BACKGROUND
Section 440.15(3)(a)2, Florida Statutes, as amended, requires that the State of Florida establish a guide for use in the evaluation of permanent impairments for the calculation of impairment benefits payable and to establish the permanent impairment necessary for wage-loss benefits payable under Section 440.15(3)(a)3, Florida Statutes, as amended. Moreover, “This schedule must be based on medically or scientifically demonstrable findings as well as the systems and criteria set forth in the American Medical Association’s Guides to the Evaluation of Permanent Impairment; the Snellen Charts, published by the American Medical Association Committee for Eye Injuries; and the Minnesota Department of Labor and Industry Disability Schedules. This schedule should be based upon objective findings. The schedule shall be more comprehensive than the AMA Guides to the Evaluation of Permanent Impairment and shall expand the areas already addressed and address additional areas not currently contained in the guides.”
This Guide, known also as the schedule, is established by the three-member panel, set forth in Section 440.13(12)(a), working in cooperation with the Division of Workers’ Compensation. In establishing this Guide, the three-member panel and the Division were assisted by an advisory panel of representative health care specialties and by a member of the Florida Bar.
Evaluation or rating of permanent disability has long been recognized as an important and complex subject. In the past much confusion has resulted from inadequate understanding by physicians and others of the scope of medical responsibility in the evaluation of permanent disability and the difference between “permanent disability” and “permanent impairment.”
It is vitally important for every physician to be aware of his or her proper role in the evaluation of permanent disability under any private or public program for the disabled. It is equally important that physicians have the necessary authoritative material to assist them in competently fulfilling their particular responsibility—the evaluation of permanent impairment. It is the purpose of this book to correct a past confusion of terms and to provide a series of practical guides to the evaluation of various types of permanent impairments.
The following explanation of generally used terms in programs for the disabled is provided.
(1) Permanent Impairment—This is a purely medical condition. Permanent impairment is any anatomic or functional abnormality or loss after maximal medical improvement has been achieved, which abnormality or loss the physician considers stable or non-progressive at the time evaluation is made. It is always a basic consideration in the evaluation of permanent disability.
(2) Permanent Disability—This is not a purely medical condition. A patient is “permanently disabled” or “under a permanent disability” when his/her actual or presumed ability to engage in gainful activity is reduced or absent because of “impairment” which, in turn, may or may not be combined with other factors. A permanent condition is found to exist if no fundamental or marked change can be expected in the future.
(3) Evaluation (Rating) of Permanent Impairment—This is a function that physicians alone are competent to perform. Evaluation of permanent impairment defines the scope of medical responsibility and therefore represents the physician’s role in the evaluation of permanent disability. Evaluation of permanent impairment is an appraisal of the nature and extent of the patient’s illness or injury as it affects his personal efficiency in one or more of the activities of daily living. These activities are self-care, communication, normal living postures, ambulation, elevation, traveling and non-specialized hand activities.
(4) Evaluation (Rating) of Permanent Disability—In the last analysis, this is an administrative and not solely a medical responsibility and function. Evaluation of permanent disability is an appraisal of the patient’s present and future ability to engage in gainful activity as it is affected by such diverse factors as age, sex, education, economic and social environment, in addition to the definite medical factor-permanent impairment. The first group of factors has proved extremely difficult to measure. For this reason, permanent impairment is in fact the sole or real criterion of permanent disability far more often than is readily acknowledged. In actual practice, however, the final determination of permanent disability is an administrative decision as to the patient’s entitlement. Under no circumstances shall this guide be used to determine disability. This guide is intended to be used solely for the purpose of rating impairments. Competent evaluation of permanent impairment requires an adequate and complete medical examination, and the avoidance of subjective impressions and such factors, as age, sex, or employability.
(5) Maximum Medical Improvement or Date of Maximum Medical Improvement—the date after which further recovery from, or lasting improvement to, an injury or disease can no longer reasonably be anticipated, based upon reasonable medical probability.
PHILOSOPHY AND CONCEPTS
Section 440.02(19), Florida Statutes, as amended, states that a “Permanent impairment’ means any anatomic or functional abnormality or loss determined as a percentage of the body as a whole, existing after the date of maximum medical improvement, which results from the injury.”
An organ-system approach is used for organization in this Guide, each section representing an organ system where impairment values will be found for providing a rating for diseases or disorders within that system.
The whole-person concept is used in that specific impairments within a region or organ system have an affect on the entire physical and mental status, affecting the whole person, and are thus expressed as whole-person impairment.
Impairments are expressed in terms of the whole person, and a conversion process with appropriate tables is used for converting specific regional impairments to the whole person when indicated. These conversion tables will be found in the specific organ system sections. Also, a Combined Values Chart is provided in Section 15 for determining whole-person impairments when more than one impairment value is present.
The overall final impairment rating sustained by the individual shall be the result of the physician’s evaluation of permanent impairment as found in this Guide. If a permanent impairment is covered by this Guide, no assignment or rating of that permanent impairment at variance with this Guide is permissible. If a category applicable to the impairing condition cannot be found in this guide, then the category most closely resembling the impairment or the degree of impairment based on analogy should be chosen. Except as provided for in evaluating the spine when considering residual signs for ankylosis and spinal cord/or spinal injury, where a category represents the impairing condition, the impairment determination shall not be based on the cumulation of lesser included categories.
EVALUATION PROCESS
An evaluation for permanent impairment shall be performed by a physician as defined in Section 440.13(l)(r), Florida Statutes. Physician means a physician licensed under Chapter 458 an osteopath licensed under Chapters 458 and 459, a chiropractor licensed under Chapter 460, a podiatrist licensed under Chapter 461, an optometrist licensed under Chapter 463, or a dentist licensed under Chapter 466. In no case, however, may a physician as defined above give a permanent impairment rating for a condition for which that physician cannot professionally treat.
The evaluation for permanent impairment, including the assignment of any rating, shall not be determined before the date of maximum medical improvement. Furthermore, pursuant to Section 440.15(3)(a)4, Florida Statutes, an evaluation may occur up to six weeks before the end of temporary indemnity benefits.
The evaluation should be inclusive of a complete history of the condition under evaluation, including reference to treatment, response to treatment, and pre- existing conditions or aggravating factors when present. The evaluation shall include a thorough physical examination of the body system or systems involved. Objective findings (appropriate to the specific organ involved) should include observation, palpation, auscultation, and measurements where indicated for neuromusculoskeletal conditions. This should include observation of postural and structural abnormalities, palpation of neuromuscular structures and note of tender areas found in consistent clinical distribution corresponding to subjective complaint. Rigidity, spasm or loss of range-of-motion of joints should be noted if present.
Range of motion should be determined by using a measuring device such as a goniometer or inclinometer for extremities. Consistency and validity are necessary for determining the values obtained in joint range-of-motion evaluation. Joint measurements should be performed twice and produce comparable figures varying less than ten percent of the maximum value for the involved part.
In order for an opinion of no impairment for joint range of motion, the evaluator must record the specified ranges of motion of the involved joint.
THE BASIC RULES
The following rules are provided in order for the evaluator to properly execute an impairment rating based on the 1996 Florida Uniform Permanent Impairment Rating Schedule. These rules can be applied to all systems of the body.
1. The final impairment value, whether the result of a single or combined impairment, shall be rounded off to the nearest whole number.
2. Only upper extremities have a preferred or dominant side. When the non-preferred side is evaluated, 10% of the upper-extremity rating is subtracted before conversion to whole person.
Example:
- 40% impairment of left (non-preferred) upper extremity
- 10% of 40% = 4%
- 40% minus 4% = 36%
- 36% upper extremity = 22% whole person
- For evaluation purposes, the lower extremities do not have a preferred side.
3. All impairments for one extremity are combined before conversion to whole person.
4. Ankylosis—with fixed loss of motion in more than one plane for the same joint or area, the largest value is used for rating impairment.
5. Adding vs. Combining
With range of motion loss in multiple planes of the same joint the impairment ratings are added. When dealing with multiple hand values, the values are added.
Everything else is combined!
NOTE: When combining is necessary, use the Combined Values Chart found in Section 15. Combining the largest figure with the next largest, and so on, is a good rule to follow.
Example:
- To combine 35, 40, and 10:
- 40 combined with 35 = 61
- 61 combined with 10 = 65
6. Pre-existing conditions may not be rated unless there is objectively documented evidence of an increased loss of function to the affected area as a result of the industrial injury.
7. For those permanent impairments that are subject to confirmation only through the administration of diagnostic tests and procedures that although characterized as subjective in nature, are generally accepted and used in the medical discipline involved, the injured employee is entitled to an impairment rating of 2% of the body as a whole. This rating cannot be added or combined to another impairment for a condition provided for in other sections of this Guide. For example, if an injured worker has a back injury and in addition has headaches as determined by subjective complaints, the headaches are not ratable since they are included in the rating allowed for the back injury and the impairment rating is only as determined by evaluating the back injury alone.
8. Employees shall be rated for a permanent impairment, if any, as of the date of maximum medical improvement or six weeks before the expiration of 104 weeks of temporary benefits, whichever occurs first, as provided for in Section 440.15(3)(a)4.