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module 7 whole deck Flashcards

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1
Q

Define Permanent Disability (PD) in California WC.

A

Any lasting functional impairment that remains after Maximum Medical Improvement (MMI), affecting ability to compete in the open labor market.

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2
Q

Define Whole Person Impairment (WPI).

A

A percentage rating from the AMA Guides that reflects how much an injury affects the person’s overall functioning of the whole body.

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3
Q

How does PD differ from WPI?

A

WPI = medical impairment per AMA Guides; PD = adjusted rating that includes occupational and age factors per California schedule.

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4
Q

Mnemonic for PD vs WPI

A

“W to P” — Whole → Permanent (WPI is converted into PD).

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5
Q

What is the role of the AMA Guides in PD ratings?

A

Provides standardized criteria for calculating impairment percentages (WPI) before conversion to PD.

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6
Q

Which AMA Guides edition is used in CA WC?

A

The AMA Guides, 5th Edition.

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7
Q

What is conversion in this context?

A

The process of taking the medical WPI rating and adjusting it for occupation, age, and other statutory factors to arrive at a PD %.

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8
Q

Mnemonic for conversion steps

A

“WOA” — Whole person, Occupation, Age.

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9
Q

What is the Schedule for Rating Permanent Disabilities (2005 PDRS)?

A

California’s statutory system for converting WPI into PD considering age, occupation, and diminished earning capacity.

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10
Q

Why is age included in PD ratings?

A

Older workers are assumed to have greater difficulty adapting to impairment, so PD increases with age.

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11
Q

Why is occupation included in PD ratings?

A

Jobs with heavy physical demands are more affected by the same impairment than sedentary jobs, increasing PD rating.

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12
Q

Example: 10% WPI for a secretary vs construction worker.

A

Secretary’s PD may remain 10%, but construction worker’s PD may increase to 20% due to occupational demands.

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13
Q

What is DFEC (Diminished Future Earning Capacity) adjustment?

A

A statutory multiplier (from 2005 PDRS) applied to WPI to reflect loss of earning ability.

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14
Q

Mnemonic for conversion formula

A

“WAD” — WPI × Adjustment (DFEC) × Demographics (age/occupation).

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15
Q

What is the role of QME in PD rating?

A

Provide accurate WPI rating per AMA Guides; state impairments clearly so DEU can apply conversion formula.

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16
Q

Can QME assign final PD %?

A

QMEs give WPI ratings; final PD % is calculated by Disability Evaluation Unit (DEU) or WCAB judge.

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17
Q

What is standard rating?

A

The WPI after DFEC adjustment, before applying occupation and age modifiers.

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18
Q

What is adjusted rating?

A

The final PD % after applying age and occupation modifiers.

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19
Q

Example: 15% WPI in a 60-year-old laborer.

A

After DFEC, age, and occupation adjustments, the final PD may reach 30%.

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20
Q

What is a rating string?

A

The calculation chain showing how WPI is converted step-by-step into final PD %.

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21
Q

Mnemonic for rating string

A

“W → D → A → P” — WPI → DFEC → Age/Occupation → PD.

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22
Q

Why is clarity important in WPI reporting?

A

Ambiguous or incomplete descriptions prevent proper conversion, leading to disputes.

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23
Q

Can pain increase WPI?

A

Yes, under AMA Guides 5th, up to 3% WPI can be added for pain if documented.

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24
Q

What is apportionment’s role in PD?

A

After PD % is calculated, apportionment is applied to determine what portion is industrial.

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25
Why must QMEs cite chapter/page of AMA Guides?
Ensures transparency and allows DEU/judge to verify rating methodology.
26
What is Maximum Medical Improvement (MMI)?
The point where a condition is stable and unlikely to change substantially with further treatment; required before PD/WPI rating.
27
Mnemonic for MMI
“Stable = Rateable.”
28
Why must PD be rated only after MMI?
Before MMI, impairment may still change, making any rating inaccurate.
29
What is the Disability Evaluation Unit (DEU)?
A division of the DWC that reviews QME reports and calculates official PD ratings.
30
Can the WCAB judge adjust PD ratings?
Yes, judges can accept or adjust ratings based on evidence if DEU rating is disputed.
31
What are body part codes in rating?
Numeric codes used by DEU to classify injured body regions for conversion.
32
Mnemonic for body part coding
“CODES” — Categorize, Organize, Define, Evaluate, Schedule.
33
What is loss of pre-injury earning capacity?
A key principle behind PD ratings — impairment is tied to expected loss of earnings.
34
How is bilateral impairment handled?
Combine WPI for both sides using the Combined Values Chart (CVC) before conversion to PD.
35
Mnemonic for bilateral calculation
“BOTH” — Both sides combine first.
36
What is the Combined Values Chart (CVC)?
AMA Guides tool to combine multiple impairments without simply adding percentages.
37
Example: 10% WPI hand + 10% WPI arm.
Combined ≈ 19% WPI (not 20%), then convert to PD.
38
What is add-on for pain limit?
Up to 3% WPI per AMA Guides if pain increases functional loss.
39
What are Almaraz/Guzman cases?
Case law allowing physicians to use alternative AMA Guides chapters/methods if strict Guides rating is inaccurate.
40
Mnemonic for Almaraz/Guzman
“AG = Alternative Guides.”
41
What must QME explain when using Almaraz/Guzman?
Why the standard AMA Guides rating is inaccurate and how alternative method better reflects impairment.
42
What is a rebuttal rating?
A challenge to standard rating based on evidence that DFEC or AMA Guides doesn’t reflect actual disability.
43
Can QMEs adjust DFEC factor?
No — DFEC is statutory; QME only provides WPI and medical evidence.
44
How are psychiatric PD ratings handled?
Use GAF (Global Assessment of Functioning) per CA guides and convert to WPI then PD.
45
Mnemonic for psych rating
“GAF → WPI → PD.”
46
What is PD indemnity?
Monetary compensation paid for industrially caused permanent disability after rating is finalized.
47
Why is accuracy critical in WPI reporting?
Small errors can significantly change PD %, affecting monetary award and legal disputes.
48
Can subjective complaints alone justify WPI?
No — must be supported by objective findings or clearly explained under AMA Guides criteria.
49
What are standard vs adjusted PD again?
Standard PD = WPI × DFEC; Adjusted PD = adds age/occupation modifiers.
50
What is the 2005 PDRS occupational group number?
A number assigned to each job type to reflect its physical demands; used to adjust PD.
51
Mnemonic for occupational adjustment
“JOB#” — Job number drives PD shift.
52
What is the age adjustment table in PDRS?
A chart that increases PD for older workers and slightly decreases for younger workers.
53
Mnemonic for age adjustment
“AGE ↑ PD.”
54
Why does older age increase PD rating?
Older workers have less ability to retrain or adapt, so disability has greater vocational impact.
55
What is the FEC (Future Earning Capacity) rank?
Each body part is assigned a rank (1–8) to reflect average earning loss for that injury type.
56
How is DFEC factor derived?
DFEC is a statutory multiplier linked to FEC rank to adjust WPI to standard PD.
57
Mnemonic for DFEC
“FEC drives Dollars.”
58
Can DFEC be rebutted?
Yes, but only with strong vocational/economic evidence that actual earning loss differs from the schedule.
59
Who can rebut DFEC?
Vocational experts with labor market data; not the QME.
60
What is the apportionment step in rating?
After final PD % is calculated, non-industrial % is subtracted to find the industrial PD %.
61
Mnemonic for sequence
“WPI → PD → Apportion.”
62
Why must QME describe activities of daily living (ADLs)?
AMA Guides impairment is based on impact on ADLs; required for valid WPI rating.
63
List core ADLs in AMA Guides.
Self-care, communication, physical activity, sensory function, hand activities, sleep, travel.
64
Mnemonic for ADLs
“SCaPSSHT” — Self-care, Communication, Physical, Sensory, Sleep, Hand, Travel.
65
What is add-on for complex regional pain syndrome (CRPS)?
CRPS is rated per AMA Guides neuro/skin sections; can increase WPI significantly if criteria met.
66
How does QME document CRPS?
Must use Budapest/AMA criteria and explain functional loss.
67
What is upper extremity impairment conversion?
Convert hand/finger/arm % to WPI using AMA Guides tables before applying PD adjustments.
68
Mnemonic for extremity conversion
“Extremity → WPI → PD.”
69
Why is laterality important in ratings?
Dominant hand/arm injuries typically result in higher WPI/PD than non-dominant.
70
Can QME assign pain add-ons to psych claims?
No — pain add-on applies to physical WPI, psych ratings use GAF instead.
71
What is GAF scale range?
0–100; lower scores = greater impairment; used to convert psych impairment to WPI.
72
Mnemonic for psych WPI
“GAF Low → PD High.”
73
What is sexual dysfunction impairment rating rule?
Only compensable if direct injury to reproductive organs or documented psychological impairment; must follow AMA criteria.
74
What is sleep disorder impairment rating rule?
Sleep dysfunction is rated only if caused by work injury and documented per AMA Guides.
75
Why are precise anatomic terms needed in WPI?
Vague language prevents correct conversion; body part must match PDRS codes.
76
What is the range of PD % used for indemnity?
PD can range 1%–100%; payments scale with % and pre-injury wages.
77
Mnemonic for PD payout idea
“% Drives Pay.”
78
Why is understanding conversion vital for QMEs?
Even though QME doesn’t set final PD, clear WPI allows fair and defendable ratings, reducing disputes.
79
How are multiple impairments rated?
Convert each to WPI, combine with the Combined Values Chart (CVC), then adjust for DFEC, age, and occupation.
80
Mnemonic for multiple impairment steps
“C-WAD” — Combine WPI, Adjust DFEC/Age/Occupation, Done.
81
Why must QME describe objective findings?
Objective deficits are required by AMA Guides; subjective complaints alone cannot support WPI.
82
What if an impairment doesn’t match AMA chapter?
QME may use Almaraz/Guzman to justify alternate chapter or method with clear rationale.
83
Can WPI be 0% if patient has symptoms?
Yes — if no objective impairment is found or symptoms don’t meet AMA criteria.
84
What is the pain add-on limit again?
Up to 3% WPI maximum per Guides when pain adds measurable functional loss.
85
Why must QME describe ROM (Range of Motion)?
ROM loss is key metric in many body part ratings under AMA Guides.
86
Mnemonic for ROM rating
“MOTION → %.”
87
How is spinal impairment usually rated?
By DRE (Diagnosis-Related Estimates) or ROM method if DRE doesn’t fit; must document which method used.
88
What is DRE category system?
5 categories (I–V) for spinal injuries, each with defined impairment % ranges.
89
Mnemonic for DRE
“I Mild → V Severe.”
90
Can QME switch from DRE to ROM?
Yes, if DRE doesn’t fit; must justify using Almaraz/Guzman reasoning.
91
Why document neurologic deficits?
Radiculopathy or nerve injury can increase WPI and change rating category.
92
How to rate amputations?
Use AMA tables for specific level; convert regional impairment to WPI, then to PD.
93
Mnemonic for amputation
“Level → % → WPI → PD.”
94
What is ankylosis rating?
Fusion/stiff joint is rated using specific AMA impairment tables for that joint.
95
Why include surgical history in rating?
Surgical changes (fusion, prosthetics) alter impairment level and may increase WPI.
96
What is assistive device adjustment?
Use of braces, canes, etc. can increase impairment if medically necessary and permanent.
97
Mnemonic for device impact
“ADDS” — Assistive Device = Disability Shift.
98
What is Combined Values Chart (CVC) key rule?
Combine, don’t add; prevents exceeding 100% and reflects overlapping functional loss.
99
Can WPI exceed 100%?
No — maximum whole person impairment is 100%.
100
Why note dominance (right vs left hand)?
Dominant hand impairment often rated higher due to greater functional impact.
101
How to handle multiple surgeries on one body part?
Rate final impairment considering all residuals; don’t rate each surgery separately.
102
Why use exact AMA table numbers?
Allows DEU/judges to verify rating and avoids disputes about methodology.
103
What if Guides don’t cover a condition?
QME may use analogy to similar body part/function with explanation and literature support.
104
Mnemonic for unsupported condition
“ANA” — Analogize, Note rationale, Apply % carefully.
105
How can QME defend rating in deposition?
Cite AMA Guides pages, show objective findings, and explain each adjustment step clearly.
106
Why is consistent terminology important in reports?
Ensures DEU can match impairment to correct body part codes and avoids rating errors.
107
What if impairment is due to multiple pathologies in same region?
QME should integrate into one WPI for that region instead of stacking separate ratings.
108
Mnemonic for same-region integration
“ONE” — One Region, One WPI.
109
Why must QME state if impairment is ratable?
DEU cannot rate conditions not clearly described as ratable under AMA Guides.
110
What is post-surgical impairment rating rule?
Rate residual function, not just the surgery performed (e.g., fusion residual vs “had surgery”).
111
How are arthroplasties (joint replacements) rated?
Use specific AMA tables; residual motion and stability determine WPI.
112
Mnemonic for arthroplasty
“PROST” — Prosthesis Outcome Sets Table.
113
Why include complications (infection, hardware failure)?
Complications may increase impairment percentage beyond base surgical rating.
114
How to rate spinal fusion?
Usually DRE Category III–V; ROM if DRE doesn’t fit; describe fusion levels.
115
What is post-laminectomy syndrome?
Chronic pain/disability after spine surgery; rated per residual function and pain guidelines.
116
Why list specific ADL deficits?
ADL impact directly drives WPI % per AMA Guides.
117
Mnemonic for ADL tie-in
“LIST ADL.”
118
What if worker changes jobs post-injury?
PD rating still based on job at time of injury (occupation group), not new job.
119
Can QME suggest vocational adjustments?
QME may describe work limitations but cannot change statutory occupation modifier; vocational experts rebut if needed.
120
Why is work preclusion language discouraged?
QME should describe functional loss, not legal disability categories like “cannot compete.”
121
How to rate complex regional pain syndrome (CRPS)?
Meet AMA criteria (vasomotor, trophic changes, sensory findings) and assign WPI per neuro/skin sections.
122
Mnemonic for CRPS criteria
“STAMP” — Sensory, Trophic, Autonomic, Motor, Pain.”
123
What is dorsal column stimulator effect on rating?
Usually rated as spinal surgery residual with added neuro impairment if present.
124
Can QME assign work capacity percentage?
No — QME gives medical impairment; work capacity is legal/vocational determination.
125
Why describe future medical care?
Impacts ongoing treatment but not PD %; helps WCAB award medical benefits.
126
What is residual neurological deficit?
Lasting sensory/motor loss post-injury; key in WPI assignment for spine/nerve injuries.
127
How is knee impairment rated?
Based on ROM, stability, arthritis, surgical history; converted to WPI then PD.
128
Mnemonic for knee rating
“ROM+Stability+OA.”
129
Why must QME avoid percent of whole body language not tied to Guides?
Only AMA Guides-based WPI is acceptable; avoid vague “50% disabled” statements.
130
What is scheduled loss vs unscheduled?
CA uses scheduled rating system; unscheduled injuries may require vocational analysis but still follow PDRS.
131
Mnemonic for schedule use
“SCHEDULE FIRST.”
132
What is the impact of SB 899 on PD ratings?
Made AMA Guides 5th mandatory and emphasized apportionment to non-industrial causes.
133
Why should QME know legal updates?
Staying current prevents invalid ratings and deposition challenges.
134
What is PD cap for injuries <70%?
Maximum number of weeks of indemnity payments based on PD %, set by statute.
135
Mnemonic for PD payout
“% → Weeks → $.”
136
Why must QME document pre-injury status?
Establishes baseline function to show industrial impact and support rating accuracy.
137
Can PD ever exceed 100%?
No — 100% represents total permanent disability (TPD).
138
What is Total Permanent Disability (TPD)?
Inability to compete in open labor market; statutory lifetime benefits if PD = 100%.
139
Mnemonic for TPD
“Full = Forever Pay.”
140
What is life pension in CA WC?
Additional weekly payment after PD >70% but <100% once indemnity runs out.
141
Why is WPI clarity vital for life pension eligibility?
PD % drives whether worker crosses the 70% threshold for life pension.
142
What is apportionment’s final step in PD?
Subtract non-industrial % from total PD to get industrial PD for benefits.
143
Mnemonic for final step
“PD minus Non = Pay.”
144
What if QME fails to discuss apportionment?
WCAB may default to 100% industrial PD and employer pays full award.
145
Why are add-ons (sleep, sexual, pain) scrutinized?
Often litigated; must meet strict AMA Guides criteria to be valid.
146
How should QME describe assistive device use?
State if device is permanent/medically necessary; can increase impairment.
147
Can QME assign work preclusion categories (e.g., semi-sedentary)?
No — that’s a vocational/legal issue, not medical impairment.
148
Why describe overlapping impairments clearly?
Prevents double counting when combining values.
149
Mnemonic for overlap
“NO DOUBLE DIP.”
150
What is rating string transparency?
Showing every step (WPI → DFEC → Age/Occ → Apportion) to allow DEU/judge to verify.
151
Why must QME give narrative clarity?
Poorly worded reports lead to misratings, depositions, and delays.
152
What if condition improves after MMI rating?
Supplemental report may revise WPI/PD if medically justified.
153
Can WPI increase after surgery?
Yes, if surgery worsens function; QME must issue updated rating.
154
What is return-to-work impact on PD?
Return to work does not change rating but may affect vocational evidence for DFEC rebuttal.
155
Why avoid vague pain descriptions?
Pain add-on requires detailed ADL impact to be valid under AMA Guides.
156
Mnemonic for pain doc
“PAIN = Prove ADL Impact Needed.”
157
What is vocational rebuttal?
Using vocational expert to show scheduled PD doesn’t reflect true earning loss.
158
Why is vocational rebuttal outside QME scope?
QME provides medical impairment; vocational experts address labor market/earning capacity.
159
What is Guzman flexibility for unusual injuries?
Allows QME to pick alternative AMA chapter if standard table underestimates impairment with full explanation.
160
Mnemonic for Guzman use
“GUIDE ALT.”
161
Why is final PD % critical legally?
Determines benefit duration, possible life pension, and settlement value.
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