MMI and PPI

David Collipp, M.D.NewSouth NeuroSpineFlowood, MS July 30, 2015

MMI, PPI, Restrictions

MMI

“a status where patients are as good as they are going to be from the medical and surgical treatment available to them.”

“a date from which further recovery or deterioration is not anticipated, although over time (beyond 12 months) there may be some expected change.”

The time at which no change in PPI greater than 3% is anticipated.

AMA Guides, 6th Edition

MMI

“Change in condition related to deterioration from natural aging or passage of time.”

“Ongoing follow up or treatment for optimal maintenance of the medical condition in question.”

Changes related to aging and passage of time, and ongoing treatments are not inconsistent with MMI.

AMA Guides, 6th Edition

MMI

“usually occurring when all reasonable medical treatment expected to improve the condition has been offered or provided.”

“MMI is not predicated on the elimination of symptoms and/or subjective complaints.”

AMA Guides, 6th Edition

PPI

PPI

A number from a book. AMA Guides 6th Edition since 2008. Mississippi is a “latest edition” State. Presently no plans for 7th Edition. “a significant deviation, loss, or loss

of use of any body structure or body function in an individual with a health condition, disorder, or disease.”

AMA Guides, 6th Edition

PPI

Why do we use the book?

Consistency between examiners. Consistency within the human body. Uniform template for comparison and

checking. To allow for questioning…

Fairness in an area that is inherently abstract.

PPI

PPI

6th Edition Principles

No impairment can exceed 100%Regional impairments will be combinedPerformed by physicians (allows DC for some spine issues)No rating of future impairmentIf more than one method is valid, use the higher ratingSubjective complaints are generally not ratableRound all fractions upMust be at MMINo rating may exceed the maximum for it’s region

PPI

PPI

The most important step in rating is having the correct diagnosis. This requires the most accurate and appropriate diagnosis.

Accurate use of the Guides requires fundamental understanding of anatomy, physiology, pathology and other appropriate clinical sciences along with an understanding of disability assessment and impairment rating issues.

PPI

An Impairment Rating does not necessarily correlate with work activity.

The example in the AMA Guides, a singer and her piano accompanist.

Impairment does not equal disability or handicap.

PPI

The General Scheme for Rating for Spine, Upper Limb and Lower Limb

MMI Diagnosis (Key Factor) Place in a Class Apply Grade Modifiers Document

PPI

Class placement is not arbitrary.

“Proximal Tibial Shaft Fracture” “Non-displaced with no significant objective

abnormal findings at MMI” “Non-displaced with abnormal examination

findings” “<10 degree angulation” “10-19 degree angulation” “20+ degree angulation” “Non-union and/or infected”

PPI

After Class placement you stay in that class

Then consider moving in the class (Grade A-E)

GMFH-Functional History GMPE-Physical Examination GMCS-Clinical Studies

All graded 0-4, then calculated to move from Grade C up (D,E) or down (A,B), or stay the same.

PPI

If the Grade Modifier for Functional History is more than 2 grades off from PE or CS, then it is not used. It is “invalid”.

If any GM is not consistent with the diagnosis or objective findings otherwise, it is not used.

Grade Modifier values are in the Guides.

PPI

Documentation often includes:

MMI with Date Diagnosis Class Grade Modifiers PPI by whole person or region (or both)

In some cases, some of the information may be excluded.

PPI

As previously mentioned:

An Impairment of nearly any amount does not preclude function (vocational or avocational).

An Impairment does not indicate Disability.

PPI

PPI

Persons with pre-existing Impairment should have the PPI appropriately apportioned.

Previous injury to the lumbar spine with PPI for surgery. Previous injury to the lumbar spine with PPI for strain (Max

3%).

If a person had lumbar fusion at 3 levels and adds one level, this is a LOWER impairment rating than if he had never had surgery.

If a person had previous lumbar strain(s) with 3% PPI, there is no way to increase that impairment with a subsequent strain, regardless of subjective complaint.

Restrictions

Restrictions

Restrictions are not limitations.

Limitations are things a person cannot do.

Restrictions are things a person shouldn’t do.

Limitations must be based upon objective information.

Restrictions are mostly based upon objective findings.

Restrictions

Objective data are measureable.

Age Habitus Strength Diagnosis Surgical outcome (2 level fusion,

TKA) ROM Neurological deficit

Restrictions

Subjective data is not measurable.

“I have pain when I do this” “I cannot stand that long, my legs

give out” “I have anxiety when I drive on that

road”

Subjective information is used to modify restrictions from an established baseline, if (and only if) relevant and consistent.

Restrictions

Subjective information that does not correlate with objective data is not used.

Subjective information might be valid and yet unrelated to an injury (e.g. age, weight, other medical conditions).

If a physician relies solely on a patient’s subjective complaints to determine restrictions then the physician is unnecessary.

Restrictions

MMI, PPI, Restrictions

End of new treatment.

May have ongoing treatment. Standardized numerical

representation of change after injury. Addressing functional abilities

related to the injury.

Questions?