Date of Adoption: January 27, 2004.

     Purpose: The department is implementing a number of changes to improve the quality and timeliness of independent medical examinations. The purpose of the proposed rules is to ensure providers know the department's requirements to be an independent medical examiner, the expectations of providers in the treatment of injured workers during an examination and other standards providers are expected to meet as approved examiners. In addition, the rules clarify requirements of attending physicians or consultants when doing impairment rating examinations.

     Citation of Existing Rules Affected by this Order: Repealing WAC 296-20-210 General rules, 296-23-255 Independent medical examinations, 296-23-260 Examination reports, 296-23-265 Who may perform independent medical examinations?, 296-23-26501 How do doctors become approved examiners?, 296-23-26502 Where can doctors get an application to become an approved examiner and other information about independent medical examinations?, 296-23-26503 What factors does the medical director consider in approving, suspending or removing doctors from the approved examiners list?, 296-23-26504 What happens if an examiner is suspended or removed from the approved examiner list by the medical director?, 296-23-26505 Is there a fee schedule for independent medical examinations?, 296-23-26506 Can a worker file a complaint about an independent medical examiner's conduct?, 296-23-267 When may attending doctors perform impairment rating examinations? and 296-23-270 Independent medical examinations two or more examiners; and amending WAC 296-20-200 General information for impairment rating examinations by attending doctors, consultants or independent medical examination (IME) providers.

     Statutory Authority for Adoption: RCW 51.32.055, 51.32.112, 51.32.114, 51.36.060, and 51.36.070.

      Adopted under notice filed as WSR 03-21-070 on October 14, 2003.

     Changes Other than Editing from Proposed to Adopted Version: Changes were made in the following sections of the proposed WAC, based upon public input and further research by the department.

     Amend WAC 296-20-2010(3) to include it is the responsibility of attending doctors and consultants to be familiar with the contents of the Medical Examiner Handbook section on rating examinations by attending doctors and consultants.

     Amend WAC 296-20-2010(5) to include a complete impairment rating report must be sent to the department or self-insurer within fourteen calendar days of the examination date, or within fourteen calendar days of receipt of the results of any special tests or studies requested as a part of the examination. Job analyses (JAs) sent to the IME provider at the time of the impairment rating exam must be completed and submitted with the impairment rating report.

     Amend WAC 296-20-2010(1) to include a chiropractic impairment rating examination may be performed only when the worker has been clinically managed by a chiropractor.

     Deleted WAC 296-20-2020. Will add nonduplicative last paragraph to WAC 296-20-2010(4).

     Attending doctors and consultants performing impairment rating examinations must be available and willing to testify on behalf of the department or self-insurer, worker, or employer and accept the department fee schedule rate for testimony.

     Other nonduplicative language included in WAC 296-20-2015.

     Amend WAC 296-23-302 Definitions, to include direct patient care. For the purpose of meeting the qualifications of an independent medical examination (IME) provider, direct patient care means face-to-face contact with the patient for the purpose of evaluation and management of care that includes, but is not limited to:

•     History taking and review of systems;

•     Physical examination;

•     Medical decision making;

•     Coordination of care with other providers and agencies. This does not include time spent in independent medical examinations.

     Provider number. A unique number(s) assigned to a provider by the department of labor and industries. The number identifies the provider and is linked to a tax identification number that has been designated by the provider for payment purposes. A provider may have more than one provider number assigned by the department.

     Amend WAC 296-23-317 (5)(a) to include providers must conduct independent medical examinations only in a professional office suitable for medical, dental, podiatric, chiropractic or psychiatric examinations where the primary use of the examination site is for medical services; not residential, commercial, educational or retail in nature.

     Amend WAC 296-23-337(1) complaints about the provider.

     Amend WAC 296-23-347 (2)(c) let the worker know that the claim documents from the department or self-insurer have been reviewed.

     Amend WAC 296-23-347 (3)(a) send a complete IME report to the department or self-insurer within fourteen calendar days of the examination date, or within fourteen calendar days of receipt of the results of any special tests or studies requested as a part of the examination. Reports received after fourteen calendar days may be paid at a lower rate per the fee schedule. The report must meet the requirements of WAC 296-23-382.

     Amend WAC 296-23-347 (3)(b) the claim file information received from the department or self-insurer should be disposed of in a manner used for similar health records containing private information after completion of the IME or any follow up test results are received. IME reports should be retained per WAC 296-20-02005.

     Amend WAC 296-23-377(2) if, after review of the records, a history from the worker and the examination, the IME provider does not concur with the attending doctor's determination of MMI, an IME report must be completed. See WAC 296-23-382.

     Added WAC 296-23-381 in table format, What rating systems are used for determining an impairment rating conducted by the independent medical examination (IME) provider?

     The following table provides guidance regarding the rating systems generally used. These rating systems or others adopted through department policies should be used to conduct an impairment rating.

     Number of Sections Adopted in Order to Comply with Federal Statute: New 0, Amended 0, Repealed 0; Federal Rules or Standards: New 0, Amended 0, Repealed 0; or Recently Enacted State Statutes: New 0, Amended 0, Repealed 0.

     Number of Sections Adopted at Request of a Nongovernmental Entity: New 0, Amended 0, Repealed 0.

     Number of Sections Adopted on the Agency's Own Initiative: New 24, Amended 1, Repealed 12.

     Number of Sections Adopted in Order to Clarify, Streamline, or Reform Agency Procedures: New 24, Amended 1, Repealed 12.

     Number of Sections Adopted Using Negotiated Rule Making: New 24, Amended 1, Repealed 12;      Pilot Rule Making: New 0, Amended 0, Repealed 0; or Other Alternative Rule Making: New 0, Amended 0, Repealed 0.
     Effective Date of Rule: March 1, 2004.

January 27, 2004

Paul Trause

Director

OTS-6667.4

AMENDATORY SECTION(Amending WSR 97-09-036, filed 4/14/97, effective 5/15/97)

WAC 296-20-200   General information for impairment rating examinations by attending doctors, consultants or independent medical examination (IME) providers.   (1) The department of labor and industries has promulgated the following rules and categories to provide a comprehensive system of classifying unspecified permanent partial disabilities in the proportion they reasonably bear to total bodily impairment. The department's objectives are to reduce litigation and establish more certainty and uniformity in the rating of unspecified permanent partial disabilities pursuant to RCW 51.32.080(2).

     (2) The following system of rules and categories directs the ((examiner's)) provider's attention to the actual conditions found and establishes a uniform system for conducting rating examinations and reporting findings and conclusions in accord with broadly accepted medical principles.

     The evaluation of bodily impairment must be made by experts authorized to perform rating examinations. ((This system recognizes and provides for this.)) After conducting the examination, the ((examiner)) provider will choose the appropriate category for each bodily area or system involved in the particular claim and include this information in the report. The ((examiner)) provider will, therefore, in addition to describing the worker's condition in the report, submit the conclusions as to the relative severity of the impairment by giving it in terms of a defined condition rather than a personal opinion as to a percentage figure. In the final section of this system of categories and rules are some rules for determining disabilities and the classification of disabilities in bodily impairment is listed for each category. These last provisions are for the department's administrative use in acting upon the expert opinions which have been submitted to it.

     (3) In preparing this system, the department has complied with its duty to enact rules classifying unspecified disabilities in light of statutory references to nationally recognized standards or guides for determining various bodily impairments. Accordingly, the department has obtained and acted upon sound established medical opinion in thus classifying unspecified disabilities in the reasonable proportion they bear to total bodily impairment. In framing descriptive language of the categories and in assigning a percentage of disability, careful consideration has been given to nationally recognized medical standards and guides. Both are matters calling for the use of expert medical knowledge. For this reason, the meaning given the words used in this set of categories and accompanying rules, unless the text or context clearly indicates the contrary, is the meaning attached to the words in normal medical usage.

     (4) The categories describe levels of physical and mental impairment. Impairment is anatomic or functional abnormality or loss of function after maximum medical ((rehabilitation)) improvement has been achieved. This is the meaning of "impairment" as the word is used in the guides mentioned above. This standard applies to all persons equally, regardless of factors other than loss of physical or mental function. Impairment is evaluated without reference to the nature of injury or the treatment therefore, but is based on the functional loss due to the injury or occupational disease. The categories have been framed to include conditions in other bodily areas which derive from the primary impairment. The categories also include the presence of pain, tenderness and other complaints. Workers with comparable loss of function thus receive comparable awards.

     (5) These rules and categories (WAC 296-20-200 through 296-20-690) shall only be applicable to compensable injuries occurring on or after the effective date of these rules and categories.

     (6) These rules and categories (WAC 296-20-200 through 296-20-690) shall be applicable only to cases of permanent partial disability. They have no applicability to determinations of permanent total disability.

[Statutory Authority: RCW 51.04.020, 51.04.030, 51.32.112, 51.32.114 and 51.36.015. 97-09-036, § 296-20-200, filed 4/14/97 effective 5/15/97. Statutory Authority: RCW 51.04.020(4) and 51.04.030. 91-07-008, § 296-20-200, filed 3/8/91, effective 5/1/91; Order 74-32, § 296-20-200, filed 6/21/74, effective 10/1/74.]

     (1) Impairment rating examinations shall be performed only by doctors currently licensed in medicine and surgery (including osteopathic and podiatric) or dentistry, and department-approved chiropractors subject to RCW 51.32.112. The department or self-insurer may request the worker's attending doctor conduct the impairment rating when appropriate. If the attending doctor is unable or unwilling to perform the impairment rating examination, a consultant, at the attending doctor's request, may conduct a consultation examination and provide an impairment rating based on the findings. The department or self-insurer can also request an impairment rating examination from an independent medical examination (IME) provider. A chiropractic impairment rating examination may be performed only when the worker has been clinically managed by a chiropractor.

     (2) Whenever an impairment rating examination is made, the attending doctor or consultant must complete a rating report that includes, at a minimum, the following:

     (a) Statement that the patient has reached maximum medical improvement (MMI) and that no further curative treatment is recommended;

     (b) Pertinent details of the physical examination performed (both positive and negative findings);

     (c) Results of any pertinent diagnostic tests performed (both positive and negative findings). Include copies of any pertinent tests or studies ordered as part of the exam;

     (d) An impairment rating consistent with the findings and a statement of the system on which the rating was based (for example, the AMA Guides to the Evaluation of Permanent Impairment and edition used, or the Washington state category rating system - refer to WAC 296-20-19000 through 296-20-19030 and WAC 296-20-200 through 296-20-690); and

     (e) The rationale for the rating, supported by specific references to the clinical findings, especially objective findings and supporting documentation including the specific rating system, tables, figures and page numbers on which the rating was based.

     (3) It is the responsibility of attending doctors and consultants to be familiar with the contents of the Medical Examiner Handbook section on how to rate impairment.

     (4) Attending doctors and consultants performing impairment ratings must be available and willing to testify on behalf of the department or self-insurer, worker or employer and accept the department fee schedule for testimony.

     (5) A complete impairment rating report must be sent to the department or self-insurer within fourteen calendar days of the examination date, or within fourteen calendar days of receipt of the results of any special tests or studies requested as a part of the examination. Job analyses (JAs) sent to the IME provider at the time of the impairment rating exam must be completed and submitted with the impairment rating report.

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Overview of Systems for Rating Impairment

Rating System	Used for These Conditions	Form of the Rating
RCW 51.32.080	Specified disabilities: Loss by amputation, total loss of vision or hearing	Supply the level of amputation
AMA Guides to the Evaluation of Permanent Impairment	Loss of function of extremities, partial loss of vision or hearing	Determine the percentage of loss of function, as compared to amputation value listed in RCW 51.32.080
Category Rating System	Spine, neurologic system, mental health, respiratory, taste and smell, speech, skin, or disorders affecting other internal organs	Select the category that most accurately indicates overall impairment
Total Bodily Impairment (TBI)	Impairments not addressed by any of the rating systems above, and claims prior to 1971	Supply the percentage of TBI

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     (2) The accompanying person cannot be compensated for attending the examination by anyone in any manner.

     (3) The worker may not bring an interpreter to the examination. If interpretive services are needed, the department or self-insurer will provide an interpreter.

     (4) The purpose of the impairment rating examination is to provide information to assist in the determination of the level of any permanent impairment, not to conduct an adversarial procedure. Therefore, the accompanying person cannot be:

     (a) The worker's attorney, paralegal, any other legal representative, or any other personnel employed by the worker's attorney or legal representative; or

     (b) The worker's attending doctor, any other provider involved in the worker's care, or any other personnel employed by the attending doctor or other provider involved in the worker's care.

     The department may designate other conditions under which the accompanying person is allowed to be present during the impairment rating examination.

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     The following section of the Washington Administrative Code is repealed:

WAC 296-20-210

General rules.

OTS-6668.3

NEW SECTION
WAC 296-23-302   Definitions.   Direct patient care. For the purpose of meeting the qualifications of an independent medical examination (IME) provider, direct patient care means face-to-face contact with the patient for the purpose of evaluation and management of care that includes, but is not limited to:

     • History taking and review of systems;

     • Physical examination;

     • Medical decision making;

     • Coordination of care with other providers and agencies.     This does not include time spent in independent medical examinations.

     Impairment rating examination. An examination to determine whether or not the injured/ill worker has any permanent impairment(s) as a result of the industrial injury or illness after the worker has reached maximum medical improvement. An impairment rating may be a component of an IME.

     Independent medical examination (IME). An objective medical examination requested by the department or self-insurer to establish medical facts about a worker's physical condition.

     Independent medical examination (IME) provider. A firm, partnership, corporation, or individual doctor who has been approved and given an independent medical examination (IME) provider number by the department to perform IMEs.

     Medical director. A licensed doctor in the firm, partnership, corporation or other legal entity responsible to provide oversight on quality of independent medical examinations, impairment ratings and reports.

     Medical examiners' handbook. A handbook distributed by the department containing department policy and information to assist doctors who perform independent medical examinations and impairment rating examinations.

     Provider number. A unique number(s) assigned to a provider by the department of labor and industries. The number identifies the provider and is linked to a tax identification number that has been designated by the provider for payment purposes. A provider may have more than one provider number assigned by the department.

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     (1) Establish a diagnosis;

     (2) Outline a program of treatment;

     (3) Evaluate what, if any, conditions are related to the claimed industrial injury or occupational disease/illness;

     (4) Determine whether an industrial injury or occupational disease/illness has aggravated a preexisting condition and the extent or duration of that aggravation;

     (5) Establish when the accepted industrial injury or occupational disease/illness has reached maximum medical improvement;

     (6) Establish an impairment rating;

     (7) Evaluate whether the industrial injury or occupational disease/illness has worsened; or

     (8) Evaluate the worker's mental and/or physical restrictions as well as the worker's ability to work.

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     (1) Providers who wish to bill or get paid for independent medical examinations or related services must apply for and receive an IME provider number. Issuance of an IME provider number does not guarantee IME referrals.

     (2) Providers must have and maintain a current license to practice in the state in which they conduct IMEs and meet at least one of the two following requirements:

     (a) Board certification in their medical specialty; or

     (b) A minimum of an average of eight hours per week over the past two years of direct patient care in their medical specialty (excluding IMEs).

     (3) Only providers in the following practice specialties who meet all other requirements may perform IMEs;

	Doctors licensed to practice:
Examiner is:	Medicine & surgery	Osteopathic medicine & surgery	Podiatric medicine & surgery	Chiropractic	Dentistry
In Washington	Yes	Yes	Yes	Yes	Yes
Not in Washington	Yes	Yes	Yes	No	Yes

     (4) A provider licensed to practice chiropractic in Washington must also meet all the following requirements:

     (a) Be a chiropractic consultant for the department for at least two years;

     (b) Take an impairment rating course approved by the department; and

     (c) Attend the department's chiropractic consultant and examiners' seminar during the twenty-four months prior to application.

     (5) Business requirements:

     (a) Providers must conduct independent medical examinations only in a professional office suitable for medical, dental, podiatric, chiropractic or psychiatric examinations where the primary use of the examination site is for medical services; not residential, commercial, educational or retail in nature. The site must have, at a minimum, adequate access, climate control, light, space and equipment to provide for the comfort and safety of the injured/ill worker and provide the privacy necessary for workers to discuss their medical issues.

     (b) Providers must comply with all federal and state laws, regulations and other requirements with regard to business operations, including specific requirements for business operations for the provision of medical services.

     (c) Providers must have a private disrobing area and adequate provision of examination gowns.

     (d) Providers must have telephone answering capability during regular business hours, Monday through Friday, in order to facilitate scheduling of independent medical examinations and means for workers to contact the provider regarding their scheduled examination. If the office is open on Saturday, telephone access must be available.

     (e) In order to be assigned an IME provider number, an IME firm, partnership, corporation or other legal entity must have a medical director. The medical director must be a licensed provider and be responsible to provide oversight on the quality of independent medical examinations, impairment ratings and reports.

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     (1) American Board of Medical Specialties;

     (2) American Osteopathic Association (AOA) Bureau of Osteopathic Specialties;

     (3) American Podiatric Medical Association;

     (4) American Dental Association.

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     (1) Complaints about the provider;

     (2) Quality of reports;

     (3) Timeliness of reports;

     (4) Charges regarding any crime, gross misdemeanor, felony or violation of statutes or rules by any administrative agency, court or board;

     (5) Convictions of any crime, gross misdemeanor, felony or violation of statutes or rules by any administrative agency, court or board.

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     (1) Changes in time spent in direct patient care;

     (2) Loss or restriction of hospital admitting or practice privileges;

     (3) Changes affecting business requirements (WAC 296-23-317);

     (4) Loss of board certification;

     (5) Charges regarding any crime, gross misdemeanor, felony or violation of statutes or rules by any administrative agency, court or board;

     (6) Convictions of any crime, gross misdemeanor, felony or violation of statutes or rules by any administrative agency, court or board;

     (7) Temporary or permanent probation, suspension, revocation, or limitation placed on their license to practice by any court, board, or administrative agency in any state or foreign jurisdiction.

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     (1) Complaints about the provider;

     (2) Disciplinary proceedings or actions;

     (3) Proceedings in any court dealing with the provider's professional conduct, quality of care and criminal actions;

     (4) Ability to effectively convey and substantiate medical opinions and conclusions concerning workers;

     (5) Untimely reports;

     (6) Substandard quality of reports or failure to comply with current department policy on report contents;

     (7) Unavailability or lack of willingness to responsibly communicate with the department or self-insurer;

     (8) Unavailability or lack of willingness to testify on behalf of the department or self-insurer, worker, or employer;

     (9) Failure to stay current in the area of specialty and in the areas of impairment rating, performance of IMEs, industrial injury and occupational disease/illness, industrial insurance statutes, regulations and policies;

     (10) Failure to continue to maintain the criteria to be an IME provider;

     (11) Misrepresentation of information provided to the department;

     (12) Failure to inform the department of changes affecting the provider's status as an IME provider;

     (13) Failure to comply with the department's orders, statutes, rules, or policies; and

     (14) Failure to accept the department fee schedule rate for testimony or independent medical examinations.

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     (a) Be familiar with the contents of the medical examiner's handbook;

     (b) Review all claim documents provided by the department or self-insured employer;

     (c) Contact the worker prior to the examination to confirm the appointment date, time and location; and

     (d) Review the purpose of the examination and the questions to be answered in the examination report.

     (2) The IME provider's responsibilities during the examination are to:

     (a) Introduce himself or herself to the worker;

     (b) Verify the identity of the worker;

     (c) Let the worker know that the claim documents from the department or self-insurer have been reviewed;

     (d) Explain the examination process and answer the worker's questions about the examination process;

     (e) Advise the worker that he/she should not perform any activities beyond their physical capabilities;

     (f) Allow the worker to remain fully dressed while taking the history;

     (g) Ensure adequate draping and privacy if the worker needs to remove clothing for the examination;

     (h) Refrain from expressing personal opinions about the worker, the employer, the attending doctor, or the care the worker has received;

     (i) Conduct an examination that is unbiased, sound and sufficient to achieve the purpose and reason the examination was requested;

     (j) Conduct the examination with dignity and respect for the worker;

     (k) Ask if there is any further information the worker would like to provide; and

     (l) Close the examination by telling the worker that the examination is over.

     (3) The IME provider's responsibilities following the examination are to:

     (a) Send a complete IME report to the department or self-insurer within fourteen calendar days of the examination date, or within fourteen calendar days of receipt of the results of any special tests or studies requested as a part of the examination. Reports received after fourteen calendar days may be paid at a lower rate per the fee schedule. The report must meet the requirements of WAC 296-23-382; and

     (b) The claim file information received from the department or self-insurer should be disposed of in a manner used for similar health records containing private information after completion of the IME or any follow-up test results are received. IME reports should be retained per WAC 296-20-02005.

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     (2) The accompanying person cannot be compensated for attending the examination by anyone in any manner.

     (3) The worker may not bring an interpreter to the examination. If interpretive services are needed, the department or self-insurer will provide an interpreter.

     (4) The purpose of the IME is to provide information to assist in the determination of the level of any permanent impairment not to conduct an adversarial procedure. Therefore, the accompanying person cannot be:

     (a) The worker's attorney, paralegal, any other legal representative, or any other personnel employed by the worker's attorney or legal representative; or

     (b) The worker's attending doctor, any other provider involved in the worker's care, or any other personnel employed by the attending doctor or other provider involved in the worker's care.

     The department may designate other conditions under which the accompanying person is allowed to be present during the IME.

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     (1) If, after reviewing the records, taking a history from the worker and performing the examination, the IME provider concurs with the attending doctor's determination of MMI, the impairment rating report must, at a minimum, contain the following:

     (a) A statement of concurrence with the attending doctor's determination of MMI;

     (b) Pertinent details of the physical or psychiatric examination performed (both positive and negative findings);

     (c) Results of any pertinent diagnostic tests performed (both positive and negative findings). Include copies of pertinent tests with the report;

     (d) An impairment rating consistent with the findings and a statement of the system on which the rating was based (for example, the AMA Guides to the Evaluation of Permanent Impairment and edition used, or the Washington state category rating system - refer to WAC 296-20-19000 through 296-20-19030 and WAC 296-20-200 through 296-20-690); and

     (e) The rationale for the rating, supported by specific references to the clinical findings, especially objective findings and supporting documentation including the specific rating system, tables, figures and page numbers on which the rating was based.

     (2) If, after review of the records, a history from the worker and the examination, the IME provider does not concur with the attending doctor's determination of MMI, an IME report must be completed. (See WAC 296-23-382.)

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Overview of Systems for Rating Impairment

Rating System	Used for These Conditions	Form of the Rating
RCW 51.32.080	Specified disabilities: Loss by amputation, total loss of vision or hearing	Supply the level of amputation
AMA Guides to the Evaluation of Permanent Impairment	Loss of function of extremities, partial loss of vision or hearing	Determine the percentage of loss of function, as compared to amputation value listed in RCW 51.32.080
Category Rating System	Spine, neurologic system, mental health, respiratory, taste and smell, speech, skin, or disorders affecting other internal organs	Select the category that most accurately indicates overall impairment
Total Bodily Impairment (TBI)	Impairments not addressed by any of the rating systems above, and claims prior to 1971	Supply the percentage of TBI

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     (a) Contain objective, sound and sufficient medical information;

     (b) Document the review of the claim documents provided by the department or self-insurer;

     (c) Document the worker's history and the clinical findings;

     (d) Answer all the written questions posed by the department or self-insurer or include a description of what would be needed to address the questions;

     (e) Include objective conclusions and recommendations supported by underlying rationale that links the medical history and clinical findings;

     (f) Be in compliance with current department reporting policies; and

     (g) Be signed by the IME provider performing the examination.

     (2) An impairment rating report may be requested as a component of an IME. Impairment rating reports are to be done as specified in WAC 296-20-200 and 296-20-2010 (2)(a) through (e) and 296-23-377.

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     The following sections of the Washington Administrative Code are repealed:

WAC 296-23-255	Independent medical examinations.
WAC 296-23-260	Examination reports.
WAC 296-23-265	Who may perform independent medical examinations?
WAC 296-23-26501	How do doctors become approved examiners?
WAC 296-23-26502	Where can doctors get an application to become an approved examiner and other information about independent medical examinations?
WAC 296-23-26503	What factors does the medical director consider in approving, suspending or removing doctors from the approved examiners list?
WAC 296-23-26504	What happens if an examiner is suspended or removed from the approved examiner list by the medical director?
WAC 296-23-26505	Is there a fee schedule for independent medical examinations?
WAC 296-23-26506	Can a worker file a complaint about an independent medical examiner's conduct?
WAC 296-23-267	When may attending doctors perform impairment rating examinations?
WAC 296-23-270	Independent medical examinations two or more examiners.

© Washington State Code Reviser's Office