Introduction
Pain is a significant factor in many workers' compensation cases, yet it's often misunderstood how pain is evaluated and rated within California's permanent disability system. This blog post aims to clarify the rules surrounding pain add-ons, particularly focusing on how they apply when multiple body parts are involved and when formal pain assessments are warranted.
The Basics: What is a Pain Add-On?
Under California's 2005 Permanent Disability Rating Schedule (PDRS), which incorporates the AMA Guides 5th Edition, a pain-related impairment can be considered when pain exceeds what would be expected from the diagnosed condition. The standard approach allows for a pain add-on of up to 3% whole person impairment (WPI) when:
- The pain is substantially in excess of what would be expected from the physical findings
- The pain has a significant impact on the individual's ability to perform activities of daily living (ADLs)
The 3% Cap: A Critical Limitation
One of the most important rules to understand is that the maximum allowance for pain resulting from a single injury is 3% WPI, regardless of how many body parts are involved . This limitation is explicitly stated in the 2005 PDRS on page 1-12.
For example, if an injured worker has impairments to both the lumbar spine and knees from the same industrial injury, the total pain add-on cannot exceed 3% WPI across all affected body parts.
Multiple Body Parts vs. Multiple Injuries
There's a crucial distinction between:
- Multiple body parts affected by a single injury : The 3% cap applies across all body parts.
- Multiple separate injuries (different dates of injury) : Each injury can have its own pain cap (up to 3% WPI).
Under *Benson v. WCAB*, separate dates of injury/claims are rated separately, and each injury can have its own pain add-on up to the 3% maximum.
Informal vs. Formal Pain Assessments
The AMA Guides provide two approaches to pain assessment:
Informal Pain Add-On (§18.3d)
- Used when pain causes a slight increase in the burden of the condition
- Doesn't require extensive documentation
- Simply notes that pain exceeds what would be expected and affects ADLs
Formal Pain Assessment (§18.3f)
- Used when pain causes a more significant increase in the burden of the condition
- Requires a comprehensive evaluation and documentation process
- May involve standardized pain assessment tools
- Requires detailed clinical reasoning
What Constitutes a Formal Chapter 18 Pain Assessment?
A formal Chapter 18 pain assessment involves:
- Documentation of Pain Substantially in Excess :
- The physician must document that the pain is substantially in excess of what would be expected from the objective findings and standard impairment ratings.
- This requires explaining why the standard impairment ratings don't adequately capture the actual impact of the pain.
- Impact on Activities of Daily Living (ADLs) :
- Specific identification of which ADLs are affected by the pain.
- Detailed assessment of how the pain impacts the injured worker's ability to perform various activities.
- Pain Severity and Frequency Assessment :
- Documentation of pain severity (slight, moderate, or severe).
- Documentation of pain frequency (constant, frequent, intermittent, or occasional).
- Standardized Pain Assessment Tools :
- May include standardized pain assessment questionnaires or tools.
- Provides objective documentation of subjective pain complaints.
- Explanation of Clinical Reasoning :
- Detailed explanation of why a formal pain assessment is warranted.
- Why the standard rating methodology doesn't adequately capture the impairment.
Multiple QMEs and Pain Add-Ons
When multiple Qualified Medical Evaluators (QMEs) are involved in a case, each evaluating different body parts, it's important to understand:
- Each QME can evaluate pain for their respective body region.
- Each QME can recommend a pain add-on for the body part(s) they're evaluating.
- However, the total pain add-on across all body parts from the same injury cannot exceed 3% WPI.
Case Example: Lumbar Spine and Bilateral Knee Impairments
Consider a case where an injured worker has:
- Lumbar spine impairment with a 3% pain add-on already applied
- Right knee impairment rated at 22%
- Left knee impairment rated at 6%
If the knee QME determines that the bilateral knee pain is substantially in excess of what would be expected from these ratings, they have several options:
- Recommend that a portion of the existing 3% pain add-on be reallocated from the lumbar spine to the knees.
- Determine that the lumbar pain add-on adequately covers all pain-related impairment.
- Perform a formal Chapter 18 pain assessment to provide detailed documentation supporting their recommendation.
Common Misconceptions
Misconception #1 : Each body part can get its own 3% pain add-on
Reality : The 3% maximum applies to the entire injury, not to each body part.
Misconception #2 : Pain add-ons can exceed 3% with proper documentation
Reality : The 3% cap is absolute for a single injury, regardless of documentation.
Misconception #3 : Pain add-ons can be applied to body parts with 0% WPI
Reality : As confirmed in *Blackledge* (WCAB en banc, 2010), pain add-ons can only increase an existing ratable WPI and cannot be applied to a body part with 0% WPI.
Best Practices for Requesting Pain Assessments
When requesting a formal Chapter 18 pain assessment, ask the QME to:
- State whether the pain is in excess of what the Guides already contemplate and identify the affected ADLs.
- Specify whether their opinion is under §18.3d (slight increase, no formal analysis) or requires a formal §18.3f pain assessment.
- If a pain add-on is warranted, assign whole-number portions of the single pain add-on to each affected body part, with the sum total not exceeding 3% WPI.
- Confirm there is an underlying ratable WPI for each body part receiving a pain add-on.
- If there are separate injuries, identify the date of injury and clarify whether the opinion and any pain add-on is being provided per injury.
Conclusion
Understanding the rules surrounding pain add-ons is crucial for properly evaluating permanent disability in California workers' compensation cases. While pain is a significant factor in many injuries, the system places clear limitations on how pain can be rated and incorporated into permanent disability assessments.
By understanding these rules, injured workers, employers, claims administrators, and medical-legal evaluators can ensure that pain is properly evaluated within the established framework, leading to more accurate and consistent permanent disability ratings.
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*Disclaimer: This blog post provides general information about California workers' compensation law and is not intended as legal advice. For specific guidance on your case, please consult with a qualified workers' compensation attorney.*