August 23, 2014

What are the AMA Guidelines and Why Are They Important to My Case?

I am often asked how I know when a case is ready to settle.  There are many factors that go into this judgment call, one of the most important being the disability rating assigned to my client.

What is a "disability rating" and how does it impact the settlement value of a Georgia workers compensation case?

The Georgia workers’ compensation statute looks to the American Medical Association (AMA) Guidelines as the required framework for a physician to assign a disability rating to a claimant.   The AMA Guidelines are designed to assist physicians in objectively evaluating a claimant’s injuries and limitations.  AMA Guidelines currently exist for a wide variety of body systems – including, for example, the muskuloskeletal system, the cardiovascular system, the immune system, etc.  The AMA Guidelines are used in Georgia workers’ compensation cases, but they can also be used in personal injury matters.  Click on the link to read how a Virginia accident lawyer discusses how he uses the Guidelines when evaluating a vehicle accident caes.

Here is a summary of the current AMA Guideline for the cervical spine (thanks to Spinal-Logic.com):

Category I (0%)

  • No significant clinical findings
  • No muscle spasm or guarding
  • No documentable neurological impairment
  • No alteration in structural integrity
  • No fractures

Category II (5-8%)

  • History and exam relevant to a specific injury

May include:

  • Muscle spasm
  • Asymmetrical loss of range of motion
  • Complaints of radiculopathy without objective findings
  • No alteration of structural integrity

Or:

  • Significant radiculopathy
  • Disc herniation at expected site verified by imaging study
  • Patient improved after nonoperative treatment

Or one of the following Fractures:

  • Less than 25% compression of one vertebral body
  • Healed posterior element fracture without loss of structural integrity or radiculopathy
  • Spinous or transverse process fracture with displacement

Category III (15-18%)

Significant signs of radiculopathy:

  • Dermatomal pain and/or sensory loss
  • Loss of reflexes
  • Loss of strength
  • Muscular atrophy
  • Neurologic impairment verified by electrodiagnosis

Or:

  • Significant radiculopathy with disc herniation verified by imaging study
  • Improvement of radiculopathy following surgery

Or one of the following Fractures:

  • 25-50% compression of one vertebral body (healed without loss of structural integrity)
  • Posterior element fracture with displacement into the spinal canal (healed without loss of structural integrity)

Category IV (25-28%)

  • Bilateral or multilevel radiculopathy.
  • Alteration in motion segment integrity determined from flexion extension radiographs as 3.5mm or greater of translation or angular motion 11 degrees greater than each adjacent level (radiculopathy need not be present).

Or:

  • More than 50% compression of one vertebral body without residual neurological compromise.

Category V (35-38%)

  • Significant impairment of the upper extremity requiring adaptive functional devices.
  • Single level total neurologic loss.
  • Multilevel neurological dysfunction.

As you can see, this particular Guideline requires the examining physician to look at numerous factors and requires conclusions that fall within a proscribed range.  In other words, a claimant with a Category IV cervical spine injury can qualify a disability rating of between 25 and 28%.  The doctor has some leeway but the goal would be for similarly limited claimants to receive similar disability ratings regardless of who conducts the exam.

Not all physicians will issue an AMA Guideline rating and I have found that sometimes, treating doctors will refer a claimant out for a functional capacity evaluation (FCE) to determine the patient’s specific capacity for various physical activities like lifting, pushing, pulling, etc.  In my experience, FCE evaluations often introduce a level of subjectivity into the disability rating process as clinicians performing the FCE tests are called upon to evaluate effort and motivation.  This is especially true when the facility conducting the FCE receives most or all of its business from insurance companies.

In some instances, I will challenge the validity of a disability rating if I feel that the evaluating physician introduced too much subjectivity into the process. 

Once a disability rating has been assigned, the Code provides for a calculation whereby the rating percentage is multipled by the claimant’s average weekly wage number and by a multiplier.  The resulting product is called the Permanent Partial Disability amount and that figure becomes part of my settlement negotiation.

Obviously the higher the disability rating, the more serious the injury and the more uncertainty there will be for the claimant’s future.

Disability ratings are almost always issued when the claimant is approaching "maximum medical improvement" or that point where the claimant’s condition is beginning to stabalize.  If you have been receiving weekly wage benefits and your doctor is beginning to talk about issuing a disaiblity rating, you need legal representation to help you understand what is happening and to mazimize your recovery.