II. Indications

  1. Define occupation specific limitations related to Impairments

III. History

  1. Demographics
    1. Age
    2. Educational background and capability
    3. Social factors
  2. Job requirements and employee capabilities
    1. Specific tasks required for a patient's job
    2. Which of the required tasks can the patient perform
    3. Has the patient reached a maximal medical therapy
      1. In effect, are Impairments limiting current tasks improved to an expected level

IV. Approach

  1. Initial Evaluation Review
    1. Identify the third party who is making the Disability request and the indication (e.g. legal, employment, insurance)
    2. Identify the medical provider's role (e.g. consultant, treatment, independent medical examiner)
    3. Identify the key issues to be addressed and the applicable guidelines (e.g. FMLA, SSI)
    4. Obtain patient consent for release of information, fees and follow HIPAA regulations
  2. Diagnoses and Impairments
    1. See Functional Capacity Evaluation
    2. Identify physical and mental diagnoses and Impairments
    3. Use validated functional tools (including patient-reported outcome tools)
  3. Activity Limitations and Participation Restrictions
    1. Obtain job descriptions and understand the specific tasks an employee is expected to perform
    2. Apply limitations and restrictions based on the employee's ability to perform specific required activities
    3. Restrictions should be consistent and reasonable
  4. Assessment and Plan
    1. Maintain accurate and timely documentation, and conclusions should be consistent with objective evaluation
    2. Make use of electronic forms with consistent data when possible
    3. Include regular follow-up visits for reassessment and actvity modification when work restrictions are recommended
    4. Assigning causality and apportionment (percent permanent Disability) often requires Consultation
    5. Avoid permanent Disability assignments until all rehabilitation activities have been completed
  5. Assign Codes and Charges
    1. Assessments requested by third parties are billed separately from a patient's private insurance
    2. Documentation for third party requested evaluation (e.g. Worker Compensation) should be in its own progress note
    3. Consider time-based coding when completing forms, evaluating Disability and communicating with consultants

V. Types: Classifications

  1. Behavior
  2. Communication
  3. Body Disposition
  4. Personal care
  5. Locomotion
  6. Dexterity
  7. Situational
  8. Skill

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