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Advisory 93-04

Evaluation of Maximum Medical Improvement and Impairment by Doctors

Please note: Because of a contractual agreement with the American Medical Association, the Guides to the Evaluation of Permanent Impairment, Third Edition, 2 nd Printing, published by the American Medical Association cannot be published on the website. When following the references made in this advisory, you should refer to your printed copy of the guidelines.

Articles 8308-4.16, 4.25, 4.26 of the Texas Workers' Compensation Act (the Act), and Rules 28 TAC 130.1 and 130.2 provide for medical examinations by doctors based on the procedures identified in the Guides to the Evaluation of Permanent Impairment, Third Edition, 2 nd Printing, published by the American Medical Association. The "Guides" required that certain procedures be performed in making medical assessments and rating impairments. Pages 4-10 in the "Guides." attached, generally describe this evaluation process. Of course, relevant parts of the entirety of the "Guides" should be used when assessing an impairment rating.

All evaluations under the Act are extremely important to the appropriate delivery of benefits. However, the evaluation of maximum medical improvement (MMI) and the rating of impairment are particularly important because these determinations impact income benefits. For this reason, a doctor must take extra care to ensure that the evaluation and rating process is performed consistent with sound medical practice and in accordance with the "Guides." Further, the Commission encourages a doctor performing an evaluation to explain to the worker the evaluation process as identified in the "Guides."

An evaluation or certification under the "Guides" and the Act must include a physical examination and evaluation by the doctor. Although the "Guides" provide that any knowledgeable physician or any other knowledgeable person may compare the clinical findings on a particular patient with the criteria in the "Guides." a doctor must conduct a physical evaluation and is responsible for the integrity of the evaluation process. This means the doctor must evaluate the complete clinical and non-clinical history of the medical condition(s), perform an examination of the injured worker, analyze the medical history with the clinical and laboratory findings, and assess and certify an impairment rating according to the Act, Commission Rules, and the "Guides."

It is the responsibility of the Commission to ensure benefits are provided to the injured workers of the State of Texas. If information is provided to the Commission, which indicates that the evaluation process was not conducted in accordance with the "Guides" and sound medical practice, the Commission will review the facts to determine what weight to give the report. The Commission may request or order the doctor to perform a re-assessment of clinical findings or re-determination of MMI or impairment rating to include an examination by the doctor. In a number of decisions, including 93-46 and 93040, the Appeals Panel has remanded the case for rehearing on the basis of an improper medical evaluation or report.

Workers should receive what they are entitled to - no more, no less. Each participant must do his or her part to enable the Commission to fulfill its responsibility to ensure fair benefits and quality medical care to injured workers.

Signed this 9 th day of March, 1993.

Todd K. Brown
Executive Director

Distribution:

Austin Carrier Representatives
TWCC Staff
Public Information List



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