Board Bulletins and Subject Numbers

May 16, 2018

The Board adopted new Permanent Impairment Guidelines for Schedule Loss of Use Evaluations (see Subject Number 046-1011, issued December 28, 2017) effective January 1, 2018. The 2018 Guidelines clarify how to evaluate permanent impairment when maximum medical improvement is reached. This includes measuring active ranges of motion and comparing them to contralateral body parts where applicable.

To support the new Guidelines, the Board has revised the Doctor's Report of MMI/Permanent Impairment (Form C-4.3). Form C-4.3 now includes two attachments to better capture the outcomes of the medical evaluation of impairment and determination of permanency. If a patient has a permanent partial impairment, the medical provider should complete Attachment A for all body parts and conditions for which a schedule of loss of use award is appropriate, except for serious facial disfigurement, vision or hearing loss. The table in Attachment A allows the medical provider to easily complete the body part(s) or condition(s) involved in the Schedule Loss of Use evaluation.

Attachment B should be used for all body parts and conditions for which a non-schedule award (classification) is appropriate. Complete both Attachment A and B when evaluating a patient with injuries that involve both schedule and non-schedule body parts and/or conditions.

The provider should complete Attachment A and/or Attachment B for each body part and condition for which he/she treated the patient. A provider should use Form C-72.1 for Occupational Loss of Hearing or Form C-4.3 with an attached narrative for Traumatic Hearing Loss. For vision schedule loss of use, attach a medical narrative to Form C-4.3, or submit an Attending Ophthalmologist's Report (Form C-5). For Serious Facial Disfigurement, Form C-4.3 with an attached narrative should be submitted.

Changes have also been made to the following Independent Medical Examination Reports:

• Independent Examiner's Report of Independent Medical Examination (Form IME-4) has been modified to capture information on the duration of the exam and medical documentation review.
• Claimant's Notice of Independent Medical Examination (Form IME-5) has been changed to capture the IME entity that is scheduling the exam.

Finally, two new Independent Medical Examination Report forms are available on the Board’s website. The new forms include:

• Attachment for Report of Independent Medical Examination Scheduled Loss of Use (Form IME-4.3A)
• Attachment for Report of Independent Medical Examination Non-Scheduled Permanent Partial Disability (Form IME-4.3B)

The IME evaluator must fill out the IME-4 cover sheet, along with the appropriate listed attachments for either Schedule Loss of Use and/or Non-Schedule Permanent Partial Disability. The IME evaluator should also provide a narrative report. All three elements (Form IME-4, with attachments, and narrative) are required for a complete IME report.

The IME evaluator should evaluate all body part(s) and condition(s) involved. If there are injuries to both schedule body parts and non-schedule body parts, assessment as to the permanency should be provided in the narrative.

The updated paper versions of the revised forms (dated 5-18) are available on the Board’s website, and must be used effective immediately for new cases. The version date is located on the bottom left corner of the form. The Board will accept paper versions of the previous Form C-4.3 (dated 10-15) on cases with a medical prior to May 16, 2018. The electronic version of the form (Form EC-4.3) will be updated in the near future, and until then the current version will be accepted by the Board.

Training on the new 2018 SLU Guidelines is available. The Board will be hosting webinars on May 16th and May 23rd. Please check the Board's website for registration information on the webinars: Schedule Loss of Use Informational Webinars.Schedule Loss of Use Informational Webinars. A recorded version of the webinar will be available on the Board’s website.