| (a) Authorized Doctor.
(1) Only an authorized doctor may certify maximum medical
improvement (MMI), determine whether there is permanent impairment,
and assign an impairment rating if there is permanent impairment.
(A) Doctors serving in the following roles may be authorized
as provided in subsection (a)(1)(B) of this section.
(i) the treating doctor (or a doctor to whom the treating
doctor has referred the injured employee for evaluation of MMI and/or
permanent whole body impairment in the place of the treating doctor,
in which case the treating doctor is not authorized);
(ii) a designated doctor; or
(iii) a required medical examination (RME) doctor selected
by the insurance carrier and approved by the division to evaluate
MMI and/or permanent whole body impairment after a designated doctor
has performed such an evaluation.
(B) Prior to September 1, 2003 a doctor serving in
one of the roles described in subsection (a)(1)(A) of this subsection
is authorized to determine whether an injured employee has permanent
impairment, assign an impairment rating, and certify MMI. On or after
September 1, 2003, a doctor serving in one of the roles described
in subsection (a)(1)(A) of this section is authorized as follows:
(i) a doctor whom the division has certified to assign
impairment ratings or otherwise given specific permission by exception
to, is authorized to determine whether an injured employee has permanent
impairment, assign an impairment rating, and certify MMI; and
(ii) a doctor whom the division has not certified to
assign impairment ratings or otherwise given specific permission by
exception to is only authorized to determine whether an injured employee
has permanent impairment and, in the event that the injured employee
has no impairment, certify MMI.
(2) Doctors who are not authorized shall not make findings
of permanent impairment, certify MMI, or assign impairment ratings
and shall not be reimbursed for the examination, certification, or
report if one does so. A certification of MMI, finding of permanent
impairment, and/or impairment rating assigned by an unauthorized doctor
are invalid. If a treating doctor finds that the injured employee
has permanent impairment but is not authorized to assign an impairment
rating, the doctor is also not authorized to certify MMI and shall
refer the injured employee to a doctor who is so authorized.
(3) A doctor who is authorized under this subsection
to certify MMI, determine whether permanent impairment exists, and
assign an impairment rating and who does, shall be referred to as
the "certifying doctor."
(b) Certification of Maximum Medical Improvement.
(1) Maximum medical improvement (MMI) is:
(A) the earliest date after which, based on reasonable
medical probability, further material recovery from or lasting improvement
to an injury can no longer reasonably be anticipated;
(B) the expiration of 104 weeks from the date on which
income benefits begin to accrue; or
(C) the date determined as provided by Texas Labor
Code §408.104.
(2) MMI must be certified before an impairment rating
is assigned and the impairment rating must be assigned for the injured
employee's condition on the date of MMI. An impairment rating is invalid
if it is based on the injured employee's condition on a date that
is not the MMI date. An impairment rating and the corresponding MMI
date must be included in the Report of Medical Evaluation to be valid.
(3) Certification of MMI is a finding made by an authorized
doctor that an injured employee has reached MMI as defined in subsection
(b)(1) of this section.
(4) To certify MMI the certifying doctor shall:
(A) review medical records;
(B) perform a complete medical examination of the injured
employee for the explicit purpose of determining MMI (certifying examination);
(C) assign a specific date at which MMI was reached.
(i) The date of MMI may not be prospective or conditional.
(ii) The date of MMI may be retrospective to the date
of the certifying exam.
(D) Complete and submit required reports and documentation.
(c) Assignment of Impairment Rating.
(1) An impairment rating is the percentage of permanent
impairment of the whole body resulting from the current compensable
injury. A zero percent impairment may be a valid rating.
(2) A doctor who certifies that an injured employee
has reached MMI shall assign an impairment rating for the current
compensable injury using the rating criteria contained in the appropriate
edition of the AMA Guides to the Evaluation of Permanent Impairment,
published by the American Medical Association (AMA Guides).
(A) The appropriate edition of the AMA Guides to use
for all certifying examinations conducted before October 15, 2001
is the third edition, second printing, dated February, 1989.
(B) The appropriate edition of the AMA Guides to use
for certifying examinations conducted on or after October 15, 2001
is:
(i) the fourth edition of the AMA Guides (1st, 2nd,
3rd, or 4th printing, including corrections and changes as issued
by the AMA prior to May 16, 2000). If a subsequent printing(s) of
the fourth edition of the AMA Guides occurs, and it contains no substantive
changes from the previous printing, the division by vote at a public
meeting may authorize the use of the subsequent printing(s); or
(ii) the third edition, second printing, dated February,
1989 if, at the time of the certifying examination, there is a certification
of MMI by a doctor pursuant to subsection (b) of this section made
prior to October 15, 2001 which has not been previously withdrawn
through agreement of the parties or previously overturned by a final
decision.
(C) This subsection shall be implemented to ensure
that in the event of an impairment rating dispute, only ratings using
the appropriate edition of the AMA Guides shall be considered. Impairment
ratings assigned using the wrong edition of the AMA Guides shall not
be considered valid.
(3) Assignment of an impairment rating for the current
compensable injury shall be based on the injured employee's condition
on the MMI date considering the medical record and the certifying
examination. An impairment rating is invalid if it is based on the
injured employee's condition on a date that is not the MMI date. An
impairment rating and the corresponding MMI date must be included
in the Report of Medical Evaluation to be valid. The doctor assigning
the impairment rating shall:
(A) identify objective clinical or laboratory findings
of permanent impairment for the current compensable injury;
(B) document specific laboratory or clinical findings
of an impairment;
(C) analyze specific clinical and laboratory findings
of an impairment;
(D) compare the results of the analysis with the impairment
criteria and provide the following:
(i) A description and explanation of specific clinical
findings related to each impairment, including zero percent (0%) impairment
ratings; and
(ii) A description of how the findings relate to and
compare with the criteria described in the applicable chapter of the
AMA Guides. The doctor's inability to obtain required measurements
must be explained.
(E) assign one whole body impairment rating for the
current compensable injury;
(F) be responsible for referring the injured employee
to another doctor or health care provider for testing, or evaluation,
if additional medical information is required. The certifying doctor
is responsible for incorporating all additional information obtained
into the report required by this rule:
(i) Additional information must be documented and incorporated
into the impairment rating and acknowledged in the required report.
(ii) If the additional information is not consistent
with the clinical findings of the certifying doctor, then the documentation
must clearly explain why the information is not being used as part
of the impairment rating.
(4) After September 1, 2003, if range of motion, sensory,
and strength testing required by the AMA Guides is not performed by
the certifying doctor, the testing shall be performed by a health
care practitioner, who within the two years prior to the date the
injured employee is evaluated, has had the impairment rating training
module required by §180.23 (relating to Division Required Training
for Doctors) for a doctor to be certified to assign impairment ratings.
It is the responsibility of the certifying doctor to ensure the requirements
of this subsection are complied with.
Cont'd... |
