Value Drivers in Personal Injury by Jeffrey D. Bohn
How Doctors DocumentVALUE DRIVERS in Personal Injury Claims Today By: Jeffrey D. Bohn Esq. (all graphics used with permission Mark Blane, Esq.) San Francisco, San Jose, Walnut Creek, San Mateo, Carlsbad, Cupertino, Palo Alto, Oakland, Pleasant Hill, Sunyvale, Fresno, North Sacramento, South Sacramento TEL: 559-304-1549 Email: email@example.com www.jdbohnlaw.com
I. RISE OF THE COMPUTERS 70% of auto cases in the United States are evaluated using computer ―Claims Assessment Software‖ programs like: COLOSSUS CLAIMS OUTCOME ADVISOR INJURY CLAIMS EVALUATIONS DECISION POINT TEACH MYND AIM ICE InjuryIQ The list of companies using these programs include 16 of the Top 20 Auto Property & Casualty Insurers in the United States!
INFORMATION ON COLOSSUS FOR THIS LECTURE COMES FROM: Dissatisfied former claims adjusters; Defense Attorneys; Information leaked from Bad Faith Trials, Discovery, and Depositions on how COLOSSUS is used, tuned, and entered into analysis, etc.
II. THE “DAVINCI CODE” OF VALUE IN PI CLAIMS TODAY The Injuries (ICD-9 Codes) + Frequency/Intensity, & Duration of Treatment (CPT Codes, CPT Code interlay) + Frequency, & Duration of Complaints from Injuries + Duties Under Duress + Loss Enjoyment of Life + Economic Loss + Prognosis/Future Care + AMA 4th or 5th Edition Impairment by a M.D. or D.O.?
VALUE BEGINS WITH THE INJURY PROPERLY DOCUMENTED IN THE CHARTNOTESAS DOCTORS, YOU MUST DOCUMENT: ICD-9 CODES, with Descriptions of Injuries CPT CODE INTERLAY, documenting the modalities of medical care DURATION and COMPLAINTS of the Injuries
COLOSSUS ANALYSIS Uses 10,600 VALUE DRIVERS on EVERY PI claim! 600 are Injury Codes, and 10,000 are ―factors‖ (ER visit? TENS unit used? Surgery? D.C. care? M.D. care? Etc.) Begins with the ICD-9 Code and ends whether there is an AMA impairment.
COLOSSUS INSPECTS FIVE ELEMENTS IN A PI CLAIM1. Trauma (type of accident, property damage, etc.)2. Impairment (must be 4th or 5th Edition AMA)3. Disability (known as Duties under Duress)4. Loss of Enjoyment of Life5. Disfigurement (if any)
Insurance Companies Using COLOSSUS and Claims Assessment Software AIG Infinity (Great American) Allstate Metlife American Family Metropolitan CNA Nationwide State Farm CSAA Travelers/Aetna Chubb Truck Farmers USAA Grange Wausau Hartford Zenith
III. DOCUMENTING THE PATIENT UPON THEIR ARRIVAL Active Care vs. Passive Care What did the patient ACTIVELY do before seeing you? Is there a GAP in Medical Care? No problem, document active care in your chartnotes!
SOAP Notes Subjective/Objective findings, Assessment, and Plan Make daily SOAP notes complete legible understandable avoid the use of nonstandard shorthand; SOAP notes are one of the chief data sources for Colossus; Track Prognosis periodically (details on Prognosis later)
Another Typical Example of Chart NotesAnother Bad Example:
Good Example of Chart Notes Good Example (clear):
IV. ICD-9 CODE & CPT CODE INTERLAY ICD-9 Codes are the first to go into computer (use descriptions with codes) Followed by CPT Code Interlay Combined, they build the foundations of the PI Claim You MUST ICD-9 ALL INJURIES! Even if injury is NOT within your specialty
HIERARCHY OF INJURY VALUES Contusion Sprain/Strain? Sprain = ligament injury Strain = muscle injury Ligamentous Injury or Tear? Loss Motion Segment Integrity? Extensive Internal or External Fixation? Disc Bulging vs. Disc Herniation? Degloving Disfigurement?
Disc Bulge vs. Disc Herniation Under Colossus Colossus only recognizes ―Disc Bulge‖ or ―Disc Herniation‖ Bulges and Subluxation are downcoded to Sprain/Strain Severity of Bulge or Herniation should ALWAYS be accurately documented
Colossus Recognizes Three Physician Categories1. D.C. (Doctor of Chiropractic)2. M.D. (Medical Doctor)3. Medical Specialist (D.O. or D.O with specialty, Ortho, Neurologist, Neuro Surgeon, Psychologist, or Psychiatrist
MEDICAL FINDINGS UNDER COLOSSUS Radiculopathy: value is only given IF it is linked to complications of the injuries, i.e. separate injury finding; nerve damage; surgery, etc. Subluxation: only accepted by Colossus if diagnosed after 3 months post-injury! Why? It is a potentially huge value driver because there may be a finding of Loss Motion Segment Integrity!
Continued Medical Findings under Colossus Ambulance to ER: valued as a M.D. visit, UNLESS patient ADMITTED overnight; then it depends on how many days admitted, value increases If Hospitalized was ICU indicated? Anesthetic? Surgery: How many? Body part? Reduction open/closed? External/internal fixation? Any complications? Immobilization of some kind applied?
Continued Medical Findings under Colossus Therapy (PT, etc.): longer than 90 days? If so, definitely need a M.D. to support that Type Intense Duration Home traction, Bed Rest, TENS unit, Injections, MRI or CAT Scan, or Discogram, immobility, and hospitalization.
Continued Medical Findings under Colossus Medication: is viewed as therapy; Was it prescribed? Longer than 30 days? Dosage? More than one prescription? Two or more prescriptions? (then = intensive); D.C. or M.D. can document this!
Continued Medical Findings under Colossus Pain Level: Only valuable if part of a complication of injury; then pain value increases. Be careful to document your pain levels as complications of the injury. It is not good enough to merely document the pain level, relate it to a specific ICD-9 injury.
DOCUMENT ALL COMPLAINTS OF INJURIES FOR COLOSSUS Range of Motion Problems (this one is huge) Headaches (need duration, and frequency) Dizziness (usually experienced right after accident; also big; linked to visual disturbance; can be recognized as a form of Tinnitus) Anxiety (linked to depression; and sleep disturbance) Spasms (big but depends on type of injury) Radiating Pain (this one is huge on any extremity or Spine) TMJ (linked to sleep disturbance, and also recognized as a possible symptom of neck injuries)
DOCUMENT DURATION OF THECOMPLAINTS WITH DURATION OF CARE Duration in Colossus in known as the ―stabilization period.‖ Duration of the Complaints must be documented with the Duration of Care! Always ―bookend‖ medical care (D.C. or P.T.) with M.D. or D.O. Especially after 90 days of continued care Colossus will accept ANY duration period if justified and properly documented!
Duration of Care Treatment Period: Unlike other body parts, the neck and back require specific treatment dates. Weight assigned with a D.C. ―sandwiched‖ between a M.D. increases the longer the D.C. treats. The same affect is realized if the D.C. treatment is punctuated with a visit to a specialist.
Massage Therapy Treatment by LMT’s, and MT’s is inputted differently than either chiropractic or medical doctor visits. The indicators for duration of treatment for these providers are as follows: Short (less than 90 days); Short intensive Prolonged (longer than 90 days); Prolonged Regular
History of Treatments (VALUEDRIVERS) Required by Colossus Medication Home Traction Tens Unit Injections MRI Discogram Myleogram Immobilization Confined to bed Hospitalization
Treatments (Value Drivers) Medication: must be prescribed in the chartnotes. Duration short term or long term. Short term is less than 30 days. As expected, long term has a greater affect on value than short term. Home Traction: must be documented in the chartnotes that it is prescribed and the duration required. Prescription of a Tens Unit: must be documented in the chartnotes. It can be at home or provided in the office. Duration must be documented in the chartnotes.
Treatments (Value Drivers) Injections: must be described as to TYPE and NUMBER in the chartnotes. The number and type have an effect on value. MRI, Discogram, and Myleogram: must also be documented in the chartnotes. Each has an incremental affect on the value of the claim. Immobilization: must be documented in the records as well as the TYPE (Philadelphia collar, C-collar, Lumbar Support, etc.), and each one has a direct weighted impact on value. Duration is also important to value and must be documented in the chartnotes.
Treatments (Value Drivers) Confined to bed: must be documented in the records as well as duration. This has a substantial affect on the value of the claim. Hospitalization: is a very significantly weighted factor in the value of a claim.
V. PROGNOSIS DOCUMENTATION AT THE CONCLUSION OF CARE Document a Prognosis of the patient periodically. Every two or three weeks is ideal. Is the patient: GOOD? UNDETERMINED? POOR? GUARDED?
Prognosis Documentation at the Conclusion of Care (Continued)• Is the prognosis undetermined? Why? Is treatment concluded and no complaints remain? Are there on-going complaints, but no more treatment recommended? There should always be a ―yes‖ to this; range of motion; less headaches, but patient still has them, etc. Are there on-going complaints and additional treatment is recommended? A ―yes‖ to this = active care, but if you are a D.C., it must be validated by a M.D. Is prognosis guarded at this time?
Prognosis Documentation at the Conclusion of Care (Continued)A – UndeterminedB – No treatment recommended/no complaintsC – Complaints/no treatment recommendedD – Complaints/treatment recommendedE – Guarded
VI. PRIOR INJURY, OR SUBSEQUENT INJURY? Aggravation: prior injury, no symptoms, accident, then symptoms. Exacerbation: prior injury, symptoms, accident, then symptoms. Subsequent injury: document these carefully and use the above terms to properly document. These are the definitions the computers use!
VII. RELEASING THE PATIENTNever release a patient ―MMI reached‖ or ―MCIreached‖ (unless utilizing a permanentimpairment rating for a specific body part).WHY? It is a confusing medical documentationthat tends to harm the patient; particularly if thepatient still needs to do home stretchingexercises, or future medical needed.
Releasing the Patient (Continued)Keep your medical goal in mind: REMEMBER, your goal, as CHIROPRACTORS, and M.D.’s is to bring the patient to a point in their medical care, so they can start “participating in their own recovery.”Document this way in your Final Report!
VIII. FUTURE MEDICAL TREATMENT? HOW TO DOCUMENT THIS: TYPE: (whether it is more chiropractic, or home exercises, or both); FREQUENCY/INTENSITY: (how many times per month, week, or every two weeks, etc.); DURATION: (how long; 6 months, 1 year, 2 years, the computer will not give credit beyond 3 years); COST: (need your medical opinion based on community standards) and most important the: *Percentage of Probability: document as follows: 0-50% POSSIBLE (computer gives no credit, too speculative; just what a jury would do); 51-75% PROBABLE 76-100% DEFINITE*How likely the patient needs future medical care
IX. BIO-MECHANICS OF INJURY/PROPERTY DAMAGE On low initial property damage estimates, two more estimates from independent repair shops are always a good idea MIST Category (minor impact soft tissue): goal here is to take out of this category within 30 days
X. AMA PERMANENT IMPAIRMENT? HOW TO DOCUMENT THIS: Concerning the issue of impairment or disability, lamentably, Colossus will not give credence to reports from D.C.’s They must come from a M.D., or D.O. with Specialty. Ironically, the D.C.’s are the foundation of Medical Care for most injury claims, and their foundations help set up the eventual AMA impairment.
AMA Impairment (Continued)The BIGGEST VALUE DRIVER on a PIclaim (followed closely by the injuriesthemselves, i.e. ICD-9 Codes) is thePermanent Impairment Rating.However, it must be done with thefollowing FOUR CONSIDERATIONS:
Four Considerations for AMA Rating1. M.D. or D.O (if D.O., then preferably a D.O. with a specialty);2. Need it to be AMA, 4th or 5th Edition;3. Need body part that has impairment to be MMI (only time you document MMI in a PI Case!!);4. Needs to be at LEAST 2% WHOLE BODY impairment. Computer automatically assumes 2% AMA impairment on every case and is the first value driver to be deleted if not in settlement demand!
AMA Rating Not every case will have an impairment rating (about 75% will, and 25% will not because it is not warranted), but every case should be evaluated for one. Thus, it is in the patient’s best interest to have it documented if warranted and supported by the INJURY and BIO-MECHANICAL force of the impact. Is also an area where most attorneys fail documenting in their PI demands!
MAIN POINTS FOR AMA 5th EDITION IMPAIRMENT DOCUMENTATION: Objective of AMA Impairment: to provide a standardized method to assess permanent impairment and the impact of the permanent impairment on the ability to perform activities of daily living (ADL).
How Permanent Impairment differs from Disability: Disability: is how the impairment affects and changes the person’s ability to perform personal, social, or employment demands; Impairment: is a medical assessment; and Disability is a NON-medical assessment.
Head Injury Impairments which may be entered into Colossus are related to: Sight Hearing Equilibrium Air passage Mastication
VALUE DRIVERS Colossus Looks For in an AMA Impairment The body part or system impaired; The degree (amount) of impairment assigned by the M.D. (% whole person).
Colossus Needs Impairment to be: AMA (American Medical Association) derived; Medically documented; Permanent and Stationary for the patient. Also known as stable or static: stable: stopped receiving treatment static: time has elapsed since treatment stopped and the condition of the injury has not improved
Five Areas That Can Be Documented For AMA Impairment: Diagnostic Related Estimate (DRE) 80% of time used. Range of Motion (ROM) – range of motion on Spine or extremities; any restriction/impairment of one movement type will often affect another type of movement. Anklyosis – injury to the joint Amputation – loss of limb Diagnostic Based Estimate (DBE)
Five Questions for AMA Impairment Documentation: Is there an area of injury? Was it diagnosed by a D.C., M.D., or Specialist? Was treatment rendered? Was MMI reached as to injured area? Were Objectable Ratable Complaints or Findings under AMA guidelines found and documented?
Objectable Ratable Complaints, or Findings under AMA Guidelines: Ratable Examples for Spine: Loss of Range of Motion (ROM) ROM that stays in DRE is 5% which = muscle spasm Muscle Weakness Loss of Motion Segment Integrity (LMSI) Residual Muscle Spasm, trigger points, splinting to palpation Fracture Surgery (maybe ratable) Radiculopathy (maybe ratable) Need nerve study up to Category III rating, if resolved, then it is equivalent to muscle spasm.
Objectable Ratable Complaints, or Findings under AMA Guidelines: Ratable Examples for Extremities: Fusion Joint-space reduction Gait derangement Nerve damage Muscle weakness Loss of Range of Motion (ROM) ROM that stays in DRE is 5% which = muscle spasm
Other Ratable Factors, or Findings under AMA Guidelines: Disc Herniation Cord Impingement Spinal Stenosis Spondylolisthesis Gait problems Swelling/Spasm
For AMA Permanent Impairment rating purposes, the Musculoskeletal System is divided into 4 units: Spine Pelvis Upper Extremity (arm) Lower Extremity (leg)
AMA Documented Muscle Spasms Muscle Spasms: Huge Value Driver; also known as ―splinting,‖ trigger points, and myospasms Found by diagnostics or palpation Definitely Ratable Practice Tip: always check the paraspinals thru out Spine for spasm, and make it a habit to check the ―SCM’s‖ (Sternum Clavicle Mastoid) for trigger points—usually a ―Sign Post‖ of Acute Whiplash
Subluxation a.k.a. Segmental Joint Dysfunction under AMA If you diagnose this, look out for Loss Motion Segment Integrity (LMSI) Why? Because LMSI is a HUGE impairment rating for Cervical and Lumbar Spine 25% in cervical 20% in lumbar 0% in thoracic (protected by rib cage) This is why Flex/Ext. X-rays are always necessary for every legitimate whiplash injury! Every PI claim should ASSUME possible LMSI as a matter of practice!
Two Categories of Loss Motion Segment Integrity: Angulation: does the ―motion segment‖ move at angles greater than 11 degrees? (i.e., one vertebrae on top of another). If yes, LMSI diagnosis. Translation: does the ―motion segment‖ move forward/backward in slippage greater than 3.5 millimeters? (i.e., one vertebrae on top of another). If yes, LMSI diagnosis.
Tips on Measuring Ratable Factors for AMA Rating: Perform measurements in threes • take average. Check Range of Motion Measure length on injured body part Assess Muscle Atrophy Conduct Manual Muscle Testing Examine gait derangement Test peripheral nerve injury
Tips on Measuring Ratable Factors for AMA Rating:Inclinometer – erroneous if not used in an exact level position; position for Lumbar Spine at T12/S1 for accurate measurement.Digitization of X-rays always a good practice (less than 2% margin of error)Read X-rays for possible LMSITake Flex/Ext. X-rays, the ―Davis 7 Series‖
AMA Rating Values in General: 0% = $0.00 5% = $5,600.00 10% = $11,050.00 13% = 12,050.00 20% = 29,150.00 28% = $30,550.00*Values vary depending on all value drivers used on aclaim; each case is so unique it is like a thumbprint.
Pre-existing Impairment and New Impairment?Colossus will evaluate the differencebetween pre-existing impairment and thecurrent impairment percent
Future Impairment?Colossus does not consider futuretreatment in its assessment that couldcause impairment; too speculative.
Duties Under Duress VALUE DRIVERS DUD: Documenting the difficulty and the reason for the difficulty in performing the duties is all that is needed. Examples include: household duties domestic responsibilities job duties These should be documented in your chartnotes.
Loss of Enjoyment of Life VALUE DRIVERS LEOL: Is considered a permanent loss. The loss of enjoyment of life valuation screens appears in a Colossus consultation only in cases of impairment and only after a certain threshold is passed. Examples include loss of enjoyment of: Domestic duties Household duties Hobbies Sports Work
Real World Settlement Amounts Utilizing VALUE DRIVERS: Defendant Insurance Company: State Farm Medical Specials: $8,500.00 Wage Loss: $0.00 (Student) Injuries: Soft Tissue Property Damage: $8,200.00 Gap in Care: 2.5 Month Gap in care (gap documented), just one ER visit then began D.C. visits; Chiropractic Care term was 3-4 months; M.D. ―bookended‖ D.C. care MRI of left Shoulder; Finding: completely normal! M.D. explanation: can still have nerve irritation in whiplash injury, or trauma/injury without compression, and still entitled to best diagnostic tool on the market to rule out nerve impingement. Injections: 1 steroid injection AMA Impairment 5th Edition: 7% WPI, cervical spine, by M.D.Settlement: $30,000.00
Real World Settlement Amounts Utilizing VALUE DRIVERS: Defendant Insurance Company: Progressive Medical Specials: $11,000.00 Wage Loss: $2,000.00 Injuries: Soft Tissue with Disc protrusion, and bulge with a positive MRI finding Property Damage: $15,680.00 No Gap in Care, but patient treated with 2 chiropractors; 1 for the 1st 3-4 months, then a 1.5 month gap, and then continued with another chiropractor for 3 more months! There was 1 ER visit, no admittance to hospital. M.D. ―bookended‖ chiropractic care on the second chiropractor only, thus no M.D. involved with first chiropractor. AMA Impairment 5th edition: 15% WPI (5% cerv.. 5% lumb; 5% thoracic), by M.D.Settlement: $42,500.00, first offer was $37,000.00! Case settled in 5 days! Offered to over-night check.
Two Places VALUE DRIVERS Need To Be Located In your Medical Documentation In the Attorney Settlement Demand
Steps that Need to be done: Take legible Records; List every injury (utilize the VALUE DRIVERS in this presentation); Record properly Chart Notes and Reports with VALUE DRIVERS; Document Prognosis, DUD, and LOEL; Obtain AMA impairment rating Work with the Right Attorney
XI. To Summarize: All injuries have an injury profile Absent accurate information in the chartnotes, the severity rating for an individual claim will not reflect a reasonable value Thus, the above is what every doctor should know in how to document VALUE DRIVERS in personal injury claims
By: Jeffrey D. Bohn Esq. (all graphics used with permission) Locations: San Francisco, San Jose, Walnut Creek, San Mateo, Carlsbad,Cupertino, Palo Alto, Oakland, Pleasant Hill, Sunyvale, Fresno, North Sacramento, South Sacramento TEL: 559-304-1549 559-485-1212 Email: firstname.lastname@example.org www.jdbohnlaw.com