West Virginia Code of State Rules › Agency 85 - Workers' Compensation › Title 85 - PROCEDURAL RULE WORKERS' COMPENSATION RULES OF THE WEST VIRGINIA INSURANCE COMMISSIONER › Series 85-20 - Medical Management Of Claims, Guidelines For Impairment Evaluations, Evidence, And Ratings, And Ranges Of Permanent Partial Disability Awards › Appendix 3

Current through Register Vol. XLI, No. 28, July 12, 2024
Balancing means maintaining body equilibrium to prevent
				  falling when walking, standing, crouching, or running on narrow, slippery, or
				  erratically moving surfaces; or maintaining body equilibrium when performing
				  gymnastic feats.
Stooping means bending the body downward and forward by
				  bending spine at the waist, requiring full use of the lower extremities and
				  back muscles.
Kneeling means bending the legs at knees to come to rest on
				  knee or knees.
Crouching means bending the body downward and forward by
				  bending legs and spine.
Crawling means moving about on hands and knees or hands and
				  feet.
Reaching means extending hand(s) and arm(s) in any
				  direction.
Handling means seizing, holding, grasping, turning, or
				  otherwise working with hand or hands. Fingers are involved only to the extent
				  that they are an extension of the hand, such as to turn a switch or shift
				  automobile gears.
Fingering means picking, pinching, or otherwise working
				  primarily with fingers rather than with the whole hand or arm as in
				  handling.
Feeling means perceiving attributes of objects, such as
				  size, shape, temperature, or texture, by touching with skin, particularly that
				  of fingertips.
EXHIBIT A
PSYCHIATRIC DIAGNOSES (WITH CORRESPONDING
				  INTERNATIONAL CLASSIFICATION OF DISEASES, NINTH REVISION CODES) NOT CONTRIBUTED
				  TO BY A WORK-RELATED INJURY
THE ONSET OF THE FOLLOWING DIAGNOSES ARE, BY DEFINITION, NOT
				  SIGNIFICANTLY CONTRIBUTED TO BY A WORK-RELATED INJURY UNLESS THE DISORDER ENDS
				  IN THE PHRASE "DUE TO A GENERAL MEDICAL CONDITION" WHERE THE GENERAL MEDICAL
				  CONDITION IS CAUSED BY THE WORK RELATED INJURY. ALTHOUGH THESE DIAGNOSES MAY BE
				  PRESENT IN AN INDIVIDUAL AND THESE DIAGNOSES SHOULD BE CONSIDERED IN
				  APPORTIONMENT, UNLESS SPECIFICALLY EXCEPTED IN WRITING, THESE DIAGNOSES SHOULD
				  NOT RECEIVE AN IMPAIRMENT RATING.
Disorders Usually First Diagnosed in Infancy, Childhood, or
				  Adolescence
Mental Retardation (317, 318.x, 319)
Learning Disorders (315.x, 315.xx)
Motor Skills Disorder (315.4)
Communication Disorders (315.xx, 307.x)
Pervasive Development Disorders (299.x, 299.xx)
Attention-Deficit and Disruptive Behavior Disorders (314.xx,
				  314.9)
Feeding and Eating Disorders of Infancy or Early Childhood
				  (307.xx)
Tic Disorders (307.xx)
Elimination Disorders (307.x, 787.6)
Other Disorders of Infancy, Childhood, or Adolescence
				  (309.21, 313.89, 307.3, 313.9)
Delirium, Dementia, and Amnestic and Other Cognitive
				  Disorders
All (except for Cognitive Disorder, NOS) (294.xx, 290.xx,
				  294.1, 294.8, 293.89)
Substance-Related Disorders
All (303.xx, 291.x, 291.xx, 304.xx, 305.x, 305.xx, 292.xx,
				  292.x)
Schizophrenia and Other Psychotic Disorders
All (295.xx, 297.x, 298.x, 293.xx)
Mood Disorders
All Bipolar Disorders (296.0x, 296.4x, 296.5x, 296.6x,
				  296.7, 296.89, 296.80, 296.90)
Cyclothymic Disorder (301.13)
Anxiety Disorders
Social Phobia (300.23)
Obsessive-Compulsive Disorder (300.3)
Generalized Anxiety Disorder (300.02)
Somatoform Disorders
All (300.8x, 300.11, 307.xx, 300.7, 300.82) (except Pain
				  Disorder)
Factitious Disorders
All (300.16, 300.19)
Dissociative Disorders
All (300.12, 300.13, 300.14, 300.6, 300.15) (except
				  Dissociative Disorder, NOS)
Sexual and Gender Identity Disorders
All (302.7x, 306.51, 302.4, 302.8x, 302.2, 302.3, 302.9,
				  302.6, 302.85, 302.6, 302.9)
Eating Disorders
All (307.1, 307.51, 307.50)
Sleep Disorders
All (307.4x, 347, 780.59)
Impulse-Control Disorders Not Elsewhere Classified
All (312.3x)
Personality Disorders
All (301.x, 301.xx)
Other Conditions That May Be A Focus Of Clinical Attention
				  (316, All "V" Codes, 780.9, 313.82, 300.9, 799.9)
EXHIBIT B
WEST VIRGINIA WORKERS' COMPENSATION
				  DIVISION
Impairment Guideline for RATING Psychiatric
				  Impairment
Exhibit B shall be used to determine a claimant's
				  psychiatric impairment rating using the classification consistent with the AMA
				  Guides to the Evaluation of Permanent Impairment, Fifth Edition, in conjunction
				  with the Axis V Global Assessment of Functioning Scale (GAF, DSM-IV-TR 2000,
				  page 34), the claimant's treatment needs, and functional status. Axis V refers
				  only to psychological, occupational, and social functioning and the examiner
				  must NOT include impairment in functioning as a result physical limitations in
				  the formulation of the GAF (GAF, DSM-IV-TR 2000).
Disorders believed to have resulted from brain injury, such
				  as cognitive disorders, should NOT be rated using this guideline, but should be
				  evaluated according to relevant sections of Chapter 4 of the AMA Guides to the
				  Evaluation of Permanent Impairment, Fourth Edition.
The diagnoses of Pain Disorder and Dissociative Disorder,
				  NOS, while important in the presentation and treatment of the underlying
				  physical condition, should not receive an impairment rating.
The impairment percentage may only be determined after the
				  claimant has reached maximum medical improvement. Rows 1-5 should guide the
				  examiner to an impairment classification in row 6 with the corresponding whole
				  person impairment percentage range in row 7. Within each class, the examiner
				  must justify the specific choice of rating along the range based on information
				  in rows 1-5 to formulate an overall impairment rating. This rating should then
				  be apportioned to account for pre-existing or non work-related contributors as
				  noted in the Guideline for Psychiatric Independent Medical Examination - Report
				  Online (Exhibit C).
1. GAF
2. Symptom Severity
3. Level of Functioning
4. Treatment Needs
5. ADLs, Social Functioning, Concentration,
						  Adaptation
6. Impairment Classification
7. Whole person impairment
100-91
No symptoms.
Superior functioning in a wide range of activities,
						  life's problems never seem to get out of hand, is sought out by others because
						  of his or her many positive qualities.
None or infrequent outpatient treatment
No Impairment
Class 1: No Impairment
0%
90-81
Absent or minimal symptoms (e.g., mild anxiety before an
						  exam). Generally satisfied with life, no more than everyday problems or
						  concerns (e.g., an occasional argument with family members).
Good functioning in all areas, interested and involved
						  in a wide range of activities, socially effective.
None or infrequent outpatient treatment
No Impairment
Class 1: No Impairment
0%
80-71
If symptoms are present, they are transient and
						  expectable reactions to psychosocial stressors (e.g., difficulty concentrating
						  after family argument).
No more than slight impairment in social or occupational
						  functioning (e.g., temporarily falling behind in work).
None or infrequent outpatient treatment
No Impairment
Class 1: No Impairment
0%
70-61
Some mild symptoms (e.g., depressed mood and mild
						  insomnia). -OR-
Impairment levels are compatible with most useful
						  functioning. Some difficulty in social or occupational functioning (e.g.,
						  occasional absences or theft within the household), but generally functioning
						  pretty well, has some meaningful interpersonal relationships.
None or infrequent outpatient treatment
Impairment levels are compatible with most useful
						  functioning
Class 2: Minimal Impairment
0-5%
60-51
Moderate symptoms (e.g., flat affect and circumstantial
						  speech, occasional panic attacks) -OR-
Impairment levels are compatible with some, but not all,
						  useful functioning. Moderate difficulty in social or occupational functioning
						  (e.g., few friends, conflicts with co-workers).
Continuous outpatient treatment
Impairment levels are compatible with some, but not all,
						  useful functioning
Class 3: Mild Impairment
6-14%
50-41
Serious symptoms (e.g., suicidal ideation, severe
						  obsessional rituals, frequent shoplifting). -OR-
Impairment levels significantly impede useful
						  functioning. Requires direction and supervision in the performance of ADL's.
						  Any serious impairment in social or occupational functioning (e.g., no friends,
						  unable to keep a job).
Intensive outpatient treatment, day hospital, occasional
						  to frequent inpatient hospitalization.
Impairment levels significantly impede useful
						  functioning
Class 4: Moderate Impairment
15-29%
40-31
Some impairment in reality testing or communication
						  (e.g., speech is at times illogical, obscure, or irrelevant). -OR-
Major impairment in several areas, such as work, family
						  relations, judgment, thinking, or mood (e.g., depressed man avoids friends,
						  neglects family and is unable to work).
Intensive outpatient treatment, day hospital, occasional
						  to frequent inpatient hospitalization.
Impairment levels significantly impede useful
						  functioning
Class 4: Moderate Impairment
15-29%
30-21
Behavior is considerably influenced by delusions or
						  hallucinations - OR - serious impairment in communication or judgment (e.g.,
						  sometimes incoherent, acts grossly inappropriately, suicidal preoccupation)
Inability to function in almost all areas (e.g., stays
						  in bed all day, no job, home or friends).
Permanently in assisted living to complete
						  institutionalization
Impairment levels preclude useful functioning
Class 5a: Severe Impairment
30-49%
20-11
Some danger of hurting self or others (e.g., suicide
						  attempts without clear expectation of death; frequently violent; manic
						  excitement) -OR- Gross impairment in communication (e.g., largely incoherent or
						  mute)
Occasionally fails to maintain minimal personal hygiene
						  (e.g., smears feces).
Permanently in assisted living to complete
						  institutionalization
Impairment levels preclude useful functioning
Class 5b: Very Severe Impairment
50-70%
10-0
Persistent danger of severely hurting self or others
						  (e.g., recurrent violence) -OR- serious suicidal act with clear expectation of
						  death.
Persistent inability to maintain minimal personal
						  hygiene.
Permanently in assisted living to complete
						  institutionalization
Impairment levels preclude useful functioning
Class 5b: Very Severe Impairment
50-70%
EXHIBIT C
WEST VIRGINIA WORKERS' COMPENSATION
				  COMMISSION
GUIDELINE FOR PSYCHIATRIC INDEPENDENT MEDICAL
				  EXAMINATION -
REPORT OUTLINE
The following is an outline of the standard
				  psychiatric independent medical examination report. The bolded items should be
				  addressed in every report to ensure consistency. Although there is no
				  substitute for quality clinical assessment, the areas subsumed under each
				  bolded section should also be addressed when possible. Note that each area
				  allows for both subjective and objective data, therefore attention to the
				  application of data to Workers' Compensation issues should be emphasized. The
				  italicized language represents commentary to aid in clarification of the
				  outline.
I Identifying Data
Claimant Name:
Social Security Number:
Date of Birth:
Claim Number(s):
Date of Injury:
Date of Interview:
Date of Report:
II Consent
Be sure to include a statement about the following:
the nature and purpose of the examination,
that the examiner is a psychiatrist,
that the examination is for the purpose of WV Workers'
				  Compensation Division,
that there is an inherent lack of confidentiality,
that a written report will be issued to the WV Workers'
				  Compensation Division,
that the examiner may be asked to provide information in
				  court or directly to the WV Workers' Compensation Division that the examiner
				  will not be treating the claimant, but may express management recommendations
				  that may influence their care indirectly, and that no physician-patient
				  relationship will be established.
III Chief Complaint
IV History of Present Illness
A. Injury
Provide the claimant's account of the injurious event.
				  Include the following:
1. Employer name
2. Position or job title
3. Duties and responsibilities, including supervisory
				  duties
4. Whether injury occurred in the usual course of
				  employment
5. Whether claimant was working at an outside position (that
				  is, not with the employer) or was self employed
6. Events leading up to injury
7. Events of injury including:
a. How injury occurred b. Whether others were injured c.
				  Whether there were any witnesses to injury
8. Events following injury, including:
a. When medical care was sought b. Where medical care was
				  sought c. Means of arriving to medical care
9. Whether, at time of interview, physical symptoms are
				  worse, better, or same since injury.
B. Psychiatric Information
For each diagnosis, include the following
				  information:
A. Name of diagnosis with modifiers, specifiers, remission
				  status and subtypes as per the most recent edition of the Diagnostic and
				  Statistical Manual of Disorders of the American Psychiatric Association
B. Criterion-based support for the diagnosis
C. Associated support for diagnosis including:
1. Non-criteria signs and symptoms
2. Diagnoses made by other clinicians that support the
				  current diagnosis.
D. Onset date of diagnosis when minimal criteria were met
				  (estimate if necessary)
E. Course of diagnosis since onset to time of
				  interview
F. Severity of diagnosis around time of interview (mild,
				  moderate, severe)
G. Past management, with outcomes including:
1. Medications or other biological treatment with doses and
				  duration
2. Psychological treatments
3. Social treatments
4. Compliance with management
H. Whether symptoms of diagnosis impair ability to work, If
				  so, describe how.
I. Describe any past psychiatry history not otherwise
				  accounted for by all above diagnoses, include:
1 Impatient treatment
2. Outpatient treatment
3. Consultations
4. Marital/family/pastoral counseling
5. AA/NA/rehab/detox
6. Psychotropic meds
V. Personal and Social History
A. Social Information
1
.
Residence history
2. Marriage history
3. Stressors history - note all pertinent stressors that
				  have occurred since injury
4. "Pursuit of everyday living" history
1. Report life circumstances, activities, hobbies and
				  interests prior to injury
2. Report if any life circumstances, activities, hobbies or
				  interests have been affected by the psychiatric diagnoses above
B. Education Information
C. Employment Information
1. List all prior positions, including duration
2. Discuss if claimant has been terminated from any
				  job
3. Discuss if claimant has been laid-off from any job
4. Discuss if claimant has entered resignations under
				  duress
5. Discuss if claimant has received any written
				  reprimands
6. If in military service, report if claimant has received
				  any Article 15's, and what type of discharge claimant received
D. Legal Information
Include:
1. Criminal history, charges, incarceration
2. Non-Workers' Compensation civil litigation
3. Prior Workers' Compensation claims
VI. Review of Systems
1. Provide a review of the claimant's general organ and
				  neurological systems.
VII. Past Medical History
A. List documented diagnoses
B. List claimant-reported diagnoses
C. List past surgeries
D. Discuss any head injuries
E. Discuss any seizure history
F. Report signs and symptoms at time of interview
G. List past psychoactive medications and analgesics, if not
				  already reported
H. List current medications
VIII Family Medical and Family Psychiatric
				  History
IX Mental Status Exam
X Summary of Other Sources of
				  Information
Include pertinent psychiatric information from the following
				  sources:
A. Documents
B. Other interviews (for example, of spouse, coworkers or
				  other clinicians)
C. Psychological testing
D. Data
E. Other
XI Psychiatric Diagnostic List
Provide psychiatric diagnoses at the time of the
				  interview
XII Opinions
For each of the following areas, report only those opinions
				  held with reasonable medical certainty and support with an explanation.
A. Diagnoses
Offer a statement that each of the above psychiatric
				  diagnoses (in Section XI) is present with reasonable medical certainty.
For each separate diagnosis in A, report information in
				  areas B-F.
B. Maximum medical improvement
For each diagnosis, report whether the claimant has reached
				  maximum medical improvement for that specific diagnosis. Support this opinion.
				  If the claimant has been significantly noncompliant with management
				  recommendations, then state that no opinion is offered with regard to that
				  specific diagnosis about maximum medical improvement.
C. Disability
Report if the signs or symptoms of the specific diagnosis
				  alone render the person disabled for the purposes of working in the same or
				  similar position as was held at the time of the injury. If disabled, support
				  this opinion discussing how each sign or symptom impairs work efficiency and
				  the ability to be employed. If the claimant has not reached maximum medical
				  improvement for this specific diagnosis, but is disabled, estimate the time to
				  recovery for maximum medical improvement.
D. Impact on Pursuit of Everyday Living
Offer an opinion, for each specific diagnosis, about how
				  that diagnosis and its symptoms affect the claimant's pursuit of everyday
				  living. Support this opinion with a discussion of the claimant's pre-and
				  post-injury life circumstances, activities, hobbies and interest. The opinion
				  should distinguish between psychiatric and non-psychiatric reasons for changes
				  in the claimant's pursuit of everyday living. Offer an estimate as to the
				  degree of overall impact on pursuit of everyday living as mild, moderate or
				  severe in intensity.
E. Causation and Appointment
For each specific diagnosis, offer an opinion with regard to
				  the causation of that diagnosis. A statement of causation should relate the
				  onset and presentation of the diagnosis to the work-related injury. The
				  relationship between the injury and the diagnosis should be use one of the
				  following phrases:
1. Sole precipitant (The injury is judged to be the only
				  reasonable factor related to the onset and progression of the disorder).
2. Major contributor (The injury is judged to be a major
				  factor with regard to the onset and progression of the disorder. The injury
				  predated the onset of the disorder).
3. Moderate contributor (The injury is judged to be a
				  moderate factor with regard to the onset and progression of the disorder. The
				  injury predated the onset of the disorder).
4. Minor contributor (The injury is judged to be a minor
				  factor with regard to the onset and progression of the disorder. The injury
				  predated the onset of the disorder).
5. Major aggravant (The injury is judged to be a major
				  factor in the progression of an already existing disorder. The injury postdated
				  the onset of the disorder).
6. Moderate aggravant (The injury is judged to be a moderate
				  factor in the progression of an already existing disorder. The injury postdated
				  the onset of the disorder).
7. Minor aggravant (The injury is judged to be a minor
				  factor in the progression of an already existing disorder. The injury postdated
				  the onset of the disorder).
8. Unrelated or coincidental (The injury is not associated
				  with the onset or progression of the disorder).
A discussion should include all other factors that are
				  associated with the cause, onset and progression of the disorder in any
				  situation except for when the injury is the sole precipitant. These non
				  work-related factors should be carefully assessed. These non work-related
				  factors should be considered to account for some percentage of the total effect
				  on disability (work efficiency) and the pursuit of everyday living of the
				  disorder. A statement of the percentage of total impairment as due to non
				  work-related factors should be made apportionment percentage).
F. Impairment Rating
A statement that no impairment rating is offered should be
				  made for an individual diagnosis if the diagnosis has not reached maximum
				  medical improvement, or does not disable the claimant and there is no effect on
				  the pursuit of everyday living.. In all other cases, an impairment rating to
				  account for the combined effects on disability (work efficiency) and the effect
				  on the pursuit of everyday living should be made. An unapportioned impairment
				  rating of total impairment should follow the West Virginia Workers'
				  Compensation Guidelines for Psychiatric Impairment (see Exhibit B). The
				  unapportioned total impairment rating should then be apportioned for non
				  work-related factors by a simple calculation to determine the percentage due to
				  non work-related factors and those due to the work-related injury. The
				  percentage calculated due to a work-related injury shall represent the final
				  psychiatric impairment rating for the specific diagnosis.
G. Total Psychiatric Impairment Rating
A statement that combines the total final psychiatric
				  impairment ratings for each diagnosis to conclude a single total psychiatric
				  impairment rating should be made.
XIII Recommendations
A. Recommendations should be made for further evaluation to
				  complete the independent medical examination.
B. Recommendations should be made for further management of
				  the patient's psychiatric condition. These recommendations should be as
				  specific as possible.
C. For diagnoses that have not reached maximum medical
				  improvement, a recommendation to the Workers' Compensation Division for an
				  estimated time at which a follow-up independent medical examination should be
				  made.
XIV. Signature and Title