Understanding Changes in Worker's Compensation and Conducting Ratings in Nevada Speakers: - Jason Mills: An industrial claimants attorney, senior partner at GGRM law firm, and president of the State Trial Lawyers Association. - Dalton Hooks: An attorney with a background in workers' compensation, compliance officer with Nevada OSHA, and founder of Hooks Mans and Clement law firm. Key Points Covered: 1. Use of AMA Guides 5th Edition: - Nevada law (NRS 616C.110) mandates using the 5th edition of the AMA Guides for impairment rating in workers' compensation cases. - There are exceptions where Nevada law overrides the AMA Guides (e.g., apportionment and pain). 2. Apportionment: - Guided by NRS 616C.099, apportionment must be based on documented prior conditions through medical records, past ratings, or evidence of previous surgery. - Adjustments to compensations are made based on documented prior impairments rather than the physician's conjectures. 3. Mental Stress Injuries: - They are specifically rated in Nevada if the claim has been accepted under NRS 616C.180. - Pain can be considered in the assessment if it impacts the range of motion but is not directly rated. - The D-9C form is used for rating mental impairments. 4. Legislative Changes (SB 274): - Effective January 1, 2024, limitations on certain types of physicians (MDs, DOs, DCs) rating specific body parts will be removed. - The rotation system for selecting rating physicians will change to random selection. 5. Examinee Bill of Rights (AB 244): - New legislation that provides rights to individuals undergoing compelled medical examinations. - Includes rights like 21 days notice, the presence of an observer or interpreter, note-taking, recording of the exam, and the ability to halt an exam if disrupted. - It provides remedies for violations, including actual damages, fines, or exclusion of information obtained from the exam. 6. Regulations and Implementation: - New regulations are being drafted to adapt to these legislative changes. - Practitioners need to stay informed and adapt to these regulations once they become effective. 7. Transparency and Accountability: - Moves towards greater transparency in the selection and refusal process for rating physicians. - Publication of assignment, mutual agreement, and refusal data is expected to increase transparency. The lecture emphasized the importance of adhering to Nevada statutes and understanding the variations between medical assessment and legal interpretation. The speakers also stressed the significance of certification and compliance with new regulations, as well as the potential liabilities practitioners may face due to the Examinee Bill of Rights.

This course provides a thorough understanding of impairment ratings, particularly focusing on the combined values chart critical for evaluating multiple impairments. It targets both experienced practitioners and newcomers to the field. The course begins with foundational knowledge, progressing from basics to advanced concepts over time. Participants will learn to avoid exceeding a 100% impairment rating since full impairment signifies death, emphasizing the correct application of the combined values chart for accurate calculations. The course covers various methods suggested by the guides for combining values, ultimately advocating starting with the highest impairment and moving to the next highest value as the fairest approach. Participants will not delve into all book chapters but will focus on the neuromusculoskeletal system due to its high prevalence in work-related injuries. Chapters on the central and peripheral nervous system, pain, spine, upper and lower extremities will be covered, with special attention to documenting how injuries affect daily activities (ADLs). The course also explains the development and revisions of the AMA Guides, the significance of maximum medical improvement (MMI), and the distinction between impairment and disability. It emphasizes objective clinical findings over subjective complaints in determining impairment ratings. For those in California, it discusses how the state uses these impairment ratings to compute workers' compensation disability through a two-step process. It also touches on nuances such as apportionment, causation, and how unrelated medical conditions should be documented and considered. The course will involve practical applications, including how to perform a final evaluation at MMI, understand the importance of combining versus adding values for multiple impairments, and preparing and submitting reports, incorporating ADL assessments and computer-generated calculations. The course acknowledges that not all conditions and syndromes are addressable by the AMA Guides and thus advises using clinical judgment for unlisted or poorly understood conditions, comparing them to similar conditions with measurable impacts on function and ADLs. Lastly, the course discusses the concept of pain as it relates to impairment ratings, how pain is integrated into most current conditions in the guides, and approaches to individuals presenting ambiguous and controversial pain syndromes. Throughout the course, attendees are encouraged to use the AMA Guides as a framework but also rely on clinical judgment and are reminded of the importance of detailed reporting to support any variations from the standard guidelines.

This course covers the evaluation of spinal impairments, focusing particularly on two methods: the DRE (Diagnosis-Related Estimates) method and the Range of Motion (ROM) method. The DRE method is preferred and encouraged for use in cases of specific injuries or when conditions can be categorized clearly within the DRE framework. It involves five categories to classify impairments of the cervical, thoracic, and lumbar spine based on the signs and symptoms, evidence from diagnostic studies, alterations in motion segment integrity, and history of spinal surgery or fusion. Categories for DRE method: - Category I: No objective findings, only subjective complaints (0% impairment) - Category II: Nonverifiable radicular complaints, muscle spasm/guarding, history of radiculopathy that has resolved with conservative treatment (5-8% impairment) - Category III: Verifiable radiculopathy that hasn’t fully resolved, surgery to address radiculopathy with some level of ongoing symptoms (10-13% for lumbar, 15-18% for cervical and thoracic) - Category IV: Alteration of motion segment integrity, presence of fusion, no neurologic deficit (20-23%) - Category V: Combines elements of categories III and IV with substantial neurological impairment, or fusion surgery with unresolved radiculopathy (25-28% for lumbar and thoracic, and much higher for cervical) The Range of Motion method is secondary to the DRE and used when the injury isn't distinct or specific and when multiple spinal segments are involved. The ROM method also includes a neurological component and is more intricate, involving actual ROM measurements. Key points highlighted in the course include: - The choice of evaluation method comes after ensuring the patient has reached maximum medical improvement (MMI). - The DRE method is straightforward and favored by guidelines such as those from the State of California. - If the patient declines surgery which could potentially resolve the impairment, clarification with a claims examiner is needed before going ahead with a Permanent & Stationary (P&S) report. - The ratings within the categories should correspond with the level of the patient's limitations in activities of daily living (ADLs) and should be justified. - Corticospinal tract involvement requires combining the DRE with additional considerations for more severe neural impairments. Throughout the course, emphasis is placed on documentation, justification of impairment ratings within the categories, and following guidelines and consensus opinion to ensure appropriate and defensible impairment determinations.

The course discusses the evaluation and impairment rating of spine-related injuries, particularly in the context of workers' compensation. It covers three main methods for determining impairment: 1. DRE (Diagnosis-Related Estimates) Method: This is the preferred method for evaluating distinct spinal injuries with a clearly identified cause. It involves categorizing injuries based on their severity and presence of specific clinical findings. 2. Range of Motion Method: This method is utilized when the cause of an impairment is less clear but can be categorized into a DRE category. It involves measuring the range of motion in several planes, using tools such as inclinometers for flexion, extension, lateral bending, and rotation of the cervical, thoracic, and lumbar spine. It includes three components - specific disorders, range of motion, and neurological assessment. Impairment ratings are determined using tables in the AMA Guides, and the values are added up within a joint region (e.g., cervical, thoracic, lumbar). 3. Neurological Assessment: It's used to evaluate neurological impairment due to nerve injury. This includes both motor and sensory deficits that are graded based on the severity of the loss of function. The examiner determines the percentage of impairment for the affected nerve and multiplies it by a predetermined maximum value for that nerve to calculate the impairment rating. The course emphasizes the importance of accuracy, consistency, and proper techniques in measuring range of motion. It explains the criteria for test validity (repetitions must fall within a certain range, the straight leg raise test for lumbar motion, etc.) and the necessity of providing the raw data in reports for verification purposes. Additionally, there are comprehensive walkthroughs on how to use specific tables from the AMA Guides to determine impairment ratings based on the collected data. When combining impairments for different spinal regions or combining range of motion and neurological impairments, the combined values are used to generate a whole person impairment percentage. Throughout the course, there is also discussion on the subjectivity present in clinical judgment, especially in determining the percentage of nerve impairment and potential errors that could affect the reliability of the impairment ratings. The importance of providing thorough explanations and justifications for the chosen values to ensure the validity and acceptability of the impairment ratings is also stressed.

The course provides instructions on how to evaluate and calculate impairment ratings for upper extremity injuries based on medical and legal guidelines, particularly focusing on the California workers' compensation system and the American Medical Association (AMA) Guides to the Evaluation of Permanent Impairment. The key points covered in the course include: 1. Understanding of the California Labor Code: The course reviews provisions related to medical treatment for injured workers and how case law can influence interpretations of "cure and relieve" versus "cure or relieve." 2. Utilization of AMA Guides: The course instructs participants on how to use the AMA Guides, particularly emphasizing the assessment of upper extremities (hand, wrist, elbow, and shoulder). It explains how to evaluate impairments through clinical measurements, like range of motion, and how to use the instruments correctly (e.g., goniometers). 3. Importance of Accurate Assessment: The course stresses the need for accurate clinical evaluation, including active motion versus passive motion, and comparing bilaterally when appropriate. It notes that the uninjured side of the body should be used as a normal baseline unless there was a previous injury. 4. Completing Impairment Worksheets: Participants learn to complete impairment worksheets with the step-by-step process of recording amputations, range of motion, sensory loss, and other disorders. Guidance on combining values to calculate total impairment for a body part and converting it to a whole-person impairment is provided. 5. Case Law Impact: The course discusses how recent case law may influence impairment assessment, and it encourages staying updated on legal precedents that could affect evaluations. 6. Importance of Medical Evidence: It reiterates the requirement to justify deviations from guidelines with a preponderance of evidence-based medical literature, especially in disputed treatments (like aromatherapy or magnetic healing). 7. Sensory Impairment Evaluation: Focus is placed on sensory evaluation, with two-point discrimination tests being the primary method. A clear distinction between partial and complete sensory loss and its contribution to total impairment is made. 8. Understanding Amputations: The course goes into the specifics of evaluating amputations at different levels and instructs using charts to determine impairment values, adjusting for partial amputations and considerations for functional impact. 9. Addressing Specific Cases: Throughout, the course provides examples and workshop scenarios, helping participants apply their knowledge of evaluating upper extremity impairments in practical examples and calculating resultant impairment percentages. 10. Importance of Documentation: The course underscores the importance of thoroughly documenting evaluations in medical reports and ensuring reports are complete, particularly by addressing apportionment for cases involving permanent disability. The course is interactive and designed to clarify complex topics related to impairment evaluation, clarify any confusion with practical examples, and ensure healthcare providers can provide accurate impairment ratings that comply with the required guidelines.

The course is focused on the evaluation and grading of impairments of the upper extremity according to the American Medical Association (AMA) Guides to the Evaluation of Permanent Impairment. The core concepts covered include: Amputation: Determining impairment ratings for amputated digits and limbs, using relevant tables and converting these to whole person impairments. Range of Motion (ROM): Assessing joint functionality by measuring active motion, and grading impairment based on motion deficits, with distinctions made between the shoulder, elbow, wrist, and fingers. Peripheral Nerve Disorders: Evaluating sensory and motor losses by identifying the nerve involved, grading the loss, and calculating nerve impairment without double-counting for restricted motion unless due to other causes beyond nerve injury. Other Disorders: Considering specific disorders such as bone and joint deformities (e.g., digit lateral deviation, joint instability), arthroplasty, muscular tenderness impairments, and tendonitis, and understanding how to combine these with other ratings following specific rules. Strength Evaluation: Using grip strength and manual muscle testing as last-resort measures for impairment when other factors do not adequately address the loss, provided certain conditions are met (e.g., waiting at least a year post-injury/surgery). Vascular Disorders: Rating impairments due to vascular issues following guidance from the AMA Guides, with particular attention to differentiating between various conditions and their severity. Use of Worksheets: Applying structured worksheets for consistent and comprehensive evaluation of upper extremity impairments across various categories and combining these to obtain an overall impairment rating. Complex Regional Pain Syndrome (CRPS): Understanding the criteria for CRPS types I and II and how to differentiate between them when grading impairment. Detail-Oriented Approach: Emphasizing careful attention to AMA Guide tables, footnotes, and rules when providing impairment ratings to ensure accurate and defensible evaluations. Throughout the course, participants are instructed on correct application of the AMA Guides' methodology, incorporating clinical judgment, history, and exam findings to rate how impairments affect patients' activities of daily living. Special emphasis is placed on adhering to the strict criteria of the AMA Guides and justifying deviations when necessary, providing clear rationale and documentation for decisions made during the evaluation process.