V1.0
IMPAIRMENT ASSESSMENTS FOR
LUMP SUM COMPENSATION
AND INDEPENDENCE
ALLOWANCE
OPERATIONAL GUIDELINES
2014
This is a living document content; we’ll review it regularly and amend it when it needs updating.
Impairment Assessment Lump Sum/Independence Allowance Operational Guidelines
2014
While we’ve done everything we can to ensure that it’s correct, the legal information in this document is only a summary. Your
Impairment Assessment Service Schedule has more detailed legal information.
Contents
1.
Introduction................................................................................................................... 3
Key contact details ......................................................................................................... 3
2.
Service specifications .................................................................................................. 5
Overview ........................................................................................................................ 5
3.
Roles and responsibilities ............................................................................................... 6
Service Requirements .................................................................................................. 7
ACC’s referral ................................................................................................................. 7
The assessment ............................................................................................................. 7
Useful information to include in your reports ................................................................... 7
Writing the apportionment sections................................................................................. 8
The apportionment methods ........................................................................................... 8
Examples of apportionment ............................................................................................ 9
Assessing by analogy ....................................................................................................11
4.
Rapidly deteriorating conditions .....................................................................................11
The respiratory system ...............................................................................................12
Overview .......................................................................................................................12
5.
Notes on some commonly incountered conditions .........................................................12
The visual system ........................................................................................................13
Overview .......................................................................................................................13
6.
Example ........................................................................................................................13
Mental injury ................................................................................................................17
Background and context ................................................................................................17
Apportioning for conditions ............................................................................................17
Examples ......................................................................................................................17
‘Not otherwise specified’ cases ......................................................................................20
7.
Example ........................................................................................................................20
Pain ...............................................................................................................................22
Overview .......................................................................................................................22
Assessment method ......................................................................................................22
8.
The spine ......................................................................................................................25
Overview .......................................................................................................................25
Example ........................................................................................................................25
9.
Rating multi-level spinal impairments ............................................................................26
Travel ............................................................................................................................28
10.
When can you claim for travel? .....................................................................................28
Invoicing.......................................................................................................................29
Additional information ....................................................................................................29
Functional sub-units ......................................................................................................29
Cases of ‘did not attend’ ................................................................................................29
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2014
1. Introduction
These guidelines aim to help ACC-approved assessors to assess ACC clients who
have a ‘whole-person impairment’ as a result of their injuries. The assessments help
us to decide whether these clients are entitled to compensation in the form of an
independence allowance or lump sum compensation.
You should read these guidelines in conjunction with:
•
•
•
The Impairment Assessment Service Schedule (your ‘contract’)
The ACC User Handbook to the AMA “Guides to the Evaluation of Permanent
Impairment”, 4th Edition (the ACC User Handbook to AMA4)
The American Medical Association Guides to the Evaluation of Permanent
Impairment, Fourth Edition (AMA4 Guides).
Your impairment assessments must comply with all three of these documents.
We’ll update these guidelines as and when required. We’ll email each new version to
you once it’s available on the ACC website at www.acc.co.nz.
Key contact details
Your role in undertaking impairment assessments on ACC’s behalf is likely to involve
contact with a number of our teams. Here are their contact details.
ACC Provider Helpline
Ph: 0800 222 070
Email: providerhelp@acc.co.nz
ACC Client/Patient
Helpline
Ph: 0800 101 996
Provider registration
Ph: 04 560 5211
Email: registrations@acc.co.nz
Fax: 04 560 5213
Post: ACC, PO Box 30 823,
Lower Hutt 5040
ACC eBusiness
Ph: 0800 222 994,
Email: ebusinessinfo@acc.co.nz
option 1
Impairment
Assessment and Lump
Sum Units
Ph: 0800 101 996
Email: ials@acc.co.nz
For regions north of New Plymouth and Gisborne:
ACC Hamilton Service Centre,
PO Box 952, Waikato Mail Centre, Hamilton 3240
Fax: 07 848 7201
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For New Plymouth, Gisborne and all areas south:
ACC Dunedin Service Centre,
PO Box 408, Dunedin 9054
Fax: 0800 844 850
Health Procurement
If you have a question about your contract or need to
update your details, please contact the ACC Health
Procurement team:
Email: health.procurement@acc.co.nz
Ph: 0800 400 503
Supplier managers
Supplier managers can help you to provide the services
outlined in your contract. Contact the Provider Helpline for
details of the supplier manager in your region.
ACC website
For more information about ACC, please visit:
www.acc.co.nz
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2. Service specifications
Overview
Who qualifies for the independence allowance and lump sum
compensation?
ACC clients who have a ‘whole-person impairment’ as a result of their injuries may
be entitled to compensation in the form of an independence allowance or lump sum
compensation. The independence allowance is available to those injured on or
before 31 March 2002, and lump sum compensation to those injured on or after 1
April 2002.
Some special rules apply if a client has a treatment injury or a work-related gradual
process disease or infection, or has made a ‘sensitive’ claim (for mental injury arising
from sexual abuse or assault). In these cases the injury date is usually considered to
be the date they first sought treatment or, for a work-related gradual process disease
or infection, the date they first couldn’t work. If this date was after 1 April 2002, they
may still qualify for an Independence Allowance if they have a:
•
•
•
treatment injury and the date of the treatment that caused the injury was before 1
April 2002.
sensitive claim and the date on which the abuse or assault last happened was
before 1 April 2002
work-related gradual process disease or infection and (in most cases) they last
performed the task that caused the injury or worked in the relevant work
environment before 1 April 2002.
The assessment referral process
Before we assess a client’s application for an independence allowance or lump sum
compensation, we gather all the relevant information about their impairment –
including whether they’ve made any previous claims for an independence allowance
or lump sum compensation.
If the client’s claim meets the criteria that allows an assessment to be undertaken,
we refer them to an ACC-approved assessor for a formal assessment. The
assessment involves rating the client’s impairment using the ACC User Handbook to
AMA4.
These are sometimes referred to as the ‘assessment tool’, and set out the
assessment procedures, report formatting and other requirements.
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Roles and responsibilities
To be effective, impairment assessments depend on everyone involved working in
partnership, with a mutual understanding of each other’s roles and responsibilities.
Here’s a list of the key people involved in the impairment assessment process:
•
•
•
•
the assessor undertakes impairment assessments and re-assessments on ACC’s
behalf.
the independence allowance and lump sum compensation teams (in our Hamilton
and Dunedin service centres) process claims for Independence Allowances and
lump sum compensation. Each team is led by an ACC team manager.
ACC claims officers/claims managers work with the injured clients and their
health treatment providers to manage the clients’ claims.
the ACC Branch Medical Advisor provides clinical opinions and advice on cases
when required.
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3. Service Requirements
ACC’s referral
When we refer a client to you we’ll indicate the condition(s) that needs to be
assessed and, if relevant, provide ‘special instructions’ for anything else that needs
to be considered.
If you find any inconsistencies between the injuries we have asked you to assess
please mention them in your assessment report – and if you have any questions
about covered injuries just contact us. See pages 3 & 4 for our phone numbers.
The assessment
The key aim of your assessment is to determine the client’s whole-person
impairment rating, using the ACC User Handbook to AMA4 and the AMA4 Guides.
Your resulting report should meet the specifications of the assessment tool. The
report format is outlined on page 11 of the ACC User Handbook to AMA4.
Note you should only rate impairments that result from conditions we cover.
Assessing a condition that our referral doesn’t mention can cause delays, not to
mention false expectations of compensation for the client.
If a non-covered medical condition affects the body site for which you’re rating the
impairment, you’ll need to consider apportionment (see below for more on this).
Useful information to include in your reports
We appreciate the time you take to draft and write your reports, which can often be
lengthy and complex. The information you provide is vital to ACC, particularly when
we’re answering client queries.
Information that’s particularly useful includes:
1. The assessment date, time and duration: clients often need reassurance that
you’ve considered all of their injuries and taken time to listen to them
2. The injuries you’ve assessed: the injuries you list in your report should be
consistent with those specified in our referral documents and any additional
injuries that we’ve asked you to assess since our referral. This avoids any doubts
about what the client was assessed for
3. Listing the documents you used in your assessment: this provides valuable
assurance to the client that you’ve considered all the medical information we sent
you. Please also include any notes from the client; this can be important if they
ask for a review of our decision on the basis that the information wasn’t
considered
4. Apportionment of non-covered conditions: this is a difficult area as the client will
see your final impairment rating, then see it reduced. The clearer you are about
your clinical reasoning for apportionment, the easier it will be for us to explain to
the client why we couldn’t include a specific non-covered condition in our final
impairment and entitlement decision
5. Providing your clinical opinion on changes since the previous assessment: if the
client’s impairment has been previously rated (we’ll give you a copy of the report),
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it’s important that you provide your clinical opinion on any deterioration or
improvement since then. This helps the client and us to understand any changes
to their impairment rating
6. Accredited Employer reports: as yours is the only report that the Accredited
Employer sees, it needs to be comprehensive enough for them to understand
how you reached your conclusion. When writing the report, make sure you only
include details about the client that are related to the injury the employer has
covered.
It’s also important to avoid making small errors. Any error, even in the spelling of a
client’s name, can lead a client to doubt your report, raise concerns about possible
rating errors and request a review of our decision.
Writing the apportionment sections
All your assessment reports should include a comment on apportionment, even if it’s
simply that it wasn’t required.
When is apportionment appropriate?
You should consider apportionment when:
•
a medical condition not covered by ACC has contributed to the impairment
percentage. You’ll need to apportion your rating into covered and non-covered
impairments
•
a body part (eg a lower limb) has been injured in more than one accident
•
the impairment spans different entitlement periods (eg lump sum compensation,
combined independence allowance and separate independence allowance). For
example, a client may have two knee injuries, one suffered in a lump sum period
and the other in a combined independence allowance period. You need to rate
the current impairment and apportion the impairment to attribute the relevant
percentages to the two separate injuries. This enables us to consider possible
entitlements according to the claim type.
Whatever method you use, remember to ensure that the final rating relates only to
impairment for the condition(s) covered by ACC.
The apportionment methods
The question that apportionment needs to answer is: “Once it stabilised, what
contribution did the particular injury make to the impairment of a body part?”
The ACC User Handbook to AMA4 (page 10) outlines two apportionment methods:
•
•
use medical records to estimate the impairment before the covered injury
happened. However, this method has its challenges. For example, you might not
have enough information to do this (especially if the injury happened many years
ago), and a non-covered condition or issue that also contributes to the overall
impairment might have developed after the covered condition.
use the available records and your assessment findings and exercise your clinical
judgement (as detailed in the ACC User Handbook to AMA4, page 10).
Resources could include your objective findings, old medical reports, previous
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impairment assessment reports, relatives’ or close friends’ comments, and
specialist opinions. Unfortunately patient histories are not necessarily reliable; in
some cases the patient is convinced that all of a particular impairment is due to
an accident despite other evidence not supporting this.
Once you’ve decided on the percentage impairment of the body part for each time
period, the impairment due to each injury is simply a case of subtraction.
Explaining apportionment in your report
It’s important that you explain your reasons for apportionment clearly and simply in
your report, so that anyone reading it can understand them. Clients often want to
discuss them when we advise them of our decisions, and it helps to reduce the risk
of clients requesting reviews of our decisions.
For example, in apportioning mental and behavioural impairment, it can be useful to
comment on how the covered and non-covered conditions affect functions such as
‘activities of daily living’, ‘social functioning’, ‘concentration, persistence and pace’
and ‘adaptation and decompensation’. See Section 6 on page 17 for more detail.
Examples of apportionment
The ACC User Handbook to AMA4 includes examples of using pre-existing
impairments based on medical records. However, a non-covered impairment might
have changed or be from a condition that arose after the injury. In these situations,
please use your clinical judgement.
Example 1
In 1982 Mr X was involved in a motorbike accident. He suffered a right-lower-tibia
fracture that required internal fixation, which resulted in his right leg shortening by
three centimetres (a 10% lower-extremity impairment).
In October 2007 Mr X’s right total hip joint was replaced owing to medical
osteoarthritis. He said it healed very well and he was pain free. The available
medical records confirmed this good result (a 37% lower-extremity impairment).
In December 2007 Mr X fell, suffering a periprosthetic fracture of his right femur.
ACC covered the injury and his right total hip joint was properly replaced in late
2008.
A history and examination at the impairment assessment appointment showed a
poor result, but no additional lower limb shortening (a 75% lower-extremity
impairment).
Mr X’s available medical records showed that he suffered osteoarthritis of both
knees and his left hip. He said he suffered constant back pain because of his right
leg shortening, and believed the osteoarthritis affecting his right side and his back
pain were a result of his 1982 injury and right leg shortening. This opinion was not
supported by specialist records.
Mr X had had previous diagnoses of depression, anxiety disorder and bipolar
disorder. He suffered migraine headaches, had a longstanding history of chronic
pain, and had a past history of head injuries and drug abuse.
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The apportionment
Mr X’s two covered injuries and his medical osteoarthritis can be apportioned as
follows:
•
•
before 1982: 0% right-lower-extremity impairment.
1982 injury: 10% right-lower-extremity impairment due to the tibia fracture (10%
minus 0%).
• October 2007 medical event: 37% right-lower-extremity impairment due to the hip
replacement, combined with the pre-existing 10% right-lower-extremity
impairment = 43%. The medical event thus increased the right-lower-extremity
impairment by 33% (43% - 10% = 33%).
• December 2007 accident: 75% right-lower-extremity impairment due to the now
poor hip replacement result, combined with the pre-existing 10% right-lowerextremity impairment = 78%. The December 2007 covered injury increased Mr
X’s right-lower-extremity impairment by 78% - 43% = 35% lower-extremity
impairment.
This means that Mr X has a 10% lower-extremity impairment, a 4% whole-person
impairment due to his 1982 accident (which was before 1 July 1999 so stands
alone), a 35% lower-extremity impairment and a 14% whole-person impairment due
to his December 2007 accident (which was after 1 April 2002 so also stands alone).
In this example, the medical condition is rated and apportioned as it contributes to
the lower-extremity impairment. The unrelated medical conditions aren’t included in
the rating or the apportionment, as they’re not considered to influence the injuryrelated impairment assessment.
Example 2
Mr Y has a stroke causing left hemiparesis and reduced motor function in his left leg.
This makes it difficult for him to walk distances and he’s limited to walking on flat
surfaces.
Mr Y then falls and fractures his neck of femur. A subsequent hip replacement has a
poor outcome when graded using AMA4 Guides (Table 65, page 87 and Table 64,
page 85).
It’s clear that Mr Y suffered a lower-limb impairment from his medical condition
before the injury. The figure to apportion can be justified using the AMA4 Guides’
brain and cranial nerve section or the Handbook’s lower-extremity section.
You could use Table 13 or Tables 38 and 39 in the AMA4 Guides (pages 148 and 77
respectively) to determine the percentage to apportion for the pre-existing
impairment for the reduced lower-limb function.
The assessment tool does not allow weakness to be combined with a diagnosisrelated estimate, so the highest current rating would be 30% whole-person
impairment.
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The apportionment
The rating would be 30% for the poor hip replacement minus 15% for the preexisting weakness. This means a 15% whole-person impairment, reflecting the effect
of the hip replacement.
Example 3
Mr Z fractures his ankle; it heals with 10 degrees of angulation. He later has an
amputation below the knee with a 7.6-centimetre stump, following an arterial
occlusion (not a covered injury).
The healed extra-articular fracture with angulation was a 15% Lower Extremity
Impairment, a 6% whole-person impairment (AMA4 Guides. Table 64. page 86).
The current state is the amputation; a 28% whole-person impairment (AMA4 Guides,
Table 63, page 83).
The fracture is no longer present, but did cause impairment, so the increase in
impairment from the amputation is therefore 28% - 6%, a 22% whole-person
impairment attributed to the arterial occlusion and subsequent amputation.
Assessing by analogy
In rare situations the AMA4 Guides won’t provide an impairment rating. If this
happens you should determine the rating by comparing the impairment with a similar
impairment of a similar body site. If you use this approach, your report must include
your reasons.
Rapidly deteriorating conditions
When we receive a claim from a client whose health condition is rapidly deteriorating
(whether it’s injury or non-injury related), our staff may ask you to conduct an
assessment via a file review.
This will need to be done as quickly as possible so that clients can qualify for lump
sum compensation. If there’s likely to be a delay, please let us know as soon as
possible.
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4. The respiratory system
Overview
The rating method for impairments of the respiratory system is detailed in the ACC
User Handbook to AMA4 Guides (page 450). However, it has been modified in
relation to mesothelioma.
Notes on some commonly incountered conditions
Mesothelioma
When we receive a claim from a client who has mesothelioma, our staff work closely
with them and their case manager to establish whether the client is well enough to
attend a face-to-face assessment or their medical condition means the assessment
needs to be done via a file review. Either way, it’s important that an assessor
undertakes the assessment, to ensure an official and independent interpretation of
and report on the clinical information.
In 2005, ACC determined that clients with confirmed diagnoses of mesothelioma
would automatically be given a whole-person impairment rating of 80% irrespective
of their clinical condition. Currently this is the only cancer rated in this manner.
When you receive a referral for a client with mesothelioma, please arrange your
assessment quickly. If for any reason there’s a delay in seeing them, let us know as
quickly as possible.
Lung cancer
Please use the method in the ACC User Handbook to AMA4 (page 45) to assess
clients with lung cancer other than mesothelioma.
Clients with cancers at other body sites should be rated using the relevent chapters
in the AMA4 Guides.
Asbestosis/pleural plaques
When we receive a claim from a client who has asbestosis or pleural plaques, we’ll
provide you with lung function tests from the previous 12 months. If these aren’t
available we’ll arrange a test before we send you the referral.
As asbestosis typically causes a restrictive defect on spirometry, this is the
component that’s usually rated. It can be difficult to apportion for co-existing lung
disease, such as when there is a mixed picture with an element of obstruction on
spirometry, for example smoking.
If needed, we can arrange for a respiratory physician to comment on the proportions
of the client’s obstructive and restrictive breathing impairments. This will help you
support your rationale for apportioning breathing impairment from exposure to
asbestos as opposed to non-ACC-covered conditions.
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5. The visual system
Overview
The rating method for clients’ visual systems is detailed in the ACC User Handbook
to AMA4 (pages 54-55).
If a client has a visual field defect, the referral documents you receive should include
a recent optometrist’s assessment indicating its full extent.
If the client needs visual field testing beyond 30 degrees, please contact one of our
service centres; they have the details of providers who undertake these tests.
Example
Mr A was cutting a tensioned wire when it sprang back, knocking off his safety
glasses and penetrating his right eye.
An urgent repair was attempted, but after the operation it was noted that the retina
had detached. An assessment also revealed a cataract in Mr A’s left eye, which was
considered unrelated to the trauma.
A visual acuity examination revealed:
• Right eye- light perception only
• Left eye – 6/12, n8
Despite further surgery to his right eye, Mr A’s vision in the right eye was completely
lost.
Calculating the impairment
In calculating the impairment due to Mr A’s injury, the assessor needs to consider
the impairment before the injury, as Mr A’s visual system was already impaired
owing to the cataract in his left eye.
Assuming the right eye had normal vision before the injury, the impairment
calculation using the worksheet from the ACC User Handbook to AMA4 (page 71)
would be as follows:
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Topic
Right
Left
No
No
6/6
6/12
20/20
20/40
See AMA4 Guides, Table 2, page 211
NS
NB
Also see ‘Visual Acuity near’ on page 54 of the ACC User
Handbook to AMA4
14/18
14/24
0
11
C
See ‘Visual Fields’ page 55 of the ACC User Handbook to
AMA4
0
0
D
Combine C and D for each eye
0
11
E
0
0
F
For worse eye, combine E and F. For the other eye,
transfer E to G. See AMA4 Guides, page 322
0
44
G
May combine 5%-10% impairment for an ocular
abnormality or dysfunction if you believe it isn’t adequately
reflected in the VA, VF or diplopia testing (see AMA4
Guides, page 209, paragraph 3)
0
0
H
0
11
I
Comment
Monocular aphakia is
present
Visual acuity (VA) distance
•
See AMA4 Guides, Table 2, page 211
A
(Snellen)
VA near
Percent loss of VA
•
•
•
•
Loss of visual field (VF)
•
Loss of VA combined with
•
•
loss of VF
Loss of ocular motility (OM)
(diplopia)
•
•
Loss of VA, VF and OM
•
Other ocular functions and
•
disturbances
•
•
Loss of VA, VF and OM and
ocular dysfunction
Convert both eyes to the
•
•
•
•
Combine A and B for each eye (see AMA4 Guides, Table
3, page 24, including footnote)
B
Note:
•
•
Aphakia = loss of lens
Pseudophakia = artificial lens
See AMA4 Guides, page 322
Enter under worse eye
See AMA4 Guides, section 803, Figure 3, page 217
Enter any rating you assess under the involved eye
Justify in your report
If an eye has additional impairment, combine G and H
If not, transfer G to I
See AMA4 Guides, page 322
See AMA4 Guides, Table 7, page 219
3
J
Convert J to whole person
3
K
0
L
3
M
visual system
Convert the visual systems
to whole person
Cosmetic deformities
•
•
•
•
See AMA4 Guides, Table 6, page 218
Can allow for permanent cosmetic deformities causing up
to 10% whole-person impairment
See AMA4 Guides, page 222, section 8.5
• Combine K and L
• See AMA4 Guides, page 322
This is a 3% whole-person impairment.
Grand total
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Following the injury and failed salvage surgery. The rating is:
Topic
Comment
Monocular aphakia is
Right
Left
No
No
present
VA distance (Snellen)
• See AMA4 Guides, Table 2, page 211
6/12
A
20/40
VA near
Percent loss of VA
•
•
•
•
Loss of VF
•
Loss of VA combined with
•
•
loss of VF
Loss of OM (diplopia)
•
•
Loss of VA, VF and OM
•
Other ocular functions and
•
disturbances
•
•
Loss of VA, VF and OM and
ocular dysfunction
Convert both eyes to the
•
•
•
•
See AMA4 Guides, Table 2, page 211
NB
Also see Visual Acuity near’ on page 54 of the ACC User
Handbook to AMA4
14/24
B
100
11
C
See ‘Visual Fields’ page 55 of the ACC User Handbook to
AMA4
100
0
D
Combine C and D for each eye
100
11
E
0
0
F
For worse eye, combine E and F. For the other eye,
transfer E to G. See AMA4 Guides, page 322
100
0
G
May combine 5%-10% impairment for an ocular
abnormality or dysfunction if you believe it isn’t adequately
reflected in the VA, VF or diplopia testing (see AMA4
Guides, page 209, paragraph 3)
0
0
H
100
11
I
Combine A and B for each eye (see AMA4 Guides, Table
3, page 24, including footnote)
Note:
•
•
Aphakia = loss of lens
Pseudophakia = artificial lens
See AMA4 Guides, page 322
Enter under worse eye
See AMA4 Guides, section 803, Figure 3, page 217
Enter any rating you assess under the involved eye
Justify in your report
If an eye has additional impairment, combine G and H
If not, transfer G to I
See AMA4 Guides, page 322
See AMA4 Guides, Table 7, page 219
33
J
Convert J to whole person
31
K
0
L
31
M
visual system
Convert the visual systems
to whole person
Cosmetic deformities
•
•
•
•
Grand total
•
•
Accident Compensation Corporation
See AMA4 Guides, Table 6, page 218
Can allow for permanent cosmetic deformities causing up
to 10% whole-person impairment
See AMA4 Guides, page 222, section 8.5
Combine K and L
See AMA4 Guides, page 322
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The impairment relating attributed to the right eye injury is therefore 31% - 3% = 28%
whole-person impairment after apportionment.
Note that in this example an injury for a person with already compromised vision
results in a higher impairment rating than if they had had normal vision beforehand. It
is important to use the visual impairment worksheets in the ACC User Handbook to
AMA4 (page 71), to support your rating and apportionment.
Using prostheses in assessment
A client’s visual system is tested with glasses or corrective lenses if they usually
wear them. However, the AMA4 Guides (page 9) also refer to the use of prostheses
in assessments.
A client who’s lost an eye may wear a cosmetic prosthetic eye, which isn’t
considered to be a contact lens as it doesn’t correct vision. As it can be removed
easily, the client’s impairment can be assessed without it. This attracts a cosmetic
rating; the AMA4 Guides (page 222) allow up to 10% impairment in this case.
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6. Mental injury
Background and context
Historically two broad approaches have been used to apportion a client’s total claimrelated impairment in relation to mental injury:
1. Focus on the covered mental injury or condition (eg post-traumatic stress
disorder [PTSD]) and exclude from the current impairment any impairment not
related to this condition.
2. Focus on the factors that led to cover (eg sexual abuse, genetics, upbringing).
Deduct a proportion of the current impairment based on those factors’
contribution to the current state, including the covered injury where it’s been
caused by a number of factors.
Both methods can be supported using the ACC User Handbook to AMA4. However,
they can result in inconsistent and inequitable outcomes for clients owing to the
different levels of assessed claim-related impairment that result, which can affect
whether they qualify for entitlements, and the levels of those entitlements. The issue
is all the more important given that mental and behavioural impairment assessments
are by their nature relatively subjective.
Apportioning for conditions
Apportioning for conditions, which focuses on the covered mental Injury, is our
confirmed approach to mental injury apportionment in impairment assessments.
Under this approach:
•
•
there’s no apportionment of the covered mental injury.
any impairments due to non-covered conditions, non-covered symptoms or
behaviours (even when these don’t meet a diagnostic threshold) are deducted.
This approach can also be applied to rating behaviours and symptoms where the
diagnostic criteria for a formal mental health condition that ACC has covered are no
longer met.
For example, if a client has previously received mental injury cover for a particular
condition, and a new assessment finds that they don’t have the condition or the
condition no longer meets the full diagnostic criteria, symptoms related to the
previously diagnosed condition might still continue. The impairment due to these
symptoms can be rated in an assessment.
Examples
A client has cover for PTSD caused in part by sexual abuse in New Zealand and in
part by earlier sexual abuse overseas. The client has another diagnosis (major
depressive disorder), which isn’t covered by ACC and pre-dated the sexual assault
in New Zealand.
The client’s current presentation is thought to relate mainly to PTSD.
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How should the client’s mental and behavioural impairment be rated and
apportioned?
As the PTSD is the covered injury, it shouldn’t be apportioned even though the
overseas event may have contributed to the cause. Cover for this episode of PTSD
has been established.
The current impairment rating determined by using Chapter 14 of the AMA4 Guides
and the ACC User Handbook to AMA4, is thought to relate mainly to PTSD.
There’s no apportionment for PTSD, but some apportionment would be expected for
the impairment that doesn’t relate to PTSD (in this case the major depressive
disorder). This can be achieved, as detailed on the Handbook (page 10), by
deducting the impairment that existed before the PTSD from the current impairment
rating, or alternatively by using your clinical judgement. It might be helpful to use
mental and behavioural functional classifications (that is ‘activities of daily living’,
‘social functioning’, ‘concentration, persistence and pace’ and ‘adaptation and
decompensation’) to justify the extent of apportionment for non-covered conditions.
28
64
PTSD
8
Major Depressive Disorder
Unimpaired
In this case apportionment would be for the major depressive disorder component:
36% - 8% = 28%.
In this example, what if the New Zealand sexual abuse was part of the overall
background to the major depressive disorder, but not a material cause?
The impairment rating is for the injury covered by ACC. If we don’t cover the major
depressive disorder, it should be apportioned. The impairment rating is not of the
sexual abuse (the event) but of the covered injury condition resulting from it (in this
example PTSD).
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When calculating a mental and behavioural impairment rating should I
apportion only for diagnosed mental health conditions that aren’t covered?
In all physical and mental impairment assessments, apportionment is necessary
when the impairment has been caused by multiple conditions. The current
impairment is rated, then apportioned into covered and non-covered impairments.
The non-covered impairment is deducted from the overall current impairment,
leaving the injury-related component.
In the case of mental and behavioural impairment, the apportionment should be for
all impairment not arising from the covered condition. It may reflect non-covered
conditions with a formal psychiatric diagnosis, but will also include factors that
contribute to the overall mental and behavioural impairment rating and that are
separate from the covered mental injury.
7
26
7
60
PTSD
Major Depressive Disorder
Unimpaired
Poor Education
In this example, the total impairment using the mental and behavioural tables relates
to PTSD, major depressive disorder and poor education (considered to be separate
from the PTSD and not causing it). The apportionment would be for major
depressive disorder and poor education: 40% - 7% -7% = 26%.
A client has cover for borderline personality disorder and polysubstance
abuse, and while sexual abuse contributed to these conditions there were
many other contributors. How should these be apportioned?
If the impairment relates fully to borderline personality disorder and polysubstance
abuse, the causal factors for these conditions should not be apportioned. If you
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believe there was impairment unrelated to the conditions, it should still be
apportioned with an appropriate explanation.
The referral letter doesn’t detail an injury, but simply refers to the read code
“sexual abuse head nos (not otherwise specified)”. What should I rate?
If you need help identifying the covered injury or extent of cover, contact the
impairment assessment unit before you undertake the assessment or write your
report.
‘Not otherwise specified’ cases
There are some cases where there is no clear specified mental injury accepted
historically by ACC. This may relate to claims accepted under the 1972 or 1982
Accident Compensation Act, where cover was extended to the physical and mental
consequences of injuries and accidents, or to historically accepted Sensitive claims
under the 1992 Accident Rehabilitation and Compensation Insurance Act for ‘mental
or nervous shock’. There may not be enough evidence for a psychiatrist who sees
the client now to determine their diagnosis at the time cover was accepted.
In these situations the clients are covered by ACC and have a right to apply for
Independence Allowances for those covered injuries.
If a client meets ACC’s legislative requirements for an assessment or a reassessment of their impairment, we’re legally required to make that happen.
We’ll refer the client to you for an assessment based on the cover granted when we
first received their claim.
If the cover at that time is unclear, we’ll ask you to use your clinical experience to
rate the effects of sexual abuse using the historical medical notes and a recently
provided psychiatrist opinion.
Example
We have accepted a client’s sensitive claim for ‘sexual abuse’. Historical counselling
reports noted symptoms of PTSD, anxiety disorder and some borderline personality
traits, but no relevant clinical opinion or diagnosis was sought at that time.
A recent psychiatric assessment diagnosed major depressive disorder, with the
psychiatrist noting that the abuse was not a material cause but one of ‘several
factors’ in the background to the depressive disorder.
The recent assessment can’t confirm from the historical notes that there was a
previous diagnosis of PTSD, and if it was evident at that time, there are no longer
any symptoms of PTSD. There are some borderline personality traits, but not
enough for diagnosis.
Given that there isn’t enough information to establish that ACC made an error in
providing cover when the claim was lodged and no evidence of a diagnosis by
someone duly qualified, the client is entitled to have their current impairment level
rated.
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The assessor would use the functional categories from the ACC user handbook to
AMA4, see pages 33-41, to rate the current presentation. The assessor would need
to justify how the rating derived relates to persisting symptoms from the historic
injury.
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7. Pain
Overview
If your assessment finds evidence that a client is in continual pain, your impairment
assessment report must show that you’ve considered page 42 of the ACC User
Handbook to AMA4 and Chapter 15 of the AMA4 Guides. The report should include:
•
•
the source of a client’s pain (eg injury/non-injury)
how you’ve considered page 42 of the Handbook, including whether you consider
the pain psychogenic
• how you’ve considered Chapter 15 of the AMA4 Guides, including the frequency
and intensity of the client’s pain
• how the chapter on the relevant organ system has considered pain and how this
is reflected in your rating
• any other relevant information.
An additional clinical assessment won’t always be required. However, please contact
the referring claims officer if you need additional information for a rating.
Chapter 15 in the AMA4 Guides doesn’t provide a separate impairment rating for
pain. Instead, it refers you to the relevant body part or organ system section. As a
result, a client’s impairment rating is unlikely to change with your consideration of
Chapter 15.
Assessment method
The first step in rating for pain should be to review its aetiology. You need to make a
distinction between pain arising from the covered physical or mental injury and
chronic pain from non-covered conditions.
Follow the ACC User Handbook to AMA4
The pain rating method is detailed on page 42 of the Handbook. Pain isn’t separately
rateable, unless it’s specifically noted in the AMA4 Guides. In general, the AMA4
Guides’ percentages for organ systems already allow for accompanying pain.
The following Handbook references to the AMA4 Guides generally apply to pain:
1. AMA4 Guides page 9 details that, in general, the impairment percentages shown
in the organ system chapters allow for pain that may accompany the impairing
conditions. Chronic pain syndrome is evaluated as described in the chapter on
pain on page 303.
2. AMA4 Guides page 13, paragraph 2 indicates that in most cases the impairment
ratings provided in the organ system/body part chapters include a consideration
of pain.
3. AMA4 Guides page 152, section 4.5 details that impairment due primarily to
intractable pain may greatly influence an individual’s ability to function.
Psychological factors can influence the degree and perception of pain. Pain will
sometimes affect the proper functioning of a specific organ system. While
impairment percentages shown in the AMA4Guides’ chapters considering organ
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systems make allowance for pain that may accompany the impairing conditions,
chronic pain should be evaluated according to criteria in the chapter on pain.
4. AMA4 Guides page 303, Chapter 15 considers the subjective nature of pain,
noting that it can’t be validated or measured objectively.
The Handbook details exceptions where pain could be rated:
•
•
•
Causalgia (now known as complex regional pain syndrome)
Cervical spine
Chronic pain syndrome – may be assessed for mental injury if a psychiatrist has
diagnosed a chronic pain syndrome arising from a physical injury
• Peripheral nerve pain syndrome
• Phantom limb pain
• Trigeminal neuralgia.
When rating chronic pain syndrome where it’s a covered mental injury, you should
use the mental and behavioural method. The AMA4 Guides (page 297) note:
“The assessment of impairment due to pain, especially in circumstances in which the
complaint exceeds what is expected on the basis of medical findings, is complex and
controversial. While pain is discussed in the chapter on pain at page 303 and
elsewhere in this book, it is germane also to the consideration of mental and
behavioural disorders.
“Mental illness may distort the perception of pain. Pain may become part of a
somatic delusion in a patient with major depression or a psychotic disorder. Pain
may become the object of an obsessive preoccupation, or it may be the chief
complaint of a conversion disorder.
“Establishing whether pain is or is not a symptom of a mental impairment may be a
difficult and complex task.
Guidelines for this process are detailed in this section in Chapter 14.
Chronic pain can also be evaluated using Chapter 15 in the AMA4 Guides (pages
303-304), which states that:
•
•
•
pain is subjective in nature; it can’t be validated or measured objectively
impairment due to pain has not been well defined
in general the impairment percentages given in the tables and figures applicable
to permanent impairment of the various organ systems include allowances for the
pain that may happen with those impairments.
The clinical assessment process for chronic pain impairment is detailed in section
15.6 of the AMA4 Guides (page 308). It involves:
•
•
•
•
•
•
•
reviewing the records
obtaining the history from the patient – including the work, family and social
history and the activities of daily living
documenting the pain complaint
performing a physical examination
arranging appropriate investigations
undertaking psychological testing – assessment tools are detailed
formulating a diagnosis including the cause/classification of the pain, with detail
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of the biopsychosocial impacts
• estimating the extent of the pain and impairment using the procedures detailed in
section 15.9 and other parts of the AMA4 Guides as appropriate.
Section 15.9 of the AMA4 Guides provides examples of impairment rating for pain.
All the examples refer assessors to the appropriate chapters to derive the ratings.
Section 15.8 provides additional comment on estimating impairment from pain. It
notes that in testing it’s important to consider whether the client can perform daily
activities rather than whether activity causes pain. The section considers the use of
functional capacity assessment in the process and discusses validity testing issues.
Section 15.8 indicates that:
1. Acute pain is not permanent impairment
2. Psychogenic pain should be assessed according to the chapter on mental and
behavioural disorders (Chapter 14)
3. Recurrent acute pain is likely to be classified as primary and nociceptive or
neurogenic. It clearly relates to a well defined disease or pathology
4. Chronic pain syndrome is likely to be classified as secondary pain. Chronic pain
in the absence of objectively validated diseases or impairments should be
assessed by a multidisciplinary group by doctors with an interest in pain
medicine, particularly in considering the effects of pain on the ability to perform
activities of daily living.
The pain intensity grid, on page 310 of the AMA4 Guides, is used to record the pain
intensity and frequency. It doesn’t in itself provide an impairment percentage rating,
but describes the degree of impairment.
Section 15.8 indicates that an impairment percentage can be determined for a
person’s pain if the condition causing the pain can be evaluated according to criteria
applicable to a particular organ system. Example 3, on page 313, looks at trigeminal
neuralgia and refers assessors to the appropriate section in the AMA4 Guides (in
this case the brain and cranial nerve section).
Overall, Chapter 15 provides a method for acknowledging and describing impairment
from pain and indicates the situations where it’s rateable. As it doesn’t actually
determine the rating, applying Chapter 15 isn’t expected to alter a rating; however, it
does acknowledge the reported severity of pain.
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8. The spine
Overview
The assessment method for spine impairments is detailed on pages 48-49 of the
ACC User Handbook to AMA4, and includes a referral to pages 94 -111 of the AMA4
Guides.
If there are multiple spinal claims, you may need to apportion the current impairment
to specific claims. It might be useful to consider the injury details on the referral and
whether the current impairment relates to them.
Back pain is a common complaint and frequently encountered in assessments.
Where it’s linked to the covered injury, it’s important that your report covers how
you’ve considered pain in your rating and includes an explanation of the Handbook’s
pain section.
Note that while radiculopathy requires the presence of significant signs to be
confirmed, this is not the same as radicular pain. Significant signs include loss of
reflexes, atrophy greater than two centimetres above or below the knee or electro
diagnostic studies. Table 71 on page 109 of the ACC User Handbook to AMA4
provides more detail on this.
The Handbook also indicates that loss of motion segment integrity and a history of
guarding are not used as differentiators.
Example
A patient currently has an L5 radiculopathy and a 50% compression fracture of L3.
How would you rate this spinal impairment? Would it be different if the impairment
had been sustained in one accident or different accidents?
The impairment rating method determines the current spinal whole-person
impairment, then deducts the impairment that relates to non-injury pathology.
However, if there are multiple injuries you also need to determine the injury (claim), if
any, to which the current impairment relates.
If there are multiple accidents, each causing injury, you might find that a timeline
helps in determining the impairments at different times, and in your apportioning
attribution.
Applying the impairment rating method
In the above example:
•
•
•
the lumbosacral region is primarily involved and both injuries are in this area
L5 radiculopathy (if confirmed by the presence of objective findings in the AMA 4
Guides, Table 71, page 109) would be a Diagnosis Related Estimate (DRE)
category III impairment
a 50% compression fracture at L3 would also place the client in DRE category III.
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The current impairment rating in the example is therefore clearly in the lumbosacral
category III range; a 10% whole-person impairment.
If the injuries had been sustained in the same accident, the rating would be
straightforward. This is a 10% impairment rating, and both injuries place the client in
this range. If there were no prior problems there would be no apportionment.
If one injury pre-dated the other, apportionment would be used to determine the
rating for each injury.
For example, if the L5 radiculopathy happened in 1999, and in 2011 there was
further injury with an L3 50% compression fracture:
•
•
the rating in 1999 would be lumbosacral category DRE III 10%
after the fracture in 2011 the spinal rating would remain unchanged at
lumbosacral category DRE III 10%. This is because:
• the rating for the 1999 L5 radiculopathy is 10%
• the rating for the fracture is 10% - 10% = 0%
• the impairment would be rated as an Independence Allowance 1999 injury 10%
whole-person impairment and a lump sum 2011 injury 0% whole-person
impairment.
Injuries in different spinal regions (cervicothoracic, thoracolumbar and lumbosacral)
should be combined as detailed in the AMA4 Guides, page 101, bullet point 8:
“If more than one spine region is impaired, determine the impairment of the other
regions, combine the regional impairments using the combined values chart to
express the patient’s total spinal impairment”.
While the current impairment in this example doesn’t change if the injuries were
caused by more than one accident, you’d need to comment on apportionment in your
report.
Rating multi-level spinal impairments
Spinal DRE Category IV
Loss of motion segment integrity is not used for rating but this category also includes
'Structural inclusions' - definition - (2) details 'multilevel motion segment structural
compromise without residual neurologic motor compromise, for example, multilevel
fracture or dislocation'.
At first glance the principle in this definition is quite clear. A person qualifies if there
is multilevel structural compromise with fractures or dislocations. A closer look at the
AMA4 Guides and The ACC User Handbook to AMA4 texts can be confusing for
some people. In the AMA4 Guides page 102 and 106 the wording is “as with
fractures or dislocations” – but on page 104 “for example, multilevel fractures or
dislocation”. The ACC User Handbook to AMA4 states: “Injuries affecting structural
integrity (Vertebral fractures and dislocations, disc injuries etc)”.
The logical consequence of this is to ask the question: must a person have fractures
and dislocations in order to qualify – or do the words “as with” and “etc” suggest that
other findings may also qualify, like spinal fusions, which after all is a multilevel
structural compromise?
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Here’s an example to help clarify.
Example
Mr S had had six lower back operations at the time of assessment. These had
resulted in a fusion of L3/L4/L5. He reported loss of sexual function and bladder
urgency.
The assessor noted:
“He presents in considerable discomfort. He uses a stick and displays an antalgic
gait. Circumferential limb measurements are symmetrical. He has loss of the lumbar
lordosis and there is a mature surgical scar measuring 10 cm over the lumbar spine.
Knee reflexes are present. (The left ankle jerk which was reported to be absent at
the last examination is now demonstrated.)”
Mr S had no fractures or dislocations and didn’t demonstrate significant signs of
radiculopathy, so he could be DRE II 5% whole-person impaired. However, he is
clearly more impaired than that normally seen in Category II.
There was multilevel structural compromise within one spinal region (cervicothoracic,
thoracolumbar or lumbosacral) and he should have been rated as DRE IV. This
would have included two-level fusions (eg L4, 5 and S1), not single-level fusions (eg
L5,S1).
This interpretation provides a more generous rating than would have occurred if
‘multilevel’ had been defined as only fractures or dislocations.
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9. Travel
When can you claim for travel?
In scheduling assessments, we always consider whether there are qualified
assessors close to where our clients live. However, if a client wishes to see someone
else and has a valid reason for doing so, we’ll arrange for an assessor to travel to
them and try to make at least two assessment appointments in the area on the same
day.
Any travel required outside the areas you are usually contracted to go to will need to
get prior approval from ACC.
Assessors may need to travel outside their usual areas when:
•
•
•
there is a shortage of impairment assessors in the area
a psychiatrist is required
an assessor is required for a specific reason.
We aren’t normally able to pay assessors for travelling beyond their usual contracted
locations for one client. However, one-off situations can be discussed with the team
manager at your local unit (see pages 3 & 4 for our phone numbers).
You can also check out our website http://www.acc.co.nz/for-providers/invoicing-andpayment/WPC115885 for more information on the travel guidelines.
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10.
Invoicing
We are only able to accept invoices in the form of XML transactions. If you’re not
already sending your invoices this way, please contact the eBusiness team on 0800
222 994, option 1.
Note that invoices must be submitted within 12 months of the dates on which you
provide your services. We aren’t able to pay invoices sent to us outside that
timeframe.
Additional information
If we ask you for more information, please send it to us using the appropriate code. If
the information that we ask for wasn’t provided in a report, despite our having asked
for it, please provide it to us at no extra cost.
Functional sub-units
Functional sub-units are an integral part of impairment assessment; they are detailed
on page 12 of the ACC User Handbook to AMA4, and your contract specifies when
they can be charged and when an assessment is defined as ‘exceptional
circumstances’.
Examples
•
You’re asked to rate two lumbar spine claims. As this involves considering the
spine, skin and pain, your service should be invoiced as one functional unit: the
spine.
• You’re asked to rate injuries to both lower limbs. As this involves considering both
lower extremities, skin and pain, your service should be invoiced as two
functional units – left and right lower extremities.
If your purchase order doesn’t match the functional units you’re assessing, please
contact your local ACC unit.
Cases of ‘did not attend’
If a client doesn’t turn up for their appointment we’re still able to pay you a fee.
There are a couple of things we need to know:
•
•
whether or not the appointment was onsite or offsite, and
which assessment you are claiming for.
If the appointment is an onsite appointment, you can claim 40% of the base fee. If it
was an offsite appointment, you can claim 60% of the base fee. The base fee may
vary depending on which type of assessment has been set up.
If there was more than one assessment, you are able to invoice for the assessment
with the higher amount.
Please include with your invoice copies of relevant correspondence and file notes.
You can call us at the local unit (see page 3 & 4 for phone numbers) if you have any
questions.
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