W. Va. Code R. agency 85, tit. 85, ser. 85-20, app 3
Balancing means maintaining body equilibrium to prevent falling when walking, standing, crouching, or running on narrow, slippery, or erratically moving surfaces; or maintaining body equilibrium when performing gymnastic feats.
Stooping means bending the body downward and forward by bending spine at the waist, requiring full use of the lower extremities and back muscles.
Kneeling means bending the legs at knees to come to rest on knee or knees.
Crouching means bending the body downward and forward by bending legs and spine.
Crawling means moving about on hands and knees or hands and feet.
Reaching means extending hand(s) and arm(s) in any direction.
Handling means seizing, holding, grasping, turning, or otherwise working with hand or hands. Fingers are involved only to the extent that they are an extension of the hand, such as to turn a switch or shift automobile gears.
Fingering means picking, pinching, or otherwise working primarily with fingers rather than with the whole hand or arm as in handling.
Feeling means perceiving attributes of objects, such as size, shape, temperature, or texture, by touching with skin, particularly that of fingertips.
EXHIBIT A
PSYCHIATRIC DIAGNOSES (WITH CORRESPONDING INTERNATIONAL CLASSIFICATION OF DISEASES, NINTH REVISION CODES) NOT CONTRIBUTED TO BY A WORK-RELATED INJURY
THE ONSET OF THE FOLLOWING DIAGNOSES ARE, BY DEFINITION, NOT SIGNIFICANTLY CONTRIBUTED TO BY A WORK-RELATED INJURY UNLESS THE DISORDER ENDS IN THE PHRASE "DUE TO A GENERAL MEDICAL CONDITION" WHERE THE GENERAL MEDICAL CONDITION IS CAUSED BY THE WORK RELATED INJURY. ALTHOUGH THESE DIAGNOSES MAY BE PRESENT IN AN INDIVIDUAL AND THESE DIAGNOSES SHOULD BE CONSIDERED IN APPORTIONMENT, UNLESS SPECIFICALLY EXCEPTED IN WRITING, THESE DIAGNOSES SHOULD NOT RECEIVE AN IMPAIRMENT RATING.
Disorders Usually First Diagnosed in Infancy, Childhood, or Adolescence
Mental Retardation (317, 318.x, 319)
Learning Disorders (315.x, 315.xx)
Motor Skills Disorder (315.4)
Communication Disorders (315.xx, 307.x)
Pervasive Development Disorders (299.x, 299.xx)
Attention-Deficit and Disruptive Behavior Disorders (314.xx, 314.9)
Feeding and Eating Disorders of Infancy or Early Childhood (307.xx)
Tic Disorders (307.xx)
Elimination Disorders (307.x, 787.6)
Other Disorders of Infancy, Childhood, or Adolescence (309.21, 313.89, 307.3, 313.9)
Delirium, Dementia, and Amnestic and Other Cognitive Disorders
All (except for Cognitive Disorder, NOS) (294.xx, 290.xx, 294.1, 294.8, 293.89)
Substance-Related Disorders
All (303.xx, 291.x, 291.xx, 304.xx, 305.x, 305.xx, 292.xx, 292.x)
Schizophrenia and Other Psychotic Disorders
All (295.xx, 297.x, 298.x, 293.xx)
Mood Disorders
All Bipolar Disorders (296.0x, 296.4x, 296.5x, 296.6x, 296.7, 296.89, 296.80, 296.90)
Cyclothymic Disorder (301.13)
Anxiety Disorders
Social Phobia (300.23)
Obsessive-Compulsive Disorder (300.3)
Generalized Anxiety Disorder (300.02)
Somatoform Disorders
All (300.8x, 300.11, 307.xx, 300.7, 300.82) (except Pain Disorder)
Factitious Disorders
All (300.16, 300.19)
Dissociative Disorders
All (300.12, 300.13, 300.14, 300.6, 300.15) (except Dissociative Disorder, NOS)
Sexual and Gender Identity Disorders
All (302.7x, 306.51, 302.4, 302.8x, 302.2, 302.3, 302.9, 302.6, 302.85, 302.6, 302.9)
Eating Disorders
All (307.1, 307.51, 307.50)
Sleep Disorders
All (307.4x, 347, 780.59)
Impulse-Control Disorders Not Elsewhere Classified
All (312.3x)
Personality Disorders
All (301.x, 301.xx)
Other Conditions That May Be A Focus Of Clinical Attention (316, All "V" Codes, 780.9, 313.82, 300.9, 799.9)
EXHIBIT B
WEST VIRGINIA WORKERS' COMPENSATION DIVISION
Impairment Guideline for RATING Psychiatric Impairment
Exhibit B shall be used to determine a claimant's psychiatric impairment rating using the classification consistent with the AMA Guides to the Evaluation of Permanent Impairment, Fifth Edition, in conjunction with the Axis V Global Assessment of Functioning Scale (GAF, DSM-IV-TR 2000, page 34), the claimant's treatment needs, and functional status. Axis V refers only to psychological, occupational, and social functioning and the examiner must NOT include impairment in functioning as a result physical limitations in the formulation of the GAF (GAF, DSM-IV-TR 2000).
Disorders believed to have resulted from brain injury, such as cognitive disorders, should NOT be rated using this guideline, but should be evaluated according to relevant sections of Chapter 4 of the AMA Guides to the Evaluation of Permanent Impairment, Fourth Edition.
The diagnoses of Pain Disorder and Dissociative Disorder, NOS, while important in the presentation and treatment of the underlying physical condition, should not receive an impairment rating.
The impairment percentage may only be determined after the claimant has reached maximum medical improvement. Rows 1-5 should guide the examiner to an impairment classification in row 6 with the corresponding whole person impairment percentage range in row 7. Within each class, the examiner must justify the specific choice of rating along the range based on information in rows 1-5 to formulate an overall impairment rating. This rating should then be apportioned to account for pre-existing or non work-related contributors as noted in the Guideline for Psychiatric Independent Medical Examination - Report Online (Exhibit C).
| 1. GAF | 2. Symptom Severity | 3. Level of Functioning | 4. Treatment Needs | 5. ADLs, Social Functioning, Concentration, Adaptation | 6. Impairment Classification | 7. Whole person impairment |
| 100-91 | No symptoms. | Superior functioning in a wide range of activities, life's problems never seem to get out of hand, is sought out by others because of his or her many positive qualities. | None or infrequent outpatient treatment | No Impairment | Class 1: No Impairment | 0% |
| 90-81 | Absent or minimal symptoms (e.g., mild anxiety before an exam). Generally satisfied with life, no more than everyday problems or concerns (e.g., an occasional argument with family members). | Good functioning in all areas, interested and involved in a wide range of activities, socially effective. | None or infrequent outpatient treatment | No Impairment | Class 1: No Impairment | 0% |
| 80-71 | If symptoms are present, they are transient and expectable reactions to psychosocial stressors (e.g., difficulty concentrating after family argument). | No more than slight impairment in social or occupational functioning (e.g., temporarily falling behind in work). | None or infrequent outpatient treatment | No Impairment | Class 1: No Impairment | 0% |
| 70-61 | Some mild symptoms (e.g., depressed mood and mild insomnia). -OR- | Impairment levels are compatible with most useful functioning. Some difficulty in social or occupational functioning (e.g., occasional absences or theft within the household), but generally functioning pretty well, has some meaningful interpersonal relationships. | None or infrequent outpatient treatment | Impairment levels are compatible with most useful functioning | Class 2: Minimal Impairment | 0-5% |
| 60-51 | Moderate symptoms (e.g., flat affect and circumstantial speech, occasional panic attacks) -OR- | Impairment levels are compatible with some, but not all, useful functioning. Moderate difficulty in social or occupational functioning (e.g., few friends, conflicts with co-workers). | Continuous outpatient treatment | Impairment levels are compatible with some, but not all, useful functioning | Class 3: Mild Impairment | 6-14% |
| 50-41 | Serious symptoms (e.g., suicidal ideation, severe obsessional rituals, frequent shoplifting). -OR- | Impairment levels significantly impede useful functioning. Requires direction and supervision in the performance of ADL's. Any serious impairment in social or occupational functioning (e.g., no friends, unable to keep a job). | Intensive outpatient treatment, day hospital, occasional to frequent inpatient hospitalization. | Impairment levels significantly impede useful functioning | Class 4: Moderate Impairment | 15-29% |
| 40-31 | Some impairment in reality testing or communication (e.g., speech is at times illogical, obscure, or irrelevant). -OR- | Major impairment in several areas, such as work, family relations, judgment, thinking, or mood (e.g., depressed man avoids friends, neglects family and is unable to work). | Intensive outpatient treatment, day hospital, occasional to frequent inpatient hospitalization. | Impairment levels significantly impede useful functioning | Class 4: Moderate Impairment | 15-29% |
| 30-21 | Behavior is considerably influenced by delusions or hallucinations - OR - serious impairment in communication or judgment (e.g., sometimes incoherent, acts grossly inappropriately, suicidal preoccupation) | Inability to function in almost all areas (e.g., stays in bed all day, no job, home or friends). | Permanently in assisted living to complete institutionalization | Impairment levels preclude useful functioning | Class 5a: Severe Impairment | 30-49% |
| 20-11 | Some danger of hurting self or others (e.g., suicide attempts without clear expectation of death; frequently violent; manic excitement) -OR- Gross impairment in communication (e.g., largely incoherent or mute) | Occasionally fails to maintain minimal personal hygiene (e.g., smears feces). | Permanently in assisted living to complete institutionalization | Impairment levels preclude useful functioning | Class 5b: Very Severe Impairment | 50-70% |
| 10-0 | Persistent danger of severely hurting self or others (e.g., recurrent violence) -OR- serious suicidal act with clear expectation of death. | Persistent inability to maintain minimal personal hygiene. | Permanently in assisted living to complete institutionalization | Impairment levels preclude useful functioning | Class 5b: Very Severe Impairment | 50-70% |
EXHIBIT C
WEST VIRGINIA WORKERS' COMPENSATION COMMISSION
GUIDELINE FOR PSYCHIATRIC INDEPENDENT MEDICAL EXAMINATION -
REPORT OUTLINE
The following is an outline of the standard psychiatric independent medical examination report. The bolded items should be addressed in every report to ensure consistency. Although there is no substitute for quality clinical assessment, the areas subsumed under each bolded section should also be addressed when possible. Note that each area allows for both subjective and objective data, therefore attention to the application of data to Workers' Compensation issues should be emphasized. The italicized language represents commentary to aid in clarification of the outline.
I Identifying Data
Claimant Name:
Social Security Number:
Date of Birth:
Claim Number(s):
Date of Injury:
Date of Interview:
Date of Report:
II Consent
Be sure to include a statement about the following:
the nature and purpose of the examination,
that the examiner is a psychiatrist,
that the examination is for the purpose of WV Workers' Compensation Division,
that there is an inherent lack of confidentiality,
that a written report will be issued to the WV Workers' Compensation Division,
that the examiner may be asked to provide information in court or directly to the WV Workers' Compensation Division that the examiner will not be treating the claimant, but may express management recommendations that may influence their care indirectly, and that no physician-patient relationship will be established.
III Chief Complaint
IV History of Present Illness
A. Injury
Provide the claimant's account of the injurious event. Include the following:
1. Employer name
2. Position or job title
3. Duties and responsibilities, including supervisory duties
4. Whether injury occurred in the usual course of employment
5. Whether claimant was working at an outside position (that is, not with the employer) or was self employed
6. Events leading up to injury
7. Events of injury including:
a. How injury occurred b. Whether others were injured c. Whether there were any witnesses to injury
8. Events following injury, including:
a. When medical care was sought b. Where medical care was sought c. Means of arriving to medical care
9. Whether, at time of interview, physical symptoms are worse, better, or same since injury.
B. Psychiatric Information
For each diagnosis, include the following information:
A. Name of diagnosis with modifiers, specifiers, remission status and subtypes as per the most recent edition of the Diagnostic and Statistical Manual of Disorders of the American Psychiatric Association
B. Criterion-based support for the diagnosis
C. Associated support for diagnosis including:
1. Non-criteria signs and symptoms
2. Diagnoses made by other clinicians that support the current diagnosis.
D. Onset date of diagnosis when minimal criteria were met (estimate if necessary)
E. Course of diagnosis since onset to time of interview
F. Severity of diagnosis around time of interview (mild, moderate, severe)
G. Past management, with outcomes including:
1. Medications or other biological treatment with doses and duration
2. Psychological treatments
3. Social treatments
4. Compliance with management
H. Whether symptoms of diagnosis impair ability to work, If so, describe how.
I. Describe any past psychiatry history not otherwise accounted for by all above diagnoses, include:
1 Impatient treatment
2. Outpatient treatment
3. Consultations
4. Marital/family/pastoral counseling
5. AA/NA/rehab/detox
6. Psychotropic meds
V. Personal and Social History
A. Social Information
1. Residence history
2. Marriage history
3. Stressors history - note all pertinent stressors that have occurred since injury
4. "Pursuit of everyday living" history
1. Report life circumstances, activities, hobbies and interests prior to injury
2. Report if any life circumstances, activities, hobbies or interests have been affected by the psychiatric diagnoses above
B. Education Information
C. Employment Information
1. List all prior positions, including duration
2. Discuss if claimant has been terminated from any job
3. Discuss if claimant has been laid-off from any job
4. Discuss if claimant has entered resignations under duress
5. Discuss if claimant has received any written reprimands
6. If in military service, report if claimant has received any Article 15's, and what type of discharge claimant received
D. Legal Information
Include:
1. Criminal history, charges, incarceration
2. Non-Workers' Compensation civil litigation
3. Prior Workers' Compensation claims
VI. Review of Systems
1. Provide a review of the claimant's general organ and neurological systems.
VII. Past Medical History
A. List documented diagnoses
B. List claimant-reported diagnoses
C. List past surgeries
D. Discuss any head injuries
E. Discuss any seizure history
F. Report signs and symptoms at time of interview
G. List past psychoactive medications and analgesics, if not already reported
H. List current medications
VIII Family Medical and Family Psychiatric History
IX Mental Status Exam
X Summary of Other Sources of Information
Include pertinent psychiatric information from the following sources:
A. Documents
B. Other interviews (for example, of spouse, coworkers or other clinicians)
C. Psychological testing
D. Data
E. Other
XI Psychiatric Diagnostic List
Provide psychiatric diagnoses at the time of the interview
XII Opinions
For each of the following areas, report only those opinions held with reasonable medical certainty and support with an explanation.
A. Diagnoses
Offer a statement that each of the above psychiatric diagnoses (in Section XI) is present with reasonable medical certainty.
For each separate diagnosis in A, report information in areas B-F.
B. Maximum medical improvement
For each diagnosis, report whether the claimant has reached maximum medical improvement for that specific diagnosis. Support this opinion. If the claimant has been significantly noncompliant with management recommendations, then state that no opinion is offered with regard to that specific diagnosis about maximum medical improvement.
C. Disability
Report if the signs or symptoms of the specific diagnosis alone render the person disabled for the purposes of working in the same or similar position as was held at the time of the injury. If disabled, support this opinion discussing how each sign or symptom impairs work efficiency and the ability to be employed. If the claimant has not reached maximum medical improvement for this specific diagnosis, but is disabled, estimate the time to recovery for maximum medical improvement.
D. Impact on Pursuit of Everyday Living
Offer an opinion, for each specific diagnosis, about how that diagnosis and its symptoms affect the claimant's pursuit of everyday living. Support this opinion with a discussion of the claimant's pre-and post-injury life circumstances, activities, hobbies and interest. The opinion should distinguish between psychiatric and non-psychiatric reasons for changes in the claimant's pursuit of everyday living. Offer an estimate as to the degree of overall impact on pursuit of everyday living as mild, moderate or severe in intensity.
E. Causation and Appointment
For each specific diagnosis, offer an opinion with regard to the causation of that diagnosis. A statement of causation should relate the onset and presentation of the diagnosis to the work-related injury. The relationship between the injury and the diagnosis should be use one of the following phrases:
1. Sole precipitant (The injury is judged to be the only reasonable factor related to the onset and progression of the disorder).
2. Major contributor (The injury is judged to be a major factor with regard to the onset and progression of the disorder. The injury predated the onset of the disorder).
3. Moderate contributor (The injury is judged to be a moderate factor with regard to the onset and progression of the disorder. The injury predated the onset of the disorder).
4. Minor contributor (The injury is judged to be a minor factor with regard to the onset and progression of the disorder. The injury predated the onset of the disorder).
5. Major aggravant (The injury is judged to be a major factor in the progression of an already existing disorder. The injury postdated the onset of the disorder).
6. Moderate aggravant (The injury is judged to be a moderate factor in the progression of an already existing disorder. The injury postdated the onset of the disorder).
7. Minor aggravant (The injury is judged to be a minor factor in the progression of an already existing disorder. The injury postdated the onset of the disorder).
8. Unrelated or coincidental (The injury is not associated with the onset or progression of the disorder).
A discussion should include all other factors that are associated with the cause, onset and progression of the disorder in any situation except for when the injury is the sole precipitant. These non work-related factors should be carefully assessed. These non work-related factors should be considered to account for some percentage of the total effect on disability (work efficiency) and the pursuit of everyday living of the disorder. A statement of the percentage of total impairment as due to non work-related factors should be made apportionment percentage).
F. Impairment Rating
A statement that no impairment rating is offered should be made for an individual diagnosis if the diagnosis has not reached maximum medical improvement, or does not disable the claimant and there is no effect on the pursuit of everyday living.. In all other cases, an impairment rating to account for the combined effects on disability (work efficiency) and the effect on the pursuit of everyday living should be made. An unapportioned impairment rating of total impairment should follow the West Virginia Workers' Compensation Guidelines for Psychiatric Impairment (see Exhibit B). The unapportioned total impairment rating should then be apportioned for non work-related factors by a simple calculation to determine the percentage due to non work-related factors and those due to the work-related injury. The percentage calculated due to a work-related injury shall represent the final psychiatric impairment rating for the specific diagnosis.
G. Total Psychiatric Impairment Rating
A statement that combines the total final psychiatric impairment ratings for each diagnosis to conclude a single total psychiatric impairment rating should be made.
XIII Recommendations
A. Recommendations should be made for further evaluation to complete the independent medical examination.
B. Recommendations should be made for further management of the patient's psychiatric condition. These recommendations should be as specific as possible.
C. For diagnoses that have not reached maximum medical improvement, a recommendation to the Workers' Compensation Division for an estimated time at which a follow-up independent medical examination should be made.
XIV. Signature and Title
W. Va. Code R. agency 85, tit. 85, ser. 85-20, app 3