate (6) marked (7)

marked (6)

Give muscle group and specific abnormalities:

Notes: · Column A: Mild Weakness = 4/5 (Complete motion against gravity and less than full resistance);
Moderate = 3/5 (Barely complete motion against gravity); Marked = 2/5 - 0/5 (Complete motion with gravity eliminated to no evidence of contractility). · Pain is considered in the rating, but must be reflected in findings described on this worksheet (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.
ZIP+4 Today's date Doctor's signature Provider No.

Step 5: Doctor's address Certification
Print Dr's name

The Physician should photocopy this worksheet for their medical records. Doctors should refer to the Medical Examiner's 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

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 worker's total medical condition. For example, the background of the worker's total medical condition might include smoking, substance abuse or concurrent medical problems. It is not necessary to defer the rating until all on-going potentially complicating conditions have been resolved. If the worker's condition is deteriorating at such a rate that medical treatment is needed for the accepted condition and the total loss of function cannot be predicted, the worker's condition is not stable, then his or her impairment should NOT be rated (unless you have received special instructions from the Claim Manager). In this situation you should make treatment recommendations.

For your mailing convenience, This form has been designed so you only need to tear the last page (pages 3 and 4) off, fold and insert into a standard window envelope. Please check to ensure the L&I address is showing through the window before sealing.

!985044239394! Department of Labor & Industries PO Box 44239 Olympia WA 98504-4239
F252-006-000 worksheet/dorso-lumbar & lumbo sacral 9-00

Page 4