Chapter
E-900 Impairment Ratings
Table of Contents. . . . . . . i 02/06 06/01
1 Purpose
and Scope. . . . . . . 1 02/06 06/01
2 Policy . . . . . . . . . . . . 1 02/06 06/01
3
General Requirements for
Impairment Ratings. . .
. . . . 1 02/06 06/01
4
Developing Medical Evidence. . 4 02/06 06/01
5 Receipt of the Impairment
Evaluation. . . . . . .
. . . . 7 02/06 06/01
6 Procedure for Submitting
Charges. . . . . .
. . . . . . 8 02/06 06/01
7 ECMS Coding
for Impairment. . . 10 02/06 06/01
8 Pre-Recommended Decision
Challenges. . . . .
. . . . . . 11 02/06 06/01
9 Issuance of a Recommended
Decision. . . . .
. . . . . . . 12 02/06 06/01
10 Final Adjudication Branch (FAB)
Development. . . . .
. . . . . . 12 02/06 06/01
11 Additional Filings for
Impairment
Exhibits
1
Impairment
Letter to Employee
2 Impairment Letter to Physician
3
Medical
development/Impairment Letter to Employee
1. Purpose
and Scope. This chapter provides
guidance on how the CE determines the extent of a covered Part E employee’s
impairment that is attributable to a covered illness, how the District Office
(DO) and the Final Adjudication Branch (FAB) will evaluate medical evidence of
impairment in the case record, what is considered to be a ratable permanent
impairment, and the potential eligibility of a covered Part E employee for
additional impairment benefits following an initial award of impairment
benefits.
2. Policy. The CE is responsible for processing
impairment rating determinations and ensuring benefits are appropriately paid
under the provisions of 42 U.S.C. 7385s, 7385s-2, 7385s-4, and 7385s-5.
3. General
Requirements for Impairment Ratings.
For an employee to be qualified for an impairment award under Part E of
the EEOICPA, the CE must first determine that the employee is a covered Part E
employee found to have contracted a covered illness through exposure to a toxic
substance at a DOE facility or RECA section 5 facility. The CE then determines if the covered Part E
employee is claiming impairment as a result of an accepted covered illness or
illnesses. In general, an impairment is
a decreased function in a body part(s) or organ(s) established by medical
evidence. The employee will not be able
to claim impairment on the Form EE-1, so the CE must be cognizant to develop
for impairment when applicable. The determination
of impairment must not delay the issuance of a recommended decision to accept
on other issues. The Secondary CE assigned
to the FAB may develop and adjudicate an impairment claim while a case with a
recommended decision to accept is pending FAB review.
a. The CE determines the
extent of an employee’s impairment that is the result of a covered illness
contracted through exposure to a toxic substance at a DOE facility or a RECA facility. An impairment
rating performed by a qualified physician who satisfies DEEOIC’s criteria for
physicians performing impairment evaluations is the basis of such a
determination. The physician’s
impairment rating report must be clearly rationalized and grounded in sound
medical opinion.
(1) An impairment
evaluation of the employee must be based upon the most current edition of
the American Medical Association’s Guides to the Evaluation of Permanent
Impairment (AMA’s Guides).
(2) An impairment evaluation must be performed by a qualified
physician who satisfies the DEEOIC’s criteria for physicians performing
impairment evaluations. In order for a
physician to be deemed qualified, he/she must hold a valid medical license and
Board certification/eligibility in the appropriate field of expertise (i.e.
toxicology, pulmonary, neurology, occupational medicine, etc.). He/she must
also show that he/she meets at least one of the following criteria: is
certified by the American Board of Independent
Medical Examiners (ABIME) and/or American
Academy of Disability Evaluating Physicians (AADEP) and/or possesses
knowledge and experience in using the AMA’s Guides
and/or possesses the requisite professional background and work experience to
conduct such ratings. Evidence of
criterion satisfaction is either requested from the rating physician (see
Exhibit 2) or gathered by DEEOIC National Office when evaluating a physician
for participation in the District Medical Consultant (DMC) program.
(a) As noted above, evidence is requested of all rating
physicians to determine whether or not they meet the required
qualifications. The physician submits
evidence of his/her medical license and certifications. If a physician does not possess either the
ABIME or AADEP certification, he/she submits a statement certifying and
explaining his/her familiarity and years of experience in using the AMA’s Guides.
(3) The impairment rating
is a percentage that represents the extent of a whole-person
impairment of the employee, based on the organ(s) or system(s) affected by an
accepted covered illness or illnesses.
The rating accounts for all accepted covered illness related impairments
and includes all conditions that are present in the covered
organ(s) or system(s) at the time of the impairment evaluation.
(4) As part of any
impairment evaluation, the physician must specify the percentage points of a
whole-person impairment that are the result of any accepted covered illness. As such, the physician must exclude any
percentage points that are due to pre-existing and/or non-employment related
impairments to the organ or body part being evaluated, insofar as that is
possible. If the CE finds that the employee contracted more than one covered
illness, the physician should specify the
total percentage points of impairment that are the result of all of the employee’s
covered illnesses.
(a) An impairment that is
the result of any accepted covered illness, that cannot be assigned a numerical
impairment percentage using the most current AMA’s Guides, will not be included in the employee’s impairment rating,
and the physician performing the impairment evaluation needs to explain the
rationale as to why a numerical impairment percentage cannot be assigned.
(b) A neurological
impairment producing mental deficits, as a result of a documented exposure
(i.e. exposure to heavy metals and chronic solvents) can be assigned a
numerical percentage using the most recent edition of the AMA’s Guides, and will be included in the
impairment rating for the employee. However,
mental deficits that are not related to a neurological impairment cannot be
assigned numerical percentages using the AMA’s Guides, and will not be included in the impairment rating for the employee, but may possibly be accepted as a
consequential injury and
eligible for medical benefits per Chapter
2-1000, of the procedure manual. A further discussion in
regard to mental deficits that are not related to a neurological impairment is
forthcoming.
(c) An impairment that is
the result of a covered illness will be included in the employee’s
impairment rating, only if the physician concludes that the condition has
reached maximum medical improvement (MMI), which means that it is
well-stabilized and unlikely to improve substantially with or without medical
treatment. Conditions that are progressive in nature, and worsen over time, such as chronic beryllium disease (CBD),
are considered to have reached MMI when the condition is not likely to
improve. The only exception to this is
if the CE finds, based upon probative medical
evidence, that an employee’s covered illness is in the terminal stages. In this instance, the employee may be
undergoing ongoing treatment and thus not have reached maximum medical
improvement (MMI). However, if DOL were
to wait for the outcome of the treatment to be known, the employee could pass
away, and the eligibility for an impairment award extinguished. Therefore, in this case, the impairment that
results from such a covered illness is included in the impairment rating for
the covered Part E employee, even if maximum medical improvement (MMI) has not
been reached.
(i) After reviewing the
medical evidence, if the CE determines that the condition has not reached
maximum medical improvement (MMI) or that it is not in the terminal stages,
then the CE does not make an impairment determination. A letter is sent to the
claimant informing him/her that an impairment determination will not be made at
this time because MMI has not been reached.
4. Developing
Medical Evidence. As part of the
development process for impairment, and in order for an employee to undergo an
impairment evaluation, the DEEOIC must obtain factual and medical evidence for
the specific covered illness, if the evidence has not already been submitted by
the employee. The development letters discussed below provide
the claimant with options concerning the method of obtaining an impairment
evaluation. The DEEOIC will pay the cost
for obtaining the required evidence and medical tests required to undergo an
impairment evaluation, and the cost for an impairment evaluation obtained by an
employee, if it meets the criteria discussed in this section. In most claims, the DEEOIC will only pay for
one evaluation by a physician or physician group, whether the evaluation was
obtained by the employee or by the DEEOIC.
However, it is at the CE’s discretion to have the employee undergo
additional evaluations at the DEEOIC’s expense.
a. The CE initiates
development by sending a development letter (Exhibit 1) to the employee, advising that he/she may be
eligible for an award based on permanent impairment. This letter is only sent for employee claims, survivors
are not entitled to benefits for permanent impairment. The letter requests that
the employee advise the DEEOIC as to whether or not he/she wants to claim
impairment as a result of the covered illness or illnesses. The letter also explains that the employee
has two options, if he/she elects to claim impairment. Option one, the employee notifies the DEEOIC
that they wish to choose a qualified physician of his/her own to perform an
impairment evaluation. Option two, the employee is requesting that the DEEOIC
arrange for an impairment evaluation to be conducted based upon specific
medical evidence. This letter describes
the evidence and physician information that must be submitted for each
option. The employee is directed to contact the district office
by phone and in writing, to communicate his/her wish to pursue a claim for
impairment. The employee is allotted a
total of sixty days to respond, with a follow up request sent to the employee
at the first thirty day interval. The CE
does not develop the impairment issue any further until a response is received
from the employee.
(1) If the employee does not respond to
the development letter within the allotted 60 days, or informs the CE that he
or she does not want to pursue a claim for impairment, the CE sends a letter to
the employee advising that the DEEOIC will not develop the claim for impairment at this
time. The CE also notifies the employee of
his/her rights to claim
b. If the employee claims impairment, and elects
option one, the CE sends a letter (Exhibit 2) to the physician the employee
has selected. The letter notifies the
physician of the employee’s eligibility, and the covered illness or illnesses
with respective ICD-9 code(s). The
letter also explains that in order for the DEEOIC to pay for one impairment evaluation, the
evaluation must not have been performed more than one year prior to the date the
report is received by DEEOIC. The letter
also explains that the impairment evaluation must be performed in accordance
with the most current edition of the AMA’s Guides,
and that specific reference to the appropriate page numbers and tables used from
the AMA’s Guides is required in the
report. The letter further notifies the physician
that he/she must submit evidence to support that he/she meets the eligibility criteria
required by DEEOIC to perform ratings. Lastly,
the CE includes a medical bill payment contractor enrollment package, which
includes: an OWCP-1500 Health Insurance Claim Form (Exhibit 5) and the EEOICP
Provider Enrollment Form (OWCP-1168).
The EEOICP Provider Enrollment Form explains how a physician enrolls
with the medical bill pay provider. The
form also discusses how to submit charges related to the impairment rating. If a physician is already enrolled, there is
no need to enroll again.
c. If the employee claims
impairment and selects option two, the CE reviews the medical evidence in
the case file, to determine if the documentation is sufficient for the DEEOIC to
request an impairment evaluation by a District DMC. If the CE determines that the medical
evidence of record is not sufficient, the CE sends a development letter (Exhibit
3) to the employee explaining the evidence/diagnostic test(s)
required in order to conduct an impairment evaluation. The CE refers to the “Required Medical
Evidence for Specific ICD-9 Codes” (Exhibit 4) job aid reference, for the
specific covered illness and associated required evidence. The CE should provide the employee with a
copy of the specific section of Exhibit 4 that relates to the employee’s
covered illness or illnesses. Please
note that Exhibit 4 is not complete and further guidance will be forthcoming in
regard to conditions not listed in Exhibit 4.
The CE also explains to the employee that the cost associated with
obtaining the required evidence will be paid by the DEEOIC. If the tests are obtained prior to a
recommended decision, the CE takes actions for payment of such bills as
discussed in this section.
d. When the CE determines the medical
evidence of record is sufficient for referral to a DMC for an impairment
evaluation, the CE prepares a Statement of Accepted Facts (SOAF) and a
memorandum with a request to the DMC that an impairment rating evaluation be
performed based on the evidence of file. The CE
forwards the request for an impairment rating evaluation along with the
appropriate medical evidence, to a DEEOIC approved DMC via the District Office
DMC scheduler.
5. Receipt of the Impairment Evaluation.
Upon completion of the impairment
evaluation and receipt in the DO, the CE reviews the report to assure all the
DEEOIC criteria have been met, as previously discussed in this section. The employee is entitled to an award of
impairment benefits, if one or more percentage points of the impairment are
found to be related to a covered illness or illnesses.
a. To calculate the award, the CE
multiplies the percentage points of the
impairment rating that are
b. If the impairment rating report submitted
by the claimant is unclear or lacks clearly rationalized medical evidence
as support, additional clarification is required. In such instances, the CE returns the
impairment rating report to the rating physician with a request for
clarification, indicating what areas are in need of remedy. If the report is returned without a
sufficient response, or no response is received, the CE may seek DMC review and
opinion as to the proper impairment rating value.
6. Procedure for Submitting Charges. When the CE sends the development letter
(Exhibit 2), EEOICP Provider Enrollment Form (OWCP-1168), and the OWCP-1500
(Exhibit 5) to the physician, the OWCP 1500 must be clearly marked at the top “PROMPT
PAY” in red ink. The CE must complete the following items on the OWCP-1500: sections
1a, 2, 3, & 5 (employee’s social security number, name, address, birth
date, and sex). “Signature on file”
should be indicated in sections 12 & 13, and in section 21 the CE enters
the ICD-9 code V70.9. Please see EEOICPA
PM 2-300 for additional guidance.
a. Upon receipt of the completed medical bill payment contractor enrollment package discussed above, the CE reviews the OWCP 1500 to be sure the physician has provided all the necessary information for the medical bill payment contractor provider to process the payment. The CE annotates in block #11 the PPA date (7 calendar dates from receipt at the District Office). The following sections must be completed: section 24A date service was performed; section 24B place of service; section 24C type of service; section 24D procedure code annotated with PE001; section 24E diagnosis code; sections 24F and 28 the amount of the charge(s); section 25 the physician’s tax ID number; section 30 total amount of charge(s); section 31 signature of the physician and date; section 32 name and address of facility where services were rendered; and section 33 physician’s name and address of the billing facility and their nine digit provider number (if the physician already has a number on file). The CE approves the bill by writing “APPROVED” in the top right hand corner along with his/her signature and date. The writing must not be placed over any relevant bill information.
b. ECMS
Coding for prior authorization. The
CE must take the following steps to complete the prior authorization process if
a final decision approving at least one medical condition has not been issued
at the time an impairment rating evaluation has been done;
(1) The CE
must first access the “claim update screen”.
(2) The CE
highlights any area in the “medical condition” box and presses the insert
key. The next screen should have
“medical condition (insert)” written at the top.
(3) The CE
must click the down arrow in the box next to “reported
c. Submission of Approved charges to the
Medical Bill Payment Contractor. Once
the ECMS coding is input, the CE forwards the completed package (EEOICP
Provider Enrollment Form (OWCP-1168) and the approved OWCP-1500) to the FO, who
mails to the medical bill payment contractor at:
Division
of Energy Employees
Occupational
Illness Program
Prompt
Pay
These bills must be
processed no later than
twenty one (21) days upon receipt in the District Office, in order to comply
with the Prompt Payment Act.
d. The DEEOIC will not pay for an impairment
evaluation if the above listed criterion is not met, and/or if the impairment
evaluation was performed by a physician prior to the date that the claim for
Part E benefits is filed.
7. ECMS
Coding for Impairment.
a. Developing for
Impairment Claims. The CE utilizes
the following ECMS coding when developing for impairment.
(1) When the CE sends an impairment development letter,
the CE enters the “DO” (Developing Other) code into ECMS. The status effective date of the “DO” entry
is the date on the letter that is sent to the claimant. Upon entry of the “DO” code, the CE selects
“IM-Impairment” as the reason code in the drop down box. If a follow up letter
to the claimant is required, the CE codes another “DO” in ECMS as discussed
above.
(2) If a follow up letter to the employee and/or to the physician is required, the CE codes another “DO” in ECMS as discussed above.
(3) ‘IC – Impairment
Claimed’. This code is used when the
claimant informs DEEOIC in writing
of intent to pursue an impairment claim.
The status effective date is the postmark date of the letter, if
available, or the date the letter is received in the DO/RC.
b. When the CE sends the request for an impairment rating evaluation
to a DMC, a “MS” (Sent to Medical Consultant) development action code is
entered into ECMS. The status effective
date of the “MS” code is the date of the memorandum to the DMC. Upon entry of the “MS” code, the CE selects
“IM-Impairment” as the reason code in the corresponding drop-down box.
c. When the district office receives the impairment
report, it is date stamped and forwarded to the CE. Upon receipt of the report, the CE enters a
“MR” (Received from Medical Consultant) development action code into ECMS. The status effective date of the “MR” code is
the date stamp of the date the report is
received into the DO. Upon entry of the
“MR” code, the CE selects “IM-Impairment” as the reason code in the
corresponding drop-down box.
d. Rules
for Impairment without Maximum Medical Improvement (MMI).
(1) When
impairment is claimed, but the employee has not reached MMI, the CE codes
C2 (Administrative Closure) with the corresponding reason code “NM-Not at
MMI”. The status effective date of the
code is the date of the letter to the claimant informing him/her that an
impairment rating cannot be made at this time due to the fact that he/she has
not reached MMI.
(2) Once
medical evidence is received in the DO indicating that the claimant is at
MMI, development is resumed. When
development for impairment is resumed, the ‘RD’ (Development Resumed) code will
be entered into ECMS. The status
effective date will be the date such evidence of MMI is received in the DO.
8. Pre-Recommended
Decision Challenges. The CE may
provide the claimant with a copy of the impairment rating report if he/she
specifically requests a copy. The
employee may either submit arguments making the challenge, and/or additional
medical evidence of impairment. However,
any additional impairment evaluation must meet the criteria discussed in above before
the CE considers it when making impairment determinations. In this instance, if the additional
evaluation differs from the one already in the file, the CE must review the two
reports in detail to determine which report has more probative value. In weighing the medical evidence, the CE must
use his or her judgment in the analysis of the reports. If the reports appear to be of equal value,
the CE may wish to refer the file to a DMC for additional consideration.
a. If the DMC opines that both impairment evaluations are of the same probative value, the CE may obtain a referee medical examination (please refer to Chapter 2-0300 “Developing and Weighing Medical Evidence” in the Procedure Manual).
9. Issuance
of a Recommended Decision. The
recommended decision must contain a thorough discussion of the impairment evidence
submitted in the case. Therefore, if
there is more than one evaluation in the file, the CE must provide a detailed discussion of the reason why one report was found
to have more probative value (see discussion below) than another. This detailed discussion of probative value is
necessary because if the employee submits additional impairment evidence to the
Final Adjudication Branch, he or she will have the burden to prove that the additional impairment evidence has
more probative value than the evaluation relied upon by the district
office. Therefore, it is important for
the discussion in the recommended decision to be thorough and complete.
10. Final
Adjudication Branch (FAB) Development. Once the recommended decision on
impairment has been issued and forwarded onto the Final Adjudication Branch for
review, the employee may submit new medical evidence or an additional impairment
evaluation to challenge the impairment determination in the recommended
decision.
a. The employee bears the burden of proving that the
additional impairment
evidence has more probative value
than the evaluation used by
the district office to determine the impairment rating.
b. Probative Value
Determinations. The FAB
representative must take many variables into consideration when weighing
impairment evaluations for probative value.
While by no means exhaustive, the FAB representative reviews impairment
evaluations to determine the following: that the opining
(1) Example. The RD is based upon Dr. X’s impairment
rating of the employee, 20% whole body due to the covered illness
asbestosis. Dr. X’s opinion is clearly
rationalized and provides a detailed analysis as to how the medical findings
were deduced, addressing the covered illness and its relation to the
rating. The employee submits an
impairment rating from Dr. Y that finds a 30%
whole body impairment due to asbestosis and other unrelated conditions. The report provides little analysis as to how
the medical findings were reached and does not provide a rationale as to why
the 30% rating is related to the covered illness of asbestosis. Both doctors possess the requisite skills and
the reports were submitted timely. The FAB representative gives credence to the
impairment rating prepared by Dr. X that was accepted in the recommended
decision, as it of more probative value than the report submitted by Dr.
Y. The clear medical rationale provided
by Dr. X lends more “believability” to the rating than that provided by Dr.
Y. In such an instance the FAB accepts
the rating accepted by the DO in the RD as having more probative value.
c. In addition to the
impairment rating(s), the FAB reviews all the relevant evidence of impairment
in the case record and bases its determination on the evidence it finds to be
most probative.
d. The Final Decision
must contain detailed rationale and discussion for any determination
concerning multiple impairment evaluations. The final decision also includes
11. Additional
Filings for Impairment Benefits. A
covered Part E employee previously awarded impairment benefits may file a claim
for additional impairment benefits. This
claim must be based on an increase in the impairment rating
from the impairment rating of the accepted covered illness or illnesses that
formed the basis for the last award of impairment benefits.
a. The covered Part E employee may not submit a Form EE-10 (Exhibit 6) for an increase in the impairment rating earlier than two years from the date of the last award of impairment benefits (i.e. date of the final decision). However, there is an exception to this requirement when the DO adjudicates a claim for additional impairment based upon a new covered illness not included in the previous award.