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“Hernia Repair With or Without
Surgery"
The Guides Newsletter – Important Clinical
Concepts from Past Issues
by Craig M. Uejo MD, MPH
This is the sixth in a series of articles
written to assist evaluators in their use and interpretation
of The AMA Guides to the Evaluation of Permanent
Impairment, Fifth Edition (Cocchiarella L, Andersson G,
AMA Guides to the Evaluation of Permanent Impairment, Fifth
Edition, AMA Press, 2001). It will be used to help summarize
key points of clarification documented in past issues of The
Guides Newsletter. References to specific issues will be
provided to allow anyone the opportunity to review the entire
issue/article for assistance in understanding and accuracy of
reporting.
This particular article will discuss the
issues of rating abdominal hernia conditions. This issue was
discussed in the Questions and Answers section of the May/June
2002 edition of The Guides Newsletter.
Abdominal Wall Hernias
These conditions are rated based on section 6.6 Hernias on
page 136 of the AMA Guides, 5th ed. Table 6-9 outlines the
clinical factors used for rating an abdominal wall hernia case
based on 3 different classes.
As noted in the Guides Newsletter issue:
There are three classes of impairment due to
hernias, resulting in up to 30% impairment of the whole
person. Common to each of the three classes is having a
hernia, eg, a “palpable defect in supporting structures of
abdominal wall.” (Table 6-9, 5th ed, 136) While Table 6-9,
Criteria for Rating Permanent Impairment Due to Herniation,
describes a “palpable defect” as necessary for each class of
impairment, Section 6.1b, Description of Clinical Studies,
states:
"Objective procedures useful in
establishing impairment by hernias include, but are not
limited to: (1) abdominal wall physical examination and (2)
imaging by roentgenography or CT scan with or without contrast
media." (5th ed, 119)
With a class 2 impairment (10% to 19%) there
is also:
"frequent or persistent protrusion at site
of defect with increased abdominal pressure; manually
reducible or frequent discomfort, precluding heavy lifting but
not hampering some activities of daily living.” (Table 6-9,
5th ed, 136)
With a class 3 impairment (20% to 30%) there
is also:
“ persistent, irreducible, or irreparable
protrusion at site of defect and limitation in activities of
daily living.” (Table 6-9, 5th ed, 136)
The maximum percentage of impairment remains
the same in the Fifth Edition as it was in the Fourth Edition,
a value that appears disproportionately high in comparison to
ratings from other chapters.
In terms of an individual declining surgery,
the Guides states:
" if a patient declines therapy for a
permanent impairment, that decision neither decreases nor
increases the estimated percentage of the individual’s
impairment. However, the physician may wish to make a written
comment in the medical evaluation report about the suitability
of the therapeutic approach and describe the basis of the
individual’s refusal. The physician may also need to address
whether the impairment is at maximum medical improvement
without treatment and the degree of anticipated improvement
that could be expected with treatment." (5th ed, 20)
Therefore, if it is clear that your patient
would not have surgery, he or she would be placed at maximum
medical improvement. You should note in your report that,
hypothetically, if the individual proceeded with surgery and
the outcome was successful, there would probably be no
impairment.
In summary: in order for any rating due to an
abdominal hernia condition, a persistent hernia needs to be
present for any degree of permanent impairment to be present.
In other words, hernias that have been surgically treated with
an absence of an abdominal protrusion or palpable defect noted
at MMI, results in no permanent impairment unless there are
other ratable factors identified. Cases that are at MMI prior
to surgery due to an unwillingness to pursue surgical
treatment are rated based on the palpable defect present.
Look for additional articles in this series, The Guides
Newsletter – Important Clinical Concepts from Past Issues,
coming in upcoming issues of this Brigham and Associates
Ezine. The AMA Guides, 5th ed. Guides to the Evaluation of
Permanent Impairment - Chapter 6: The Digestive System, page
136 -137.
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Autumn Greetings!
As the seasons are changing, so is Brigham &
Associates, with new services and products to assist you with
impairment evaluations and ratings.
As always, please feel free to contact us with questions!
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How May We Help You? |
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Did you know that Brigham and Associates has hundreds of
clients throughout the United States? Our clients are
physicians, attorneys and claims personnel. We offer a wide
range of services that have benefited our clients in all areas
of impairment assessment. Whether we are on-site providing
training or reviewing an impairment rating for accuracy we
find that our clients have found our services to be extremely
beneficial & cost efficient.
The key to our success is open communication with our
clients to tailor our services to meet their organization’s
needs. Many times our best ideas are sparked by a discussion
with a client. Recently a situation such as this arose. In
conversation with one of our existing clients we began to
become more aware of the profound effect of erroneous
impairment ratings. This effect impacted all parties involved.
The injured party has a delay in receiving their final
benefits until the case is resolved, the carrier cannot close
their case until the impairment issue is resolved, the
physician is inundated with requests for supplemental reports
to clarify his/her impairment rating and so the saga goes.
What if the impairment rating errors were identified at the
onset? Or what if the doctor had assistance with calculating
his/her impairment rating? From the result of that
conversation, we were able to introduce 3 new services in the
last month.
The first of those services is an impairment
screen in which we review all impairment ratings received
by the insurance carrier/employer/attorney. This allows us to
capture data on the errors and provide data analytics to the
carrier. The carrier/employer is able to immediately determine
reserving for permanent impairment/ disability benefits.
Additionally, they are able to strategize their claims
management of the impairment issue on their case in a
proactive manner which mitigates liability in the long run.
Next, we introduced Rating
Assessment Physical Examination Reporting Forms for claims
personnel or attorneys to provide the impairment. Once you
receive the Permanent and Stationary or similar “Final” report
and these completed forms, simply make an online referral
requesting an “Impairment Assessment”. If additional
information is required we would be pleased to contact the
physician directly. You will receive our rating directly,
which you can then provide to the physician for agreement.
This is a superb solution to obtaining accurate ratings – the
first time.
Finally, we are pleased to announce
consulting services for physicians. We are able to provide a
unique resource for physicians who are asked to perform
impairment assessments, yet prefer not to do AMA Guides
ratings. With this service physicians provide us
electronically their draft Permanent and Stationary Reports as
MS Word documents; on the basis of the information we will
prepare the AMA Guides impairment rating, insert this
into their reports, and send the reports back for their
review. We ask that the physicians complete the Rating
Assessment Physical Examination Reporting Forms, as
appropriate, to provide all the information required for the
rating. We provide a complimentary teleconference call to
orient physicians to what data is required. For physicians and
physician groups who request that we perform all of their AMA
Guides ratings, we are able to provide this service for
a low predefined set rate per case.
Our client took the
time that day to talk with us and share their needs. Out of
that conversation three excellent solutions were created and
have already proven to be beneficial for our clients. If you
would like more information on these services please give our
office a call at (888) 262-1202. |
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You've been
waiting, Here it is - on Sale - Your "Guide to the
Guides" |
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Authored by Stephen Feinberg, MD and Christopher Brigham,
MD - An Evaluator's Resource Algorithm to the AMA Guides to
the Evaluation of Permanent Impairment, Fifth Ed. Digital book
focusing on understanding the assessment of musculoskeletal,
nervous system and pain impairment. This is a supplemental
resource that will help guide anyone through the most
pertinent areas in the AMA Guides, Fifth Edition.
Description: Soft Bound 8 1/2" x 11", 74 pages Price:
$57.00 until Nov 30 (Reg Price 87.00) Purchase: Call
1-888-262-1202 |
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Click here to Purchase |
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Free Viewing
of Guides IQ on 11/1 and 11/2 |
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This on demand AMA Guides training contains over 60 modules
of training on the Guides - that will be free to you for 11/1
& 11/2 !
For those who have not yet subscribed, we are offering two
days only when everyone can view all content for free. This is
on Wednesday, November 1 and Thursday, November 2. To access
the full content of GuidesIQ on November 1st and 2nd - for
free - e-mail us at freebie@guidesiq.com and we will
send you your username and password. When you are ready to
purchase GuidesIQ, click on the button marked "Special
Purchase" on the home page. That will take you to the new user
screen to create your own account. If you have questions on
GuidesIQ, please contact webmaster@guidesiq.com or call
866.848.9205.
Guides IQ is equivalent of 3 to 4 days of seminars. The
training provides 16 hours of Category I AMA Credit & QME
Credit. You can access the resources whenever necessary – to
build knowledge and to manage a specific case. The resource is
available on a membership model: members pay a modest annual
subscription – a fraction of the true cost associated with
attending a meeting.
What does it contain?
- Video presentations on the AMA Guides – 5th and 4th
editions – demonstration of proper examination techniques
- Online self-assessment
- Digital publications
- Members only forum and monthly teleconference calls, and
much more!
Register Now!
- Price: $897.00/annual subscription
- Register: www.guidesiq.com
or Call 888-282- 1202
- Your satisfaction is fully guaranteed!
- Multiple-User Discounts Available
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Read on... |
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Chapter
Highlights of the AMA Guides to the Evaluation of Permanent
Impairment, Fifth Edition |
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Chapter Three: The Cardiovascular System: Heart and Aorta
By Aimee Lazell, CIR, WCCP
This article is the third in a series intended to point out
a few of the highlights from each chapter of the AMA Guides
to the Evaluation of Permanent Impairment, Fifth Edition
(Cocchiarella L, Andersson G, AMA Guides to the Evaluation of
Permanent Impairment, Fifth Edition, AMA Press, 2001).
We will discuss important points of reference for Chapter
Three of the AMA Guides, which addresses the
cardiovascular system, specifically the heart and aorta.
Section 3.1 - Principles of Assessment, discusses the signs
and symptoms related to heart conditions and the
interpretations of various testing techniques. Testing
required in order to determine the extent of permanent
impairment are described in this section and are described as
follows:
- Exercise testing should be performed when feasible to
quantify limitations observed while during exercise on a
treadmill.
- Functional capacity of an individual will depend on
factors such as age, gender, and level of physical activity.
- Left ventricle function is important to assess when
evaluating a patient with cardiac disease. There are two
phases of left ventricular function which contribute to a
person’s symptoms and condition. They are systolic function;
the heart’s ability to pump out blood during contraction and
diastolic; the process when the heart fills with blood
during relaxation of the myocardium and a passive filling
phase.
- Ejection fraction is a clinically used measure of
systolic function which is the percentage of blood the heart
is able to eject during one beat.
- Diastolic dysfunction may contribute to the signs and
symptoms of heart failure. It is usually diagnosed by
elevated filling pressures that result in heart failure in
the absence of systolic dysfunction or valvular
abnormalities.
Chapter 3 is a complex chapter used for rating heart
conditions relative to the heart itself and aorta. Rating
conditions according to this chapter requires sufficient
testing be performed and interpreted by a physician who is a
specialist in this field and experienced in the use of the AMA
Guides to the Evaluation of Permanent Impairment.
Watch for the next article in the series, which will
highlight sections of Chapter 4 The Cardiovascular System
Systemic and Pulmonary Arteries. |
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Click Here for Past eZine Articles |
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Upcoming
Events |
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We will be exhibiting at:
- AADEP: Annual Conference
- St. Petersburg, FL
- Nov 9-11
- National Workers' Compensation & Disability Expo
- Las Vegas, NV
- Nov 14-15
- (We have one extra "Expo" badge for any interested in
attending - please contact Mindy at
mbrigham@brighamassociates.com or on
1-888- 262-1202.)
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Lunch &
Learn! |
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Never heard of a Lunch & Learn? It's when we bring in
lunch to a group of your staff and give a brief, one hour
presentation on information that will help you become more
comfortable with the Guides and more efficient when
handling your cases. This may be done in person (depending on
how close your office is to us) or done over the internet with
a PowerPoint Presentation.
Please contact Mindy at 1-888-262-1202 if you would like
more info on this! |
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Client Call
on Nov. 22 12pm-1pm (PST) |
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We are having a "Meeting of the Minds" for our valued
clients that utilize our Impairment Rating Services. If you
have ever used our rating review services, or would like to
use our review services, please join our calls to share your
ideas or just listen and learn from others.
One of our clients reported recently that they are
experiencing a 20:1 return on investment with our reviews; a
representative from their firm will be on the call on November
22 as well. The cases they refer typically are more complex
and they reported an average savings of $10,000 per case.
Based on these results they have decided to have all ratings
reviewed. Many clients report that most treating physicians
will correct their ratings based on our review. Our goal is to
assure accurate, unbiased impairment evaluations. We are
unique in being the nationally recognized experts on the
Guides and having every case reviewed by an experienced
physician – with reports typically issued within 5 days.
We are having a client teleconference call where we can
have an open discussion of impairment rating reviews, receive
your valued input, and learn how to most effectively manage
impairment ratings.
Please email Mindy (mbrigham@brighamassociates.com) or call
1-888- 262-1202 to be placed on the list to join the call. She
will then email you the conference call phone number and
access code to be used. We look forward to the call!
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