AMA Guides® Newsletter

Articles

Maximum Medical Improvement

Charles N Brooks

Pages 1–3

DOI: 10.1001/amaguidesnewsletters.2000.SepOct01

Abstract
The term maximum medical improvement (MMI) is important to understand because an evaluator cannot determine permanent impairment until a condition is permanent and stationary. In addition, in many jurisdictions MMI represents the date beyond which at least some benefits cease or when an impairment award is made or a pension is awarded. Before rendering an opinion, the evaluating physician should become familiar with the terminology used and the definitions in the applicable federal, state, or provincial law or insurance policy. The AMA Guides to the Evaluation of Permanent Impairment does not define MMI but does state that an impairment should not be considered “permanent” until the clinical findings, determined during a period of months, indicate that the medical condition is static and well stabilized. Certain principles are common to definitions of MMI and its synonyms. A generic definition could be: “Maximum medical improvement is when further treatment will probably not result in significant, sustained improvement in the symptoms or signs of an injury or illness, or an individual's physical or mental capacities.” The signs may be physical, radiographic, laboratory, electrodiagnostic, or other findings, and the definition implies that the condition is medically stable in the sense that further treatment probably will not result in appreciable, prolonged improvement.
Letter to the Editor: The Continuing Challenge of Evaluating Carpal Tunnel Syndrome Impairment

J. True Martin

Pages 3–3, 10

DOI: 10.1001/amaguidesnewsletters.2000.SepOct02

Abstract
The author responds to The Continuing Challenge of Evaluating Carpal Tunnel Syndrome Impairment in the March/April 2000 issue of The Guides Newsletter. Carpal Tunnel Syndrome (CTS) is a clinical diagnosis based on the patient's history and objective findings on examination. Patients present with dull, aching discomfort of the hand, forearm, or upper arm; paresthesias and tingling of the hand; subjective weakness or numbness; and, occasionally, autonomic changes. Nerve conduction velocity studies are highly accurate in documenting median nerve entrapment at the level of the wrists, but this is an anatomic finding and does not mean that the entrapment produces any symptoms. An electrophysiologic study does not predict if or when the median nerve entrapment will become symptomatic, which is based on the patient's history. Electromyography (EMG) and nerve conduction velocity (NCV) studies do not help distinguish among the many etiologies of CTS. EMG/NCV testing can provide significant, highly accurate information regarding the physiologic function of the median nerve at the level of the wrist, but physicians must know how to interpret this information in the clinical setting. [The Editor responds: Several traditional findings of CTS have little or no diagnostic value, and electrodiagnosis is the diagnostic test of choice, although reported sensitivities range from 49% to 84% with specificities of 95% to 97%.]
Quick Reference: Chapter 1: The Musculoskeletal System: The Hand and Upper Extremity

Pages 4–5

DOI: 10.1001/amaguidesnewsletters.2000.SepOct03

Abstract
Spinal cord (dorsal column) stimulation (SCS) and intraspinal opioids (ISO) are treatments for patients in whom abnormal illness behavior is absent but who have an objective basis for severe, persistent pain that has not been adequately relieved by other interventions. Usually, physicians prescribe these treatments in cancer pain or noncancer-related neuropathic pain settings. A survey of academic centers showed that 87% of responding centers use SCS and 84% use ISO. These treatments are performed frequently in nonacademic settings, so evaluators likely will encounter patients who were treated with SCS and ISO. Does SCS or ISO change the impairment associated with the underlying conditions for which these treatments are performed? Although the AMA Guides to the Evaluation of Permanent Impairment (AMA Guides) does not specifically address this question, the answer follows directly from the principles on which the AMA Guides impairment rating methodology is based. Specifically, “the impairment percents shown in the chapters that consider the various organ systems make allowance for the pain that may accompany the impairing condition.” Thus, impairment is neither increased due to persistent pain nor is it decreased in the absence of pain. In summary, in the absence of complications, the evaluator should rate the underlying pathology or injury without making an adjustment in the impairment for SCS or ISO.
Impairment Tutorial: Spinal Cord Stimulation and Intraspinal Opioids:Impairment Rating Issues

James B. Talmage, Leon H. Ensalada

Pages 4–5

DOI: 10.1001/amaguidesnewsletters.2000.SepOct04

Abstract
Evaluators must understand the complex overall process that makes up an independent medical evaluation (IME), whether the purpose of the evaluation is to assess impairment or other care issues. Part 1 of this article provides an overview of the process, and Part 2 [in this issue] reviews the pre-evaluation process in detail. The IME process comprises three phases: pre-evaluation, evaluation, and postevaluation. Pre-evaluation begins when a client requests an IME and provides the physician with medical records and other information. The following steps occur at the time of an evaluation: 1) patient is greeted; arrival time is noted; 2) identity of the examinee is verified; 3) the evaluation process is explained and written informed consent is obtained; 4) questions or inventories are completed; 5) physician reviews radiographs or diagnostic studies; 6) physician records start time and interviews examinee; 7) physician may dictate the history in the presence of the examinee; 8) physician examines examinee with staff member in attendance, documenting negative, physical, and nonphysiologic findings; 9) physician concludes evaluation, records end time, and provides a satisfaction survey to examinee; 10) examinee returns satisfaction survey before departure. Postevaluation work includes preparing the IME report, which is best done immediately after the evaluation. To perfect the IME process, examiners can assess their current approach to IMEs, identify strengths and weaknesses, and consider what can be done to improve efficiency and quality.
Common Tips for IMEs (Part 1): Perfecting the IME Process

Christopher R. Brigham

Pages 6–7

DOI: 10.1001/amaguidesnewsletters.2000.SepOct05

Abstract
The pre-evaluation phase of an independent medical evaluation (IME) consists of several steps that lead to the evaluation itself. A table lists typical issues and tasks facing independent medical evaluators. The evaluation begins when the client requests an IME, and the scope of issues depends on the case's specifics and setting. The evaluating physician must understand the client's expectations and the nature of the evaluation, and specialists in the same field as the treating physician often perform the evaluation. Clients usually are responsible for obtaining medical records and other documentation. At the time of referral, the client is given the date and the time of the evaluation. Analysis of medical records is essential. Often, records provided by a client are disorganized or incomplete, and staff members can develop lists of records provided, identify missing items, and contact the client to obtain them. Staff also should notify the physician before particularly complex evaluations so the physician can allocate adequate time for a detailed review. Issues and deficiencies typically encountered in IMEs include the following: inadequate objective foundations for diagnoses and conclusions, undocumented findings, use of tests that lack validity and reliability, presence or absence of nonphysiologic and behavioral findings, and unsupported conclusions.
Literature Review

James Talmage

Pages 7–7

DOI: 10.1001/amaguidesnewsletters.2000.SepOct06
Common Tips for IMEs (Part 2): Perfecting the IME Process: Pre-Evaluation

Christopher R. Brigham, Leon H. Ensalada

Pages 8–9, 12

DOI: 10.1001/amaguidesnewsletters.2000.SepOct07
Editor's Response

Pages 10–10

DOI: 10.1001/amaguidesnewsletters.2000.SepOct08