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(continued)
B. General Approach
The evaluator shall personally take the history from the injured worker and perform the examination. The evaluator may have an assistant make an initial outline of the injured worker's history or take excerpts from prior medical records, however the evaluator must review the excerpts and/or outline with the injured worker. Occupational and medical questionnaires may be useful to assist the injured worker in compiling the details of the injury prior to the consultation with the evaluator. Any discrepancies in the various sources of information should be identified and clarified by the evaluator.
The injured worker shall at all times be evaluated in a compassionate and respectful manner.
The evaluator will should introduce him/herself, and explain to the injured worker the purpose and scope of the evaluation.
The evaluator must inform the injured worker of any significant medical findings, which could impact on his or her health. These findings may not be directly related to the work injury.
II. Components of the Report
A. Initial Page
Address the report to the referring party(ies) or the DEU office noted on the Request for Summary Rating form. Report on the face to face time and factors influencing the complexity of the examination, being aware that complexity factors may be medical in nature or medical-legal, such as apportionment.
Give names and professional description of any persons assisting with the report or performing diagnostic or consultative services. Note if there were communication difficulties (e.g. aphasia) or translation services required for the evaluation.
B. History
Medical records and history questionnaires shall be used only as an adjunct to the history as told by the patient to the physician. The physician shall personally take the history from the injured worker. Any discrepancies in the history between various sources must be identified and clarified. An appropriate history shall include:
D. Work history, including previous and current jobs, and some description of previous, and current job duties. Review and comment on a formal job description if it is available for review. Particular attention for the foot and ankle is placed on requirements for standing, walking (over even or uneven surfaces), running, squatting, sitting, kneeling, climbing, jumping, hopping, balancing, lifting, carrying, pushing or pulling with the legs or feet and use of foot controls.
This section is especially important, as the physician must extract sufficient history to assess the injured worker's pre-injury functional capacity for work activity. Determining the previous work capacity within the past several years best assesses this. Regular non-work activities can also be taken into account to determine previous functional levels.
E. Description of how and when the injury occurred and the type of occupational exposure.
F. Summary of the course of treatment for the injured worker since injury includes type of treatment and response to treatment to date.
G. Current treatment including type and frequency.
H. Description of pertinent past medical history including previous and or subsequent injuries or illnesses, and a description of any prior neurological or musculoskeletal disabilities particularly relating to the lower extremity.
I. Pertinent other past medical history and other contributing medical, psychological, or social concerns.
C. Current Complaints
The physician shall outline in the patient's words, his or her current complaints. This shall include all parts affected by the injury or injuries claimed, the character (quality), severity, frequency, and any radiation of symptoms, and what activities or interventions precipitate, aggravate or reduce symptoms. Delineate existing associated signs and symptoms of the injury. NOTE: The patient's own description of symptoms shall be "translated" later by the physician into ratable language as defined by Packard Thurber.
Any subjective complaints regarding work activity or other activities of daily living (ADL's) shall be outlined in this section. For the foot and ankle, any functional complaints in such as standing, walking (over even or uneven surfaces), running, squatting, sitting, kneeling, climbing, jumping, lifting, carrying, balancing, pushing or pulling with the legs or feet and the use of foot controls shall be listed in this section.
The use of assistive devices (if any) for mobility such as a wheelchair, cane, or crutches, shall be elicited and described as to type and frequency of use, as well as the need and type of any orthotic or prosthetic devices and special shoes.
D. Medical Records Reviewed
In this section, the physician shall list all records reviewed in the preparation of the report. Extractions from those records may be listed in this section or summarized in the History section of the report.
D. Physical Examination of the Foot and Ankle for Disability Evaluation
(1) The physical examination shall include relevant description of body habitus, and any general observations such as a limp, obvious discomfort when standing, difficulty in transferring, etc. that may be helpful in determining previous or current functional capacity. Note any assistive devices, prosthetics, orthotics, or shoes that the patient uses and describe.
(2) In all measurements or observations performed, if normal, the physician may simply state "normal". Describe tests rather than just use an acronym.
(3) Inspection: The physician shall describe any skin abnormalities, surgical scars, obvious atrophy or skeletal deformities (e.g. angulation of healed fractures, varus or valgus joint deformity, or amputation). The injured parts of the foot or ankle shall be inspected for soft tissue swelling and dislocation.
(1) Amputations shall be described anatomically.
(1) Affected areas shall be palpated for tenderness. Any painful areas shall be reported. Any alterations of skin temperature or vascular status shall be noted.
(6) Joint examination
a. The physician shall assess the affected joints and compare them to the uninjured side.
a. Joint effusion, enlargement, erythema, and instability shall be described if present. Pertinent clinical tests used in joint assessment (i.e. drawer signs, Thompson's sign, etc.) shall be described and noted as normal or abnormal. If there is an abnormal range of motion that is not secondary to the injury, give an explanation for this finding.
b. Goniometric measurement is the accepted method of evaluation of range of motion for the foot and ankle. A description of goniometric methods of measurement and estimated normal values for the foot and ankle can be found in Packard Thurber, Evaluation of Industrial Disability, Second Edition, Oxford University Press. The physician shall measure active range of motion of all affected joints of the foot and ankle as compared to the uninjured side. Any abnormal, excessive, or limited range of motion or ankylosis shall be described.
For bilateral injuries estimate the normal range of motion. Note whether the injured worker gave full effort on active range of motion and if there was any unexplained discrepancies in formally measured versus observed range of motion, or whether limitations in active range of motion was based on pain. If so, list arc range of motion precluded or inhibited by pain. If the measurement obtained were invalid based on lack of effort, so note.
(7) Leg lengths shall be measured in inches from Anterior Superior Iliac Spine (ASIS) to medial malleolus and if appropriate, other methods of leg length measurement may be included.
D. Gait and other functional assessment: Any abnormality of gait shall be described (propulsive vs. apropulsive, angle and base of gait, etc.). Evaluate patient's ability to squat, stand, kneel, heel and toe walk.
(9) Neurological examination of the foot or ankle shall be performed for any complaints of weakness, sensory impairment or dysesthesias. This shall include assessment of:
a. Motor examination
i. Atrophy of specific muscles or muscle groups of the lower extremities or foot should be described. General muscle bulk is assessed by measurement s of the calves and thighs in inches. Circumferencial measurements of the foot and ankle should be recorded. Calf measurements are taken at the point of maximum circumference. Thigh circumferences are taken at the point one-third the distance from the upper pole of the patella to the umbilicus.
ii. Muscle tone shall be described as increased, normal or decreased.
i. Muscle strength shall be graded using a scale such as those found in Appendix A. Muscle weakness due to neurologic impairment shall be differentiated by the examiner from lack of effort due to pain, disuse or lack of effort due to other causes. In cases of questionable effort, muscle weakness due to neurologic deficit can generally be corroborated by appropriate electodiagnostic testing including needle EMG and a nerve conduction study performed by an appropriately qualified physician.
b. Sensory examination shall include a screening of touch and pain sensation (pinprick) in pertinent foot, ankle and lower extremity dermatomes/peripheral nerve distributions and of joint proprioception of any involved joints. Any abnormalities shall be described fully and correlated with peripheral nerve or dermatomal pattern. If the pattern of sensory impairment is nonphysiological, this should be noted
c. Deep tendon reflexes shall be obtained and graded as 0 (absent) to 4+ (hyperactive with clonus). Plantar responses and any other abnormal reflex responses shall be recorded.
d. Coordination shall be assessed if this is a presenting complaint, or if there is suspicion of foot, ankle or lower extremity motor coordination impairment. In this case, finger to nose, heel to shin and gait should be described.
(10) Screening exam of remainder of neurological or musculoskeletal system if there is any evidence of more widespread involvement.
D. Diagnostic Studies in Lower Extremity Disability Evaluation
(1) Order diagnostic studies only when the studies may alter the recommended plan or the evaluator's opinion regarding factors of disability. The evaluator must document the need for these additional studies.
(2) List any diagnostic procedures performed, as well as the dates and the results of the procedures. Provide the name, specialty, qualifications and opinion of any consultants.
(3) Methods of Assessment
a. Clinical diagnosis of foot and ankle problems can usually be made on history and physical examination with the help of x-rays.
b. In addition to an x-ray, testing may include:
i. MRI
ii. CT
iii. Bone Scan
iv. Arthrogram
v. Use of mechanical devices to test strength and stability.
vi. EMG/NCV testing is appropriate only if there is a suggestion of nerve damage or nerve compression.
vii. Vascular studies are indicated only if there is associated vascular disruption/damage or a secondary vascular complication.
viii. Blood Studies
ix. Ultrasound
x. Diagnostic, but not therapeutic, blooks
y. There are other tests that may be performed with proper documentation of necessity:
G. Diagnosis
List the relevant diagnosis(es). When appropriate, state if the injury is right or left sided or bilateral.
H. Opinions & Discussion
State that the report represents your opinions and how those opinions were derived after carefully reviewing the forwarded medical information, the injured worker's subjective statements offered during consultation, and examination findings.
I. Causation
State an opinion as to whether the injury or illness that led to the disability arose out of the employment (AOE).
J. Permanent and Stationary
State whether the injured worker is permanent and stationary and reasons for that opinion. The term permanent and stationary means that the injured worker has reached maximal improvement or his condition has been stationary for a reasonable period of time.
K. Temporary Disability
If the injured worker is not permanent and stationary, describe the current work restrictions that might allow the worker to return to work immediately, any additional treatment and the anticipated length of time necessary to achieve permanent and stationary status.
L. Factors of Disability
The evaluator will describe the subjective and objective components of disability. Do not provide a "rating" but describe the medical information in such a way as to be used by raters, judges and other concerned parties. The following information shall be included:
1. Subjective Factors of Disability
Translate the injured worker's symptoms into ratable language using the terminology found in section 9727 of title 8 of the California Code of Regulations, and reproduced here in Appendix B. Subjective factors are those that cannot be directly measured or observed, such as pain, stiffness, and paresthesia. It is important to note that this is the physician's assessment of residual symptoms and is based on the examination, the physician's experience with similar injuries and his/her expert medical opinion. It is not simply a catalog of an individual's complaints, as this might inaccurately inflate the disability rating if the complaints are not consistent with the physician's findings. Statements in this part of the report should be consistent with the nature of the injury and with the objective findings. Work restrictions based on subjective factors that are out of proportion to objective findings require specific explanation.
The recommended description of subjective disability should include the activity which produces disabling symptoms; the intensity, frequency and duration of symptoms; a description of the activities that are precluded and those that can be performed with the symptoms; and the means necessary for relief.
2. Objective Factors of Disability
Note those findings which can be measured, observed or demonstrated on testing. They include, but are not limited to: range of motion, strength, sensation, reflexes, amputation, anatomical measurements, disfigurement, and radiographic or other diagnostic results.
Note if assistive devices, prosthetics, or orthotics are required and describe the device. Note if the device causes any limitation in motion.
3. Work Capacity
Report work restrictions for the activities the injured worker was performing at the time of the injury and for potential activities in the open labor market.
The evaluator will estimate the total or partial loss of the injured worker's pre-injury capacity to lift, walk, push, pull, climb, walk on uneven ground, squat, kneel, crouch, pivot, bear weight or other activities involving comparable physical strength. The best means is to describe the injured worker's loss of capacity, such as loss of one-quarter of his ability to lift.
Use of job history and/or description as well as other activities of daily living to estimate the pre-injury capacity, should be noted in the report to substantiate the evaluator's opinion on loss. Be as specific as possible, incorporating the injured worker's history, the RU-90, the DEU Form 100, and a formal job analysis, if it is available.
M. Apportionment
State if apportionment is indicated and provide reasons for the statement. Indicate in the report whether apportionment is for a pre-existing condition under Labor Code section 4750, an underlying disease process under Labor Code section 4663 or a subsequent non-industrial injury under Labor Code section 4750.5.
N. Further medical care
Give your recommendation for current and future treatment. If the injured worker is currently receiving treatment, indicate whether the treatment is necessary to either improve or prevent deterioration of the current condition. If you believe that additional treatment is indicated to reach maximum improvement, you should explain the type of treatment, the reasons for the treatment, and the possible benefits of the treatment.
O. Vocational rehabilitation
If requested, state if the injured employee is medically qualified for vocational rehabilitation based on your review of the job analysis.
P. Affirmations and signature
The following paragraph must be included and signed and dated by the evaluator. The report must contain an original signature by the evaluator.
"I declare under penalty of perjury that the information contained in this report and its attachments, if any, is true and correct to the best of my knowledge and belief, except as to information that I have indicated I received from others. As to that information, I declare under penalty of perjury that the information accurately describes the information provided to me and except as noted herein, that I believe it to be true."
I have not violated Labor Code Section 139.3 and the contents of the report and bill are true and correct to the best of my knowledge.
The foregoing declaration was signed in __________ __________County, California on _________________ (date).
__________ Evaluator's Signature
Note: Authority cited: Sections 139, 139.2, 4060, 4061 and 4062, Labor Code. Reference: Sections 139, 139.2, 4060, 4061, 4061.5 and 4062, Labor Code.
Appendix A
Muscle Grading Chart
Results may be reported using a verbal scale or a percentage loss of muscle strength as follows. In either case, the evaluator must still describe how a given loss of muscle strength affects the injured worker's capacity to perform work.
Muscle Gradation Description
5-Normal 5-complete range of motion against
gravity with full resistance
4-Good 4-complete range of motion against
gravity with some resistance
3-Fair 3-complete range of motion
against gravity
2-Poor 2-complete range of motion with
gravity eliminated
1-Trace 1-reads evidence of slight contractility,
no joint motion
0 (Zero) 0-no evidence of contractility
Examples of Muscle Grading Charts
Results may be reported using a verbal scale or a percentage loss of muscle strength as follows. In either case, the evaluator must still describe how a given loss of muscle strength affects the injured worker's capacity to perform work.
Muscle Gradation Description
5-Normal 5-complete range of motion against gravity
with full resistance
4-Good 4-complete range of motion against gravity
with some resistance
3-Fair 3-complete range of motion against gravity
2-Poor 2-complete range of motion with gravity
eliminated
1-Trace 1-reads evidence of slight contractility, no
joint motion
0 (Zero) 0-no evidence of contractility
Kendall Lovett Description
100 % Normal The ability to hold the test position
against gravity and maximum
95 % Normal - pressure, or the ability to move the
part into test position and hold
against gravity and maximum
pressure
90 % Good + Same as above except holding
80 % Good against moderate pressure.
70 % Good - Same as above except holding
60 % Fair + against minimum pressure.
50 % Fair The ability to hold the test position
against gravity, or the ability to
move the part into test position and
hold against gravity.
40 % Fair - The gradual release from test
position against gravity; or the
ability to move the part toward test
position against gravity almost to
completion, or to completion with
slight assistance or the ability to
complete the arc of motion with
gravity lessened.
Kendall Lovett Description
30 % Poor + The ability to move the part through
partial arc of motion with gravity
lessened; moderate arc, 30% or
poor +; small arc, 20% or poor. To
avoid moving a patient into
gravity-lessened position, these
20 % Poor grades may be estimated on the
basis of the amount of assistance
given during anti-gravity test
movements: A 30% or poor +
muscle requires moderate
assistance, a 20% or poor muscle
requires more assistance
10 % Poor - In muscles that can be seen or
palpated, a feeble contraction may
be felt in the muscle, or the tendon
may become prominent during the
5 % Trace muscle contraction, but there is no
visible movement of the part.
0 % Gone No contraction felt in the muscle.
Appendix B
Subjective disability should be described in terms of location, degree, frequency, and precipitating activity. Terms describing degree and frequency are taken to have the following meanings:
Degree:
Minimal or mild pain constitutes an annoyance, but causes no handicap in the performance of activity.
Slight pain can be tolerated but causes some handicap in the performance of precipitating activity.
Moderate pain can be tolerated but causes marked handicap in the performance of precipitating activity.
Severe pain precludes precipitating activity
Frequency:
Occasional - approximately 25% of the time
Intermittent - approximately 50% of the time
Frequent - approximately 75% of the time
Constant - approximately 100% of the time
Appendix C
Description of Activities
Balancing: Maintaining body equilibrium
Bending: Angulation from neutral position about a joint (e.g. elbow) or spine (e. g. forward)
Carrying: Transporting an object, usually holding it in the hands or arms or on the shoulder.
Climbing: Ascending or descending ladders, stairs, scaffolding, ramps, poles, etc. . . using feet and legs and/or hands and arms.
Crawling: Moving about on hands and knees and feet.
Crouching: Bending body downward and forward by bending lower limbs, pelvis and spine
Jumping: Moving about suddenly by use of leg muscle, leaping from or onto the ground or from one object to another.
Kneeling Kneeling: Bending legs at knees to come to rest on knee or knees.
Lifting: Raising or lowering an object from one level to another (includes upward pulling)
Pivoting: Planting your foot and turning about that point.
Pushing: Exerting force upon an object so that the object moves away from the force (includes slapping, striking, kicking and treadle actions).
Pulling: Exerting force upon an object so that the object moves towards the force (includes jerking).
Running: Moving in a fast pace, moving the legs rapidly so that for a moment both legs are off the ground.
Sitting: Remaining in the normal seated position.
Squating: Crouching to sit on your heels, with knees bent and weight on the balls of your feet.
Standing: Remaining on one's feet in an upright position at a work station without moving about.
Stooping: Bending body downward and forward by bending spine at waist.
Turning/ Twisting: Moving about a central axis, revolve or rotate.
Use Foot Controls: Required to control a machine by use of controls.
Walking: Moving about at a moderate pace over even or uneven ground.
s 47. Method of Evaluation of Immunologic Disability.
The method of measuring immunologic elements of disability shall be as set forth below in the "Guidelines for Immunologic Testing" as adopted by the Industrial Medical Council on March 17, 1994.
STATE OF CALIFORNIA
DEPARTMENT OF INDUSTRIAL RELATIONS
INDUSTRIAL MEDICAL COUNCIL
395 Oyster Point Blvd., Ste. 102
South San Francisco, CA 94080
Tel:(650)737-2700 Fax:(650)737-2989
ADDRESS REPLY TO:
P.O. Fox 8888
San Francisco, CA 94128-8888
Guidlines For Immunologic Testing
Adopted March 17, 1994.
Laboratory testing of immunologic function is appropriate and necessary in the evaluation of industrial injuries but only in selected cases.
Immunologic function testing falls into four general categories:
I. Allergy to a specific chemical agent.
II. Allergy to common antigens from the general and home environment (e.g., pollens).
III. Malfunction of the immune system unrelated to infection.
IV. Specific infection.
Category I: Allergy To A Specific Chemical Agent
Testing shall be done only when:
A. The worker has been exposed to a specific chemical at work known to cause hypersensitivity.
B. The worker has sysmptoms or physical findings on examination that can be due to allergy to a chemical agent.
C. The specific suspected chemical agents of interest has been identified.
Testing shall not be done for chemical agents to which the worker has not been exposed.
The purpose of Category I is to confirm that the worker is allergic and reactive to a specific chemical agent. The presence of a laboratory test showing reactivity does not in itself indicate physical disability unless there also are subjective symptoms and/or objective findings of physical impairment which are consistent with such reactivity. Many people have positive reactivity tests but do not have clinical disease. Testing methods must be for the specific chemical agent. They may be blood tests for antibodies, skin tests or special tests such as lymphocyte reacitivty to beryllium.
Category II: Tendency To React To Common Allergens
This testing is of very limited use: It is allowable only when the clinical findings (e.g., sneezing, nasal obstruction or wheezing) could be due to either workplace agent or non-industrial exposure. Testing may be of the blood (IgE, RAST) or of the skin (patch, scratch or intradermal).
Category III: Testing Of Function Of The Immune System
In unusual circumstances (e.g., occupational exposures to ionizing radiation or chemotherapeutic agents), direct clinically significant damage to the immune system may occur and be relevant to the assessment of occupationally related disability. Many chemical agents other than chemotherapeutic drugs have been shown to produce subtle effects on the immune system is research studies. However, such subtle effects do not cause work-related disablilty and cannot be the basis for laboratory testing.
In the unusual circumstance in which the need for immune testing occurs, such testing shall involve some or all the following:
A. Complete blood count
B. Total serum immunoglobulin level and immunoglobulin electrophoresis
C. Total lymphocyte count and counting of T and B lymphocytes, including subsets.
Further testing of the immune system must be based on a strong clinical indication and must be supported by an explanation by the physician as to the need and purpose of the testing (which may be diagnostic or prognostic in nature but not for research pruposes).
Under circumstances such as a severely emotionally stressful event or the taking of certain medications for an industrial illness or injury, an autoimmune disorder may be precipitated or aggravated. When symptoms and/ or physical findings suggestive of this occur, serological testing for autoimmune disorders is appropriate, but only when needed to confirm the diagnosis.
Category IV: Specific infections
Serologic and other immune system testing are allowable only when the physician-obtained history, physical examination, routine laboratory test results and/or medical records confirm or cause the physican to suspect certain infections that may be occupationally-related (e.g., viral hepatitis, valley fever and HIV infection).
Testing may by specific for the infectious agent or may be nonspecific:
A. Specific tests:
1. Antigen and antibody tests that currently are available for the various types of viral hepatitis (A, B, C and delta).
2. complement fixation titer for valley fever (coccidioidomycosis) to rule in or out active disseminated disease.
3. Elisa testing for an HIV infection. If positive, the results shall be confirmed with a Western Blot test.
B. Nonspecific tests:
1. White blood cell and differential count.
2. Total lymphocyte count and counting of T and B lymphocytes, including subsets. Further testing of the immune system shall be based on strong clinical indications and shall be supported by an explanation by the physician of the need and purpose of the testing.
SUMMARY:
In the four selected categorical situations, immunological laboratory testing is appropriate only as described above. Such testing shall be performed in Workers' Compensation cases only if an abnormality would affect the determinaiton of compensability or clinical management. These conditions include detemination of disability status (temporary partial disability, temporary total disability, permanent partial disability and permanent total disability), specific work restrictions, causation of disability, apportionment, future medical treatment and the need for vocational rehabilitation.
Note: Authority cited: Section 139.2(j)(2), Labor Code. Reference: Sections 139.2(j)(2), 4060, 4061 and 4062, Labor Code.
s 48. QME Ethical Guidelines.
Note: Authority cited: Sections 139.2(j)(2) and (3) and 5307.3, Labor Code. Reference: Sections 139.2(j)(2) and (3), 4060, 4061 and 4062, Labor Code.
s 49. Definitions.
The following definitions apply to this Article:
(a) Cardiovascular evaluation. "Cardiovascular evaluation" means the determination of disability due to pathological changes of the heart and/or the central circulatory system.
(b) Face to Face time. "Face to face time" means only that time the evaluator is present with an injured worker. This includes the time in which the evaluator performs such tasks as taking a history, performing a physical examination or discussing the worker's medical condition with the worker. Face to face time excludes time spent on research, records review and report writing. Any time spent with clinical or clerical staff in performing diagnostic or laboratory tests (such as blood tests or x-rays) or time spent by the injured worker in a waiting room or other area outside the evaluation room is not included in face to face time.
(c) Medical evaluation. "Medical evaluation" means a comprehensive medical-legal evaluation as defined under section 9793 of Article 5.6, Subchapter 1, Chapter 4.5 of this Title.
(d) Neuromusculoskeletal evaluation. "Neuromusculoskeletal evaluation" means the determination of disability due to injury to the central nervous systems, the spine and extremities, and the various muscle groups of the body.
(e) Psychiatric evaluation. "Psychiatric evaluation" means the determination, by either a psychiatrist or psychologist following the IMC guidelines on psychiatric protocols, of disability due to psychopathology.
(f) Pulmonary evaluation. "Pulmonary evaluation" means the determination of disability due to pathological changes of the lungs and/or other components of the respiratory system.
(g) QME. "QME" means Qualified Medical Evaluator appointed by the Council pursuant to Labor Code section 139.2.
(h) Uncomplicated evaluation. "Uncomplicated evaluation" means a face to face evaluation in which all of the following are recorded in the medical report: Minimal or no review of records, minimal or no diagnostic studies or laboratory testing, minimal or no research, and minimal or no medical history taking.
Note: Authority cited: Section 139, Labor Code. Reference: Sections 139, 139.2 and 4628, Labor Code.
s 49.2. Neuromusculoskeletal Evaluation.
A medical evaluation concerning a claim for neuromusculoskeletal injury (whether specific or cumulative in nature) shall not be completed by a QME in fewer than 20 minutes of face to face time. Twenty minutes is the minimum allowable face to face time for an uncomplicated evaluation. The evaluator shall state in the evaluation report that he or she has complied with these guidelines and explain in detail any variance.
Note: Authority cited: Sections 139 and 139.2(j), Labor Code. Reference: Sections 139, 139.2 and 4628, Labor Code.
s 49.4. Cardiovascular Evaluation.
A medical evaluation concerning a claim for cardiovascular injury (whether specific or cumulative in nature) shall not be completed by a QME in fewer than 30 minutes of face to face time. Thirty minutes is the minimum allowable face to face time for an uncomplicated evaluation. The evaluator shall state in the evaluation report that he or she has complied with these guidelines and explain in detail any variance.
Note: Authority cited: Sections 139 and 139.2(j), Labor Code. Reference: Sections 139, 139.2 and 4628, Labor Code.
s 49.6. Pulmonary Evaluation.
A medical evaluation concerning a claim for pulmonary injury (whether specific or cumulative in nature) shall not be completed by a QME in fewer than 30 minutes of face to face time. Thirty minutes is the minimum allowable face to face time for an uncomplicated evaluation. The evaluator shall state in the evaluation report that he or she has complied with these guidelines and explain in detail any variance.
Note: Authority cited: Sections 139 and 139.2(j), Labor Code. Reference: Sections 139, 139.2 and 4628, Labor Code.
s 49.8. Psychiatric Evaluation.
A medical evaluation concerning a claim for psychiatric injury (whether specific or cumulative in nature) shall not be completed by a QME in less than one hour of face to face time. One hour is considered the minimum allowable face to face time for an uncomplicated evaluation. The evaluator shall state in the evaluation report that he or she has complied with these guidelines and explain in detail any variance.
Note: Authority cited: Sections 139 and 139.2(j), Labor Code. Reference: Sections 139, 139.2 and 4628, Labor Code.
s 49.9. Other Evaluation.
A medical evaluation concerning a claim for any injury (whether specific or cumulative in nature) not specifically included in this article shall not be completed by a QME in fewer than 30 minutes of face to face time. Thirty minutes is the minimum allowable face to face time for an uncomplicated evaluation. The evaluator shall state in the evaluation report that he or she has complied with these guidelines and explain in detail any variance.
Note: Authority cited: Sections 139 and 139.2(j), Labor Code. Reference: Sections 139, 139.2 and 4628, Labor Code.
s 50. Reappointment: Requirements and Application Form.
(a) In addition to the eligibility requirements set forth in section 11, a physician may seek reappointment on the basis that he or she was an active QME on June 30, 2000. For all physicians, applications for reappointment shall include a Reappointment Application Form in Section 10.1A, a statement of citizenship form 101 if not previously submitted, and the appropriate fee under Section 17 and shall be filed at the Council's headquarters office.
(b) Any Reappointment Application Form may be rejected if it is incompletely filled out or does not contain the required supporting documentation listed in Section 11. Upon its approval of the Reappointment Application Form, the Council shall verify that the QME has complied with all requirements under this Article.
(c) When a QME applies for reappointment, he or she shall submit a statement signed under penalty of perjury (1) that he or she has completed the education requirement and (2) that lists the dates, locations, and titles of continuing education programs and the names of the providers of those programs which he or she has taken to meet the requirement of Labor Code Section 139.2(d)(3), as well as the number of hours of attendance at each program. The Council may randomly audit QMEs for documentation of program attendance, which supports compliance with this requirement.
Note: Authority cited: Sections 139, 139.2, 4060, 4061 and 4062, Labor Code. Reference: Sections 139, 139.2, 4060, 4061, 4061.5 and 4062, Labor Code.
s 50.1. Reappointment: Failure to Comply with Time Frames.
Note: Authority cited: Section 139.2, Labor Code. Reference: Section 139.2(d)(1), Labor Code.
s 50.2. Reappointment: Unavailability Notification.
Note: Authority cited: Section 139.2, Labor Code. Reference: Sections 139.2(d) and 139.2(j)(6), Labor Code.
s 50.3. Reappointment: Evaluations Rejected by Appeals Board.
Note: Authority cited: Section 139.2, Labor Code. Reference: Sections 139.2(d) and 139.2(j)(6), Labor Code.
s 51. Reappointment: Failure to Comply with Time Frames.
All QMEs shall comply with the time frames in Sections 34 and 38 as a condition for reappointment. The Council, after hearing pursuant to Section 61, may deny reappointment to any QME who has failed to comply with the evaluation time frames in Section 34 and 38 on at least three occasions during the calendar year.
Note: Authority cited: Section 139.2, Labor Code. Reference: Sections 139.2(d)(1), Labor Code.
s 52. Reappointment: Unavailability Notification.
All QMEs shall comply with the unavailability notification requirements in Section 33 as a condition for reappointment. The Council, after hearing pursuant to Section 61, may deny reappointment of any QME who has filed notification for unavailability under Section 33 for more than 90 calendar days during the calendar year, or who has on any single occasion refused without good cause to perform a medical-legal evaluation for an unrepresented employee.
Note: Authority cited: Section 139.2, Labor Code. Reference: Sections 139.2(d) and 139.2(j)(6), Labor Code.
s 53. Reappointment: Failure of Board Certification Examination.
For Medical Doctors or Doctors of Osteopathy, in order to be reappointed, a QME shall submit a declaration under penalty of perjury that, if not board certified at the time for reappointment, he or she has not failed a board certification exam after 1985. This section shall not apply to any physician who meets the requrirment of Labor Code s139.2(b)(3)(C) (D) or (G).
s 53.1. QME Continuing Education Response Form.
Note: Authority cited: Section 139.2, Labor Code. Reference: Section 139.2, Labor Code.
s 54. Reappointment: Evaluations Rejected by Appeals Board.
The Council, after hearing pursuant to Section 61, may deny reappointment to any QME who has had more than five evaluations rejected by a Workers' Compensation Judge or the Appeals Board originally submitted at a contested hearing. The rejection shall be based on the failure of the QME's evaluation to prove or disprove a contested issue or failure to comply with guidelines promulgated by the Council pursuant to Labor Code Section 139.2(j)(2), (3), (4) or (5). A specific finding must become final and the time for appeal must have expired before any rejected evaluation shall be counted as one of the five rejections.
Note: Authority cited: Section 139.2, Labor Code. Reference: Sections 139.2(d) and 139.2(j)(6), Labor Code.
s 55. Reappointment: Continuing Education Programs.
A QME shall complete within the previous 24 months of his or her term of appointment 12 hours of continuing education in disability evaluation or workers' compensation related medical dispute evaluation given by a provider accredited by the Council.
(a) There are two types of continuing education programs:
(1) On-site programs, in which the instructor and QME are in the same location; and
(2) Distance learning programs.
(A) Providers of distance learning programs shall give either a pre- or post-course self-examination based on the program material. The provider shall grade the QME's test. Credit for the course can be given only for a passing rate of no lower than 70 percent correct responses. The Council may audit physicians' examinations and scores.
(B) Credit for distance learning courses shall be granted for the actual time spent viewing, listening to or participating in the program and for the reasonable and necessary time to take the examinations for up to six hours per program. Credit for the same distance learning program may be taken only once.
(C) All distance learning materials shall bear a date of release and shall be updated every three years. The provider shall notify the Council in writing of the revision.
(b) In addition to granting credit for attending a course or program which it gives, the Council may grant credit for:
(1) Participating in a panel on the development or review of the QME competency examination. A physician may receive one hour credit for each hour of participation on a panel. The QME shall obtain documentation of participation from the test administrator for submission to the Council.
(2) Instructing in a program given for QME credit by a provider accredited by the Council. The instructor may receive two hours of credit for each hour of instruction in an accredited provider's program or one hour of credit for each hour of participation on a panel. Credit for the same presentation may be taken only once during each calendar year. The QME shall submit documentation of participation from the program provider to the Council.
(3) Attending a program which is accepted by the QME's licensing board for renewal of his or her professional license, provided the subject matter is directly related to California impairment evaluation or workers' compensation medical dispute evaluation.
To request credit for this type of course, the QME must submit:
(A) proof of attendance;
(B) written material which describes the program content and program faculty; and
(C) documentation that the program is for continuing education credit by the physician's licensing board.
(4) Passing the QME competency examination. A QME may be granted six hours of continuing education credit for passing this examination for the purpose of receiving an initial appointment as a QME.
(c) To apply to the Council for accreditation, a provider shall submit to the Council, at least 60 calendar days before any public advertisement of the applicant's program or course is made:
(1) a completed form 118, in section 118 of these regulations.
(2) A curriculum vitae for each proposed instructor or author (for paper-based programs). A proposed instructor or author shall have education and/or training and recent work experience relevant to the subject of his/her presentation.
(3) The proposed promotional material for the program.
(d) The Council shall accredit an applicant who meets the definition of a provider in Section 1(r); submits a completed, signed and dated application which demonstrates past experience in providing continuing education programs; and proposes a program which meets the requirements of section 55(c) or a course which meets the requirements of section 11.5(a) and (i). Proposed content for continuing education program credit must relate directly to disability evaluation or California workers' compensation-related medical dispute evaluation. No credit shall be recognized by the IMC for material solely discussing the business aspects of workers' compensation medical practice such as billing, coding and marketing.
(e) The Council shall notify the applicant within 30 calendar days following the next scheduled council meeting after receipt of the application containing all the information listed in Section 55(c) whether that provider has been accredited for a two year period. Incomplete applications will be returned to the applicant.
(f) A provider that has been accredited by the Council will be given a number which must be displayed on any public advertisements of QME continuing education programs for that provider with the statement "Accredited by the California Industrial Medical Council for Qualified Medical Evaluator continuing education. Physicians may report up to ___ hours of credit for QME reappointment."
(g) On or before the date the program is first presented or distributed, the provider shall submit the program syllabus (all program handouts) to the Council. Each distance learning program shall also submit one copy of the examinations and one copy of the audio/video tapes, computer program or each issue of the journal or newsletter for which credit is to be granted.
(h) A provider may offer different QME continuing education programs during the two-year accreditation period provided the subject matter is in disability evaluation or workers' compensation related medical dispute resolution. The provider shall send the Council the program outlined and faculty for each new program at least 45 days prior to the date of presentation of the new program. The Council may require submission of program syllabi. The Council may require changes in the program based on its review of the program outline, program syllabi, promotional material or faculty if the IMC finds that any aspect of the program is not in compliance with these regulations.
(i) Promotional materials for a program must state the provider's educational objectives; the professional qualifications of program faculty (at least all relevant professional degrees); the content of program activities; the maximum number of credit hours to be granted; and the intended audience.
(j) Joint sponsorship of education programs (as between an accredited and an unaccredited provider) must be approved by the Council prior to presentation of the program.
(k) Accredited providers that cease to offer education programs shall notify the Council in writing.
( l ) Instructors shall not recruit members or promote commercial products or services immediately before, during or after a course. Providers or vendors may display/sell educational materials related to workers' compensation or applications for membership in an area adjoining a course. A course provider or faculty member shall disclose on IMC form 119, located in section 119, any significant financial interest in or affiliation with any commercial product or service discussed in a course and that interest or affiliation must be disclosed to all attendees. A provider shall file every form 119 in its possession or in its control with the Council.
(m) The provider shall issue a certificate of completion to each QME who successfully completes a continuing education program. The certificate must list the provider; provider number; date(s); location and title of the continuing education program; and the number of hours in attendance for which credit is to be granted. Credit shall be granted only for the actual time of attendance at or participation in a program. Each accredited provider may in its sole discretion limit the amount of credit hours that a course will be granted to less than the amount of time actually spent in attendance in the course.
(n) To apply for re-accreditation, a provider must submit a completed IMC Form 118. The provider may complete section 2 of the form using a new program or course or one which was given by the provider during the recent accreditation period. The Council shall give the provider 90 days' notice of the need to seek re-accreditation.
(o) The provider shall maintain attendance records for each continuing education program for a period of no less than three years after the program is given. A physician attending the program must be identified by signature. The provider must submit a copy of the signature list to the Council within 60 days of completion of the program.
(p) The provider is required to give the IMC's Evaluation Form 117 to program attendees and request they submit the form to the IMC. This information shall not be used in lieu of a certification of completion given by the provider, as specified pursuant to section (m). Destruction by a provider or its employee of a QME's Evaluation Form or failure by such provider or its employee to distribute Form 117 as part of its program shall constitute grounds for revocation of a provider's accredited status. The Council shall tabulate the responses and return a summary to the provider within 90 days of completion of the program.
(q) The Council may audit a provider's program(s) at the request of the medical director to determine if the provider meets the criteria for accreditation. The Council may audit programs randomly, when a complaint is received, or on the basis of responses on IMC Form 117. An auditor shall not receive QME credit for an audited program. The Council shall make written results of the audit available to the provider no more than 30 days after the audit is completed.
(r) The Council may withdraw accreditation of a provider or deny such a provider's application for accreditation on the following grounds (in addition to failure to meet the relevant requirements of subsection 11.5(a) or 55(c)):
(1) Conviction of a felony or any offense substantially related to the activities of the provider.
(2) Any material misrepresentation of fact made by the provider.
(3) Failure to comply with Council regulations.
(4) False or misleading advertising.
(5) Failure to comply with Council recommendations following an audit.
(6) Failure to distribute Council Form 117 cards to program attendees.
Note: Authority cited: Sections 139 and 139.2, Labor Code. Reference: Sections 139.2, 4060, 4061 and 4062, Labor Code.
s 56. Reappointment: Failure to Comply with WCAB Order or Ruling.
The Council, after hearing pursuant to Section 61, may deny reappointment to any QME who has been found in violation of any order or ruling by a Workers' Compensation Judge or the Appeals Board.
Note: Authority cited: Section 139.2, Labor Code. Reference: Sections 139.2(d) and 139.2(j)(6), Labor Code.
s 57. Reappointment: Professional Standard -Violation of Business and Professions Code Section 730.
The Council, after hearing pursuant to Section 61, may deny reappointment to any QME who has performed a QME Evaluation without QME Certification. (continued)