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Glossary of WCB Terms

Frequently Asked Questions

General

  1. What are the 2012 Guidelines? The 2012 Guidelines are the New York standards for evaluating permanent disabilities. The 2012 Guidelines address both schedule loss of use awards and non-schedule permanent disabilities. While the impairment guidelines for schedule loss of use awards are unchanged from the 1996 Guidelines, the 2012 Guidelines include new impairment guidelines for non-schedule permanent disabilities. It also includes guidance for medical professionals on how to evaluate physical function and guidance on how the Board determines loss of wage earning capacity. It is expected that attorneys, claims professionals, and others will utilize these new standards in an attempt to evaluate and settle claims.
  2. How do I obtain a copy of the 2012 Guidelines? The 2012 Guidelines are available for free in PDF format, and available on the Board's website for download and printing.
    Added 2/8/2012
  3. Do the new guidelines apply to psychologists and other mental health professionals? Yes. The new guidelines apply to anyone who is evaluating permanent impairment. Because the 2012 Guidelines do not contain specific guidelines for evaluation of psychiatric conditions (other than involving injuries to the brain in Chapter 15), mental health professionals must apply Chapter 17 to assess impairment based on psychiatric conditions.
  4. Are out of state doctors required to abide by the 2012 Guidelines? Yes. The 2012 Guidelines are the standard for evaluating permanent impairment and loss of wage earning capacity for all injured workers in New York State's workers' compensation system.
  5. What is the role of the IME Doctor? The IME doctor's role has not changed. The IME doctor may provide an opinion on the injured worker's medical status (whether MMI has been reached), whether a permanent impairment exists, the severity of the permanent impairment, and the injured worker's exertional and functional abilities.
  6. Can a PPD impairment / severity rating be done in a record review with the treating physicians C4.3 and medical records? There is no bar on a carrier filing a timely records review on the question of impairment. In making a determination on impairment and loss of wage earning capacity, the workers compensation law judge will determine the weight to be given to the report.

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History

  1. How were the 2012 Guidelines developed? The 2012 Guidelines address the evaluation of both schedule loss of use awards and non-schedule permanent disabilities. The portion devoted to schedule loss of use awards (Chapters 2-8) is taken unchanged from the 1996 Guidelines. The non-schedule permanent disability sections (Chapters 9-17) are largely based on the work of the Insurance Department's Workers' Compensation Reform Task Force and Advisory Committee (Task Force).
  2. What are the benefits of the 2012 Guidelines? The 2012 Guidelines for Determining Impairment and Loss of Wage Earning Capacity bring greater clarity to the implementation of the duration caps on permanent partial disability benefits that were an important component of the 2007 reform.

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When to use the 2012 Guidelines (vs. 1996 Guidelines)

  1. When do the 2012 Guidelines go into effect? The 2012 Guidelines go into effect January 1, 2012.
  2. Are the 1996 Medical Impairment Guidelines still valid? The 2012 Guidelines will replace the existing 1996 Medical Impairment Guidelines for the evaluation of permanent disabilities, effective January 1, 2012. However, for claims that already have at least one medical opinion finding a permanent impairment with a rating based on the 1996 Guidelines on or before January 1, 2012, the Board will determine the claimant's degree of permanent disability using the 1996 Guidelines.
    Added 2/8/2012
  3. For claims that pre-date January 1, 2012, do we use the older Guidelines? The 2012 Guidelines apply to claims without regard to date of accident.

    However, if the claim is in the process of classification under the 1996 Guidelines, it will be completed using the 1996 Guidelines. Claims that, on or before January 1, 2012, already have at least one medical opinion finding a permanent impairment with a rating based on the 1996 Guidelines will be determined using the 1996 Guidelines. Therefore, an IME or treating physician who is evaluating such a claim should use the 1996 Guidelines rather than the 2012 Guidelines.
  4. My question involves cases with dates of accident prior to 3/13/07 that become ripe for permanency. They are not subject to the 2007 legislation caps on PPD benefits based on loss of wage earning capacity. Will there still be the same evaluation by the Board for these cases under the new Guidelines as there will be for the post-3/13/07 cases (i.e. will there still be one finding for medical impairment and one for loss of wage earning capacity with the same types of evaluation)? Yes. The definition of disability for determining permanent disability benefits is the same whether the injured worker is subject to a duration limitation or not. The level of disability is not a purely medical determination, but rather a legal one based on the impact of medical and non-medical factors. Pre- and post-reform claims will be evaluated in the same manner, though pre-reform claims will not be subject to duration caps.

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Impairment Rankings

  1. Do the 2012 Guidelines apply to temporary disabilities? No. Medical providers should continue to determine temporary disability as they have previously.
    Temporary medical impairment should be rated according to the scale of mild, moderate, marked and total, and converted into a percentage as follows:
    • Mild - 25%
    • Mild to Moderate - 33%
    • Moderate - 50%
    • Moderate to Marked - 67%
    • Marked - 75%
    • Total - 100%
  2. Is Mild, Moderate and marked no longer being used? Are the new choices only Temporary Total, Temporary partial, Permanent Total, Permanent partial? Mild, moderate and marked may be used for evaluating temporary disability, though they should be converted to a numerical value (see General #5). In determining permanent impairment severity for non-schedule disabilities, the physician should use the letter severity grades instead (when available).
  3. When do you need to do a severity rating? Is it only when permanency has been established? A severity ranking should be provided when you believe (or the WCB has determined) that the claimant has a permanent disability.
  4. How should a provider evaluate medical impairment and functional capability when the claim involves both schedulable and non-schedulable body parts? If the claim involves both schedulable and non-schedulable body parts, the provider should evaluate and rank the impairment of each body part or system separately in Section E 1(b) of the C-4.3 as non-schedule impairments. The provider will not be able to give a severity rank for the schedulable body parts but should document history, physical findings, and diagnostic test results for each body part. In completing Section F, the provider should consider the impact of all of the medical impairments collectively in determining functional capabilities and exertional abilities.
  5. How do you apply impairment ratings for multiple body parts? Permanent impairment should be rated for each body part separately using the appropriate table.
    Added 6/11/2012
  6. If the claimant has an established claim for a normally scheduled body part, but it is determined that the case is not schedulable, how is permanency determined using the 2012 Guidelines? If the claim involves a normally scheduled body part that is not schedulable, the provider should evaluate the body part using Chapter 17. The provider should document history, physical findings, and diagnostic test results, but will not be able to give a severity rank. One should not attempt to characterize as Mild, Moderate, Marked or Total. The provider should also document the functional capabilities and exertional abilities in Section F of the C-4.3.
    Added 7/10/2012
  7. Should the physician complete the Pain Disability Questionnaire (PDQ) in all PPD cases? Should the PDQ be completed by the treating physician, the IME, or both? The Pain Disability Questionnaire (PDQ) is not necessary in all PPD cases. It is required only when the criteria for pain in Chapter 16 are met (ie: when an impairment is due to an extraordinarily severe, persistent painful condition).

    The PDQ should be used when appropriate by the treating physician and/or the IME.

    Added 8/23/2012
  8. Should a physician (either Treating or independent medical examiner (IME)) use the Medical Impairment Severity Crosswalk contained in table 18.1 (page 120) to document severity in the impairment evaluation? The Medical Severity Impairment Crosswalk is not to be used by a treating physician or IME who performs an impairment evaluation. The physician (treating or IME) is required to document the Class and Severity Ranking for the applicable injuries. The Severity Crosswalk plays no role in the physician's assessment and documentation of an impairment(s). The Severity Crosswalk may be used by the Workers' Compensation Law Judge in their loss of wage earning capacity determination.

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Functional Capacity Evaluations (FCE)

  1. Can the treating physician or the IME request a functional capacity examination (FCE) to evaluate the injured worker's functional capabilities as part of the functional evaluation? Yes. The functional and exertional capabilities may be determined through FCE performed by a licensed occupational or physical therapist with appropriate training. The General and Specific Requirements found in Ground Rule 14 of the Physical Medicine fee schedule must be met before the FCE can be requested. The treating physician or IME would still be responsible to review the results of the FCE and to incorporate the findings in the overall assessment. The parties are encouraged to agree on a single FCE examiner instead of requiring the claimant to undergo two separate FCEs.
  2. If the physician orders an FCE, is the physician still eligible to receive payment for a Level 5 E&M consultation code (99245) for the permanency evaluation and completion of the C-4.3? Yes. If the physician performs a complete evaluation of permanent impairment, reviews and incorporates the findings of the FCE, and fully completes the C-4.3 form, the physician is entitled to payment at the 99245 fee.
  3. Who can do the functional capacity examination (FCE)? Does the WCB authorize those physicians? The medical fee schedule provides the specific eligibility requirements for performance of an FCE. They are found in Ground Rule 14 of the Physical Medicine schedule and require that the examiner be a licensed physical or occupational therapist or other licensed provider qualified by scope of practice. If a physician were to perform an FCE, the physician would need to be authorized by the WCB.
  4. If a carrier requests a functional capacity examination (FCE), do they need to get a consent from the treating provider? No.

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Forms

  1. Will the carriers and the board still accept the C-4.3(1/11) after January 1, 2012? Is there a grace period while provider's software is upgraded to accommodate the new C-4.3(1/12)? Yes, the Board will continue to accept the C-4.3 (1/11) until June 30, 2012, but the enhanced payment of 99245 is only valid for completion of the new C-4.3 (1/12).
  2. Should IMEs use the C-4.3 form? No, IMEs should report their examination findings using the IME-4. If an IME evaluates a non-schedule permanent partial disability, the IME should record the same categories of impairment and functional ability information that the treating physician is required to provide on the C-4.3: impairment table and severity ranking, supporting history, physical findings, and diagnostic test results, and functional and exertional abilities. It may be useful to use the functional capabilities table template from the form C-4.3 (Section F.1.).

Training

  1. Does the Board offer training on the 2012 Guidelines? Yes. Free web-based training is available on the Board's web site. Programs have been designed for different audiences, including medical professionals, attorneys, and carriers.
  2. Are CME credits being offered for the completion of the 2012 Guidelines training? 1.25 hours of Continuing Medical Education (CME) credits are available for physicians who take the 2012 Guidelines For Medical Professionals course.
  3. After completing the eLearn training, why did I have difficulty printing the certificate? Some individuals may experience issues when attempting to print their eLearn certificates. The problem can be related to one of many areas including the browser being used, the browser release, computer settings, printer, printer settings etc. If you do experience any problems printing, please contact your help desk or internet service provider.
  4. When taking the eLearn training program, should the page back option be utilized? To avoid eLearn application issues, refrain from using your browsers back button or forward button. When available, the eLearn application will display a back button and forward button.
    Added 2/8/2012
  5. Do doctors in all specialties need to take the course for the new 2012 training regarding Permanent Impairment and Loss of Wage Earning Capacity? Anyone who may perform impairment and functional evaluations of injured workers with permanent disabilities should take the educational program on the 2012 Guidelines.

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Updated 7/10/2012