AMA Guides Chapter 13 The Central & Peripheral Nervous System

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AMA Guides Chapter 13The Central & Peripheral Nervous System

By Timothy Mussack

Law Offices of Bradford & Barthel, LLP

Law Offices of Bradford & Barthel, LLP – www.bradfordbarthel.comNew File Referrals: [email protected]

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Bradford & Barthel

Bradford & Barthel, LLP

@bradfordbarthel

Bradford & Barthel bradfordbarthelllp

7/14/2021

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AMA Analysis & Ratings Division

Website: https://bradfordbarthel.com/areas-of-practice/bb-ratings/

Referrals: [email protected]

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Timothy Mussack, Esq.Director, AMA Analysis & [email protected]

Don Barthel, Esq.Founding Partner(916) [email protected]

Susan ColiasRating Specialist(909) [email protected]

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Meet our Team!Tahmeena Ahmed, Esq.Managing Partner, Client Relations(818) [email protected]

Tammey WeltyDirector, Training(916) [email protected]

Kenneth Tolbert Rater(909) [email protected]


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Review WPI reporting•Does the doctor explain the WPI?

▫ Objective findings should lead to the correct Chapter, correct Table, and correct Class or Category

•Read the relevant part of the Guides▫ Introduction to that Chapter▫ Applicable section▫ Applicable Tables/ Figures▫ Examples

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Rating Considerations

• Impairment values▫ WPI▫ UE – Hand - Digits▫ LE - Foot

• Interpolation of values within Table/ Figures• Combining Impairment – overlap consideration/

limit of 100%▫ Extremity or WPI level▫ PD (after adjustment)

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Rating CorrectionsPhysician provides measurements

▫ Any knowledgeable observer may check findings with the Guides criteria (5th Edition - page 17) Look up table values Correct table impairments Correct math errors

DEU will make corrections when ratingDEU will denote potential misinterpretations of the Guides

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Chapter 13

“Cerebral” Impairment (page 308)

Mental Status – instructions

Table 13-8 or GAF for behavioral disorder

Cranial Nerves – including Trigeminal Nerve

Chapter 13 ‘by analogy’ – objective findings?

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Chapter 13• Introduction

▫ Evaluating “documented dysfunction of the brain, cranial nerves, spinal cord, nerve roots, and/ or peripheral nerves and muscles” (p 305)

• Principles of Assessment (p 306)• Impairment classes refer to ADL abilities

▫ “When subjective…and open to interpretation…obtain objective data about the severity…and integrate those findings with subjective data…”

• Clinical Studies▫ Detailed neurologic exam▫ Ancillary testing▫ Common clinical studies

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Chapter 13Methods of Evaluation• Section 13.2 – Central Nervous System Disorders

▫ CNS = brain and spinal cord▫ Several areas of function may be impaired▫ Only the most severe category of Cerebral

Impairment is used:

Tables 13-2, 13-3, 13-4, 13-6, 13-7, 13-8

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13 – CENTRAL & PERIPHERAL NERVOUS SYSTEM

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Impairment# FEC Impairment

13.01.00.00 Consciousness Disorder13.02.00.00 Episodic Neurologic Disorder13.03.00.00 Arousal Disorder13.04.00.00 Cognitive Impairment

13.05.00.00 Language Disorder13.06.00.00 Behavioral/Emotional Disorder


Combine impairments – Table 13-1

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Table 13-2 – 13.01.00.00

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Table 13-3 – 13.02.00.00

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Table 13-4 – 13.03.00.00** LC 4660.1 DOI > 1/1/2013 **statutorily precluded – cannot use A/G

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Table 13-5 (used with Table 13-6)

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Table 13-6 - 13.04.00.00

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Cerebral Impairment – Mental Status

•Table 13-6 – Class 1 – 4 - based on CDR(Clinical Dementia Rating)

▫ Table 13-5 – Impairment and CDR ‘score’ Instructions on page 319 6 categories 5 severity scores (none = 0 CDR; severe = 3.0 CDR) Memory is the primary category Secondary categories balance (and validate) scoring

▫ Three or more vs two or more secondary categories

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Mental Status – CDR score

• If at least three secondary categories are given the same numeric score as memory, then CDR = M.

• If three or more secondary categories are given a score greater or less than the memory score, CDR = the score of the secondary categories unless

• three secondary categories are scored on one side of M and two secondary categories are scored on the other side of M. In this case, CDR = M. (p 319)

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Table 13-7 – 13.05.00.00

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Table 13-8 – 13.06.00.00

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Cerebral Impairment – Emotional or Behavioral DisordersInstructions page 325:• Relationship between neurology and psychiatry• “Originating in verifiable neurologic impairments

(eg, stroke, head injury)”, use Chapter 13• Psyche manifestations without “documented

neurologic impairments” use Chapter 14 (for California WC, as instructed in the 2005 PDRS –GAF)

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Cerebral Impairment• Example - from one injury:

▫ Paroxysmal Disorder (spasm or seizure) Table 13-3 – Class 2 – 25% WPI

▫ Sleep Disorder * Table 13-4 – Class 2 – 10% WPI

▫ Mental Status (CDR scoring) Table 13-6 – Class 2 – 20% WPI

▫ Emotional or Behavioral Table 13-8 - Class 2 – 15% WPI

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Cerebral Impairment• Each of these are considered Cerebral Impairment,

and only the most severe is applied (page 308)[compare PD values after adjustment]

Paroxysmal Disorder (seizure)▫ Table 13-3 – Class 2 – 25% WPI▫ Sleep Disorder * [LC 4660.1 precludes “increases in

impairment ratings…arising out of a compensable physical injury” for DOI on or after 1/1/2013]

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Cranial Nerves I through XII

Impairment# Impairment

13.07.01.00 Cranial Nerve I – Olfactory13.07.02.00 Cranial Nerve II – Optic13.07.03.00 Cranial Nerve III IV, VI– Oculomotor, Trochlear & Abducens

13.07.04.00 Cranial Nerve V– Trigeminal13.07.05.00 Cranial Nerve VII - Facial13.07.06.01 Cranial Nerve VIII – Vestibulocochlear – Vertigo13.07.06.02 Cranial Nerve VIII – Vestibulocochlear – Tinnitus13.07.07.00 Cranial Nerve IX, X – Glossopharyngeal & Valgus13.07.08.00 Cranial Nerve XI – Spinal Accessory13.07.09.00 Cranial Nerve XII – Hypoglossal

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Cranial Nerves – I through XII13.07.01.00

▫ Cranial Nerve I – sense of smell - Max = 3% WPI▫ Chapter 11 – page 262 – 1%-5%

13.07.02.00 – Tables 13-9, 13-1013.07.03.00 - Tables 13-9, 13-10

▫ Cranial Nerve II, III, IV, VI – optic nerve, muscles of the eyes

▫ More detail/more complex cases, addressed in Chapter 12

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Table 13-11 (Cranial Nerve V)

P 331

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Cranial Nerves13.07.04.00 – Table 13-11

▫ Cranial Nerve V – Trigeminal Nerve ▫ ‘facial neuralgic pain’ Without objective findings, this should not be used for

headaches.▫ Headaches The DWC/ DEU stated position is maximum 3% WPI for

residual headache pain following direct trauma but without objective findings

Use 13.01.00.99

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Cranial Nerves13.07.05.00 – Table 13-12

▫ Facial Nerve - VII

13.07.06.01 – Table 13-13 ▫ Nerve VIII - Vertigo

13.07.06.02 – Table 13-13 ▫ Nerve VIII – Tinnitus

Chapter 11 – Hearing Loss

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Cranial Nerves

Table 13-14 (tongue, larynx)

13.07.07.00 – Cranial Nerves IX, X▫ Glossopharyngeal & Valgus

13.07.08.00 – Cranial Nerves XI▫ Spinal Accessory

13.07.09.00 – Cranial Nerve XII▫ Hypoglossal

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Section 13.5 – Movement Disorders

Table 13-15, on page 336 of the AMA Guides, is used to evaluate Impairment due to Station and Gait Disorders that can develop from a CNS or peripheral neurologic impairment.

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Section 13.5 – Movement Disorders

Table 13-15 (p. 336)

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Station and Gait – Overlap?The impairment Classes for Station and Gait Disorders from Table 15-6c, and Table 13-15, to include the range of impairment and the narrative description, are the same.

The instructions and discussions for the use of Tables 17-5, 15-6c, and 13-15 do not offer any differentiation between unilateral or bilateral Station and Gait Disorder.

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Gait

From the Comment section for Example 17-2, on page 529 of the AMA Guides:

A gait evaluation is never combined with any other method…

Class 4 from Table 13-15 and 15-6c = 40-60% WPIcannot stand without help…

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Section 13.6–Upper Extremities13.09.00.00

• Related to Central Impairment

• Tables 13-16 (one upper extremity) and 13-17 (two upper extremities) are used to evaluate Impairment of Two Upper Extremities from any lesion in the brain (page 338).

• Difficulty with Digital dexterity is the common issue referenced in each Table

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Upper Extremities

Tables 13-16, 13-17, page 338

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P 340

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Section 13-7 – Spinal Cord

Impairments resulting from spinal cord injuries and other adverse conditions (p 340)

▫ Station and gait▫ Upper extremities▫ Respiration▫ Bladder▫ Anorectal▫ Sexual

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Section 13-8 – Chronic PainPage 343 of the AMA Guides, Section 13.8 is used to evaluate impairment related to chronic pain.

Chronic pain in this section covers the diagnoses of causalgia, posttraumatic neuralgia, and reflex sympathetic dystrophy.

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Section 13-8 – Chronic Pain

To rate an impairment for causalgia, posttraumatic neuralgia, and RSD in an upper extremity, use Table 13-22. If a lower extremity needs to be rated for causalgia, posttraumatic neuralgia, or RSD, use the station and gait impairment criteria given in Table 13-15, page 343

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P 343

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Chronic Pain

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Impairment# FEC Impairment

13.11 .01.01 Chronic Pain–Upper Extremities–Causalgia13.11.01.02 Chronic Pain–Upper Extremities–Post–traumatic Neuralgia13.11.01.03 Chronic Pain–Upper Extremities–Reflex Sympathetic Dystrophy13.11.02.01 Chronic Pain–Lower Extremities–Causalgia13.11.02.02 Chronic Pain–Lower Extremities–Post-traumatic Neuralgia13.11.02.03 Chronic Pain–Lower Extremities–Reflex Sympathetic Dystrophy

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Chronic pain – as a defined diagnosis –▫ CRPS; RSD; causalgia Table 16-16

OR

“Chronic pain is pain that lasts more than several months (variously defined as 3 to 6 months, but certainly longer than “normal healing”).”

▫ https://nccih.nih.gov/health/pain/chronic.htm

Chapter 13 - Chronic Pain

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Chronic PainCausalgia – following trauma to a peripheral nerve

▫ Burning pain▫ Swelling ▫ Skin changes: smooth, mottled, cold,

sweaty▫ The AMA Guides does not offer a separate

definition for “Post-traumatic Neuralgia” on page 343

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Chronic Pain

RSD- without known nerve lesions; minor soft tissue trauma

▫ Burning pain▫ Temperature changes (warmer, then

colder)▫ Abnormal sweating▫ Trophic changes: changes in skin, nail,

hair growth

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Chronic Pain

Causalgia – following trauma to a peripheral nerve▫ Burning pain

▫ Swelling

▫ Skin changes: smooth, mottled, cold, sweaty

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RSD- without known nerve lesions; minor soft tissue trauma

▫ Burning pain

▫ Temperature changes (warmer, then colder)

▫ Abnormal sweating

▫ Trophic changes: changes in skin, nail, hair growth

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Section 13-8 – Chronic Pain“diagnosis is key and based on clinical criteria”

Diagnostic studies▫ Demineralization Bone scan X-rays

▫ Altered blood flow(page 343)

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Chronic PainIn Chapter 16, on page 434:The medical evaluation is the basis for determination of permanent anatomic impairment of the upper extremities. It must be accurate, objective, and well documented….

An impairment evaluation is based on the examiner’s actual findings.

The AMA Guides require that 8 of the Diagnostic Criteria in Table 16-16 (p. 496) be present concurrently to establish the diagnosis of CRPS.

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Chronic Pain - Chapter 16

• “to rate [causalgia and RSD]…, diagnosis is key…”

• Diagnosis: rely on clinical findings, three-phase bone scan, x-rays, laser Doppler flowmetry, sudomotor reflex

Table 16-16 (p. 496)

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CRPS – Chapter 16• From Table 16-16, page 496• Diagnostic Criteria:• Skin color: mottled or cyanotic• Skin temperature: cool• Edema (swelling)• Skin dry or overly moist• Skin texture: smooth, non elastic• Soft tissue atrophy: especially in fingertips

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CRPS – Chapter 16• Joint stiffness and decreased passive motion• Nail changes: blemished, curved, talonlike• Hair growth changes: fall out, longer, finer• Radiographs: trophic bone changes,

osteoporosis• Bone scan: findings consistent with CRPS

According to the AMA Guides:• > 8 Probable CRPS• < 8 No CRPS

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CRPS I (RSD)CRPS II (causalgia)“characterized by pain, swelling, stiffness, discoloration…skeletal demineralization”

“may follow a sprain, fracture or nerve or vascular injury”

Chapter 17, p 553


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CRPS I (RSD)CRPS II (causalgia)

Use Chapter 13 (“Central & Peripheral Nervous System”):

Section 13.8 (p. 343-344)

Section 13.5 (p. 336)

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ICD-10-CM Diagnosis Code G89.21

Chronic pain due to trauma

2015 ICD-9-CM 338.21 Chronic pain due to trauma

Although this might be a working diagnosis, it does not necessarily support WPI based on Chronic Pain.

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Section 13-9 – Peripheral Nervous System

Roots of Spinal Nerves; Brachial Plexus; Peripheral Nerves

“Anatomic descriptions should be made according to the usual distributions” of the nerves roots/ nerves/ plexuses (page 345)

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Tables 13-23, 13-24

Table 13-23 – classification “due to pain or sensory deficit” (page 347)

Table 13-24 – classification “due to loss of muscle power and motor function” (page 348)

These differ somewhat from Table 16-10 and Table 16-11 from Chapter 16

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Section 13-9

• Page 347 instructions

• If multiple nerves involved, combine sensory and motor nerve impairments▫ “all nerves rated in one extremity are combined”

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2005 PDRS page 2-3

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Impairment#FEC Impairment

13.12.01.01 Peripheral Nerve System–Spine– Sensory

13.12.01.02 Peripheral Nerve System–Spine–Motor

13.12.02.01 Peripheral Nerve System–UE–Sensory13.12.02.02 Peripheral Nerve System–UE–Motor13.12.03.01 Peripheral Nerve System–LE–Sensory13.12.03.02 Peripheral Nerve System–LE–Motor

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2005 PDRS13.12.02.01 (UE - Sensory)13.12.02.02 (UE - Motor)

16.01.02.01 (Brachial Plexus)16.01.02.02 (Carpal Tunnel)16.01.02.03 (Entrapment, Other)16.01.02.04 (CRPS I)16.01.02.05 (CRPS II)

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2005 PDRS

13.12.03.01 (LE – Sensory)

13.12.03.02 (LE – Motor)

17.01.04.00 (Leg – Peripheral Nerve)

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Chapter 13

“Cerebral” Impairment (page 308)

Mental Status – instructions

Table 13-8 or GAF for behavioral disorder

Cranial Nerves – including Trigeminal Nerve

Chapter 13 ‘by analogy’ – objective findings?

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Chapter 13 - The Central and Peripheral Nervous System

To review WPI from a medical report:

Read the relevant part of the Guides▫ Introduction to that Chapter▫ Applicable section▫ Applicable Tables/ Figures▫ Examples

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• Alternative WPI is not automatic• The ‘strict’ use of the Guides is presumed correct. • Can be rebutted by “resorting to comparable

conditions described in the Guides”• The burden rests with the party disputing the

Guides.• There must be adequate evidence and reasoning

rebut the scheduled rating.

Guzman

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Timothy MussackDirector, AMA Analysis and Indemnity ValuationsBradford & Barthel, [email protected]

[email protected]://bradfordbarthel.com/areas-of-practice/bb-ratings/

AMA Guides Chapter 13 The Central & Peripheral Nervous System

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