David Collipp, M.D. NewSouth NeuroSpine Flowood, MSJuly 30, 2015

 “a status where patients are as good as they are going to be from the medical and surgical treatment available to them.”  “a date from which further recovery or deterioration is not anticipated, although over time (beyond 12 months) there may be some expected change.”  The time at which no change in PPI greater than 3% is anticipated. AMA Guides, 6 th Edition

 “Change in condition related to deterioration from natural aging or passage of time.”  “Ongoing follow up or treatment for optimal maintenance of the medical condition in question.”  Changes related to aging and passage of time, and ongoing treatments are not inconsistent with MMI. AMA Guides, 6 th Edition

 “usually occurring when all reasonable medical treatment expected to improve the condition has been offered or provided.”  “MMI is not predicated on the elimination of symptoms and/or subjective complaints.” AMA Guides, 6 th Edition

 A number from a book.  AMA Guides 6 th Edition since  Mississippi is a “latest edition” State.  Presently no plans for 7 th Edition.  “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.” AMA Guides, 6 th Edition

 Why do we use the book?  Consistency between examiners.  Consistency within the human body.  Uniform template for comparison and checking. To allow for questioning…  Fairness in an area that is inherently abstract.

 6 th Edition Principles No impairment can exceed 100% Regional impairments will be combined Performed by physicians (allows DC for some spine issues) No rating of future impairment If more than one method is valid, use the higher rating Subjective complaints are generally not ratable Round all fractions up Must be at MMI No rating may exceed the maximum for it’s region

 The most important step in rating is having the correct diagnosis. This requires the most accurate and appropriate diagnosis.  Accurate use of the Guides requires fundamental understanding of anatomy, physiology, pathology and other appropriate clinical sciences along with an understanding of disability assessment and impairment rating issues.

 An Impairment Rating does not necessarily correlate with work activity.  The example in the AMA Guides, a singer and her piano accompanist.  Impairment does not equal disability or handicap.

 The General Scheme for Rating for Spine, Upper Limb and Lower Limb  MMI  Diagnosis (Key Factor)  Place in a Class  Apply Grade Modifiers  Document

 Class placement is not arbitrary.  “Proximal Tibial Shaft Fracture”  “Non-displaced with no significant objective abnormal findings at MMI”  “Non-displaced with abnormal examination findings”  “<10 degree angulation”  “10-19 degree angulation”  “20+ degree angulation”  “Non-union and/or infected”

 After Class placement you stay in that class  Then consider moving in the class (Grade A-E)  GMFH-Functional History  GMPE-Physical Examination  GMCS-Clinical Studies  All graded 0-4, then calculated to move from Grade C up (D,E) or down (A,B), or stay the same.

 If the Grade Modifier for Functional History is more than 2 grades off from PE or CS, then it is not used. It is “invalid”.  If any GM is not consistent with the diagnosis or objective findings otherwise, it is not used.  Grade Modifier values are in the Guides.

 Documentation often includes:  MMI with Date  Diagnosis  Class  Grade Modifiers  PPI by whole person or region (or both)  In some cases, some of the information may be excluded.

 As previously mentioned:  An Impairment of nearly any amount does not preclude function (vocational or avocational).  An Impairment does not indicate Disability.

 Persons with pre-existing Impairment should have the PPI appropriately apportioned.  Previous injury to the lumbar spine with PPI for surgery.  Previous injury to the lumbar spine with PPI for strain (Max 3%).  If a person had lumbar fusion at 3 levels and adds one level, this is a LOWER impairment rating than if he had never had surgery.  If a person had previous lumbar strain(s) with 3% PPI, there is no way to increase that impairment with a subsequent strain, regardless of subjective complaint.

 Restrictions are not limitations.  Limitations are things a person cannot do.  Restrictions are things a person shouldn’t do.  Limitations must be based upon objective information.  Restrictions are mostly based upon objective findings.

 Objective data are measureable.  Age  Habitus  Strength  Diagnosis  Surgical outcome (2 level fusion, TKA)  ROM  Neurological deficit

 Subjective data is not measurable.  “I have pain when I do this”  “I cannot stand that long, my legs give out”  “I have anxiety when I drive on that road”  Subjective information is used to modify restrictions from an established baseline, if (and only if) relevant and consistent.

 Subjective information that does not correlate with objective data is not used.  Subjective information might be valid and yet unrelated to an injury (e.g. age, weight, other medical conditions).  If a physician relies solely on a patient’s subjective complaints to determine restrictions then the physician is unnecessary.

 End of new treatment.  May have ongoing treatment.  Standardized numerical representation of change after injury.  Addressing functional abilities related to the injury.