FECA PT3 PR 700

User Manual: PR 700

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FECA-PT3 Printed: 08/02/2011
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PART 3 - MEDICAL
(Issued 09/95; Trans. No. 95-39)
LIST OF CHAPTERS
3-0100 Overview
3-0200 Functions of the Medical Unit
3-0201 Staff Nurse Services
3-0202 Contract Field Nurse Certification
3-0300 Authorizing Examination and Treatment
3-0400 Medical Services and Supplies
3-0500 OWCP Directed Medical Examinations
3-0600 Requirements for Medical Reports
3-0700 Schedule Awards
3-0800 Exclusion of Medical Providers
3-0900 Administrative Matters
CHAPTER 3-0100 OVERVIEW
TABLE OF CONTENTS
Paragraph and Subject Date Trans. No.
Table of Contents 09/95 95-39
1. Purpose 10/90 91-02
2. Benefits 10/90 91-02
3. Definitions 10/90 91-02
04/93 93-24
4. Subjects Covered 09/95 95-39
3-0100-1 Purpose
1. Purpose. This part of the procedure manual describes for both physicians and
claims personnel the procedures for administering the medical care program under
the Federal Employees' Compensation Act (FECA). Examination of case files and
authorization of medical care are conducted through the cooperative efforts of the
Medical Unit and the Claims Units within each district office.
3-0100-2 Benefits
2. Benefits. The FECA provides the following benefits for Federal employees:
a. Medical Care. Services prescribed or recommended by a qualified
physician which are likely to cure, give relief, reduce the degree or the period
of disability, or aid in lessening the amount of monthly compensation may be
authorized. These services include surgery and hospitalization as well as
appliances and supplies.
b. Disability Benefits. Compensation is paid for lost wages resulting from
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the employment-related injury, disease or illness.
(1) Total Disability. A claimant is paid compensation for total
disability when the employee is medically unable to perform gainful
employment due to employment- related injury, disease or illness.
The loss of use of both hands, both arms, both feet or both legs, or
the loss of sight of both eyes, is considered prima facie evidence of
permanent total disability (section 8105 (b) of FECA), though
claimants with these disabilities are sometimes still able to work.
(2) Partial Disability. Reduced benefits are paid when the
employee is not totally disabled but is capable of performing duties
which are compatible with the medically imposed work limitations
resulting from the injury, disease, or illness. The amount of
compensation paid commensurate with the employee's loss of wage-
earning capacity (sections 8106 and 8115 of FECA).
c. Schedule Award. Compensation for permanent impairment of certain
members or functions of the body may be paid regardless of the employee's
ability to work. A schedule award is payable when the condition has reached
maximum medical improvement. The AMA Guides to the Evaluation of
Permanent Impairment form the basis for awards. Awards are also payable
for disfigurement of the face, head or neck which is likely to handicap the
claimant in maintaining or securing employment (section 8107 of the FECA).
d. Vocational Rehabilitation. Vocational rehabilitation services are
provided when an injured employee is unable to return to his previous work
(section 8104 of FECA).
e. Death Benefits. A range of benefits for the dependents of an
employee whose death was employment-related is provided (sections 8133
and 8134 of the FECA).
f. Miscellaneous Benefits. Other benefits include reimbursement for
transportation costs incurred in obtaining medical treatment or rehabilitation
services. Nursing and other paramedical services are included when they are
likely to be beneficial, and an attendant's allowance is payable in addition to
compensation to severely disabled claimants.
3-0100-3 Definitions
3. Definitions. By statute, the term "physician" includes surgeons, podiatrists,
dentists, clinical psychologists, optometrists, osteopathic practitioners, and
chiropractors within the scope of their practice as defined by state law.
a. Psychologists. OWCP has accepted the American Psychological
Association's definition of a clinical psychologist as an individual who:
(1) Is licensed or certified as a psychologist at the independent
practice level of psychology by the state in which he or she practices,
and
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(2) Either possesses a doctoral degree in psychology from an
educational institution accredited by an organization recognized by the
Council on Post-Secondary Accreditation or is listed in a national
register of health service providers in psychology which the Secretary
of the Department of Labor deems appropriate, and
(3) Possesses two years of supervised experience in health service,
at least one year of which is post degree.
b. Chiropractors. These practitioners are defined as "physicians" only to
the extent that their reimbursable services are limited to treatment consisting
of manual manipulation of the spine to correct a subluxation as
demonstrated by X-ray to exist. A chiropractor has the right to interpret his
or her own X-rays to determine whether they support the diagnosis of
subluxation and to determine any period of disability resulting from that
condition. OWCP defines subluxation as an incomplete dislocation, off-
centering, misalignment, fixation or abnormal spacing of the vertebrae.
c. Physicians' Assistants. These practitioners, who are not physicians
under the Act, receive academic training and clinical experience and may be
certified by the National Commission on the Certification of Physician's
Assistants. A report prepared by a physician's assistant which is
countersigned by a physician should be accepted as medical evidence.
d. Religious Practitioners. The Christian Science Church permits
treatment of its members only by its own practitioners, though it has no
objection to periodic examinations to determine entitlement to compensation
and to assess whether maximum medical improvement has been reached.
The FECA does not authorize treatment by nonmedical practitioners of the
healing arts, such as psychic healers or faith healers, although they may be
permitted at the claimant's expense.
3-0100-4 Subjects Covered
4. Subjects Covered. The roles of the District Medical Director, District Medical
Adviser, Medical Management Assistant, and Staff Nurse are discussed briefly in
Chapter 3-200, and the Staff Nurse's work is addressed more fully in Chapter 3-201.
Chapter 3-202 addresses certification procedures for contract nurses. The
procedures for authorizing treatment and the provision of supplies are described in
Chapter 3-300, while treatments and supplies which may be authorized under the
FECA are detailed in Chapter 3-400. The process of obtaining medical evaluations is
described in Chapter 3-500, and requirements for medical reports are detailed in
Chapter 3-600. Schedule award determinations are considered in Chapter 3-700.
Procedures for excluding a medical provider are detailed in Chapter 3-800, and
administrative matters are considered in Chapter 3-900.
CHAPTER 3-0200 - FUNCTIONS OF THE
MEDICAL UNIT
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TABLE OF CONTENTS
Paragraph Subject Date Trans. No.
Table of Contents 05/94 94-24
1. Purpose 04/93 93-24
2. Structure of the Medical Unit 04/93 93-24
3. District Medical Director (DMD) 04/93 93-24
10/90 91-02
4. District Medical Adviser (DMA) 10/90 91-02
5. Medical Management Assistant (MMA) 10/90 91-02
04/93 93-24
6. Staff Nurse 04/93 93-24
3-0200-1 Purpose
1. Purpose. This chapter describes the roles and responsibilities of OWCP
medical staff, which usually includes a senior Federally employed physician as
District Medical Director, (DMD), one or more District Medical Advisers (DMA), one or
more Medical Management Assistant(s) (MMA), and a Staff Nurse.
3-0200-2 Structure of the Medical Unit
2. Structure of the Medical Unit. The responsibility for oversight of the Office's
medical benefits program is vested in the DMD, who works under the medical
guidance of the OWCP National Office Medical Director and the administrative
supervision of the Regional Director (RD) or the District Director (DD). A district
office may have one or more DMAs (usually contract employees), and the functions
of each office's Medical Unit are aided by one or more MMAs. The Staff Nurse
coordinates the work of the Field Nurses who act on behalf of each district office in
the case management process.
3-0200-3 District Medical Director (DMD)
3. District Medical Director (DMD). The functions of the DMD include the
following:
a. Establishes liaison with regional professional societies State health
departments, and individual providers within the district office's jurisdiction.
The DMD can familiarize the medical community with the nature of the
program and its needs and objectives. Specific areas which may be
addressed include types of medical reports and their use within the program;
requirements for content and quality of medical reports and the impact of
these factors on the length of the adjudicatory process as well as continued
use of a particular consultant; the Office's commitment to the rehabilitation of
the employee and the resources available to this end; and new policies and
procedures as warranted.
Such meetings allow the DMD to transmit concerns and suggestions from the
medical community to district office managers. These contacts may be
arranged by the DMD alone, or by the DMD in conjunction with district office
management, and it may take the form of contacts with local medical
societies and other groups of physicians such as the medical staff of local
hospitals, and providers in group practices. The DMD may also obtain from
district office files the names of physicians who have served as consultants in
cases involving a particular disease, such as asbestosis, and sponsor
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meetings to discuss changes in diagnosis and treatment as well as
administrative matters.
b. Visits with major employing agencies within the district office's
jurisdiction. The DMD can also perform a useful function by encouraging
employing agency personnel to conduct limited outreach efforts with
physicians in their respective geographic areas. Such efforts may include
tours of the employing agency and demonstrations of the types of light duty
which may be available to partially disabled workers, so that physicians will
be more aware of options other than continuing the claimant on total
disability.
c. Identifies and evaluates the credentials of physicians willing to serve
as consultants (DMAs) to manage workloads. (The method of selecting a
consultant for this function is identical to the procedure for obtaining second
opinion examinations, which is described in Chapter 3-900).
d. Establishes and administers a network of medical specialists (second
opinion specialists) and DMAs who provide the Office with medical opinions
(see Chapter 3-900).
e. Provides training and guidance to Claims Examiners (CEs) and other
district office staff regarding medical issues. The DMD may properly advise
CEs concerning the tone and content of letters sent to members of the
medical community. He or she may provide formal and/or informal training
on common conditions and medical treatment issues to the district office
staff. The DMD also has an advisory role to bill pay staff within the district
office.
f. Identifies and reports medical trends to district office management and
the OWCP Medical Director. The DMD advises the DD or RD concerning
customary ranges of fees for various services in the area and advises the RD
concerning exclusion of medical providers. The DMD will monitor the
performance of referral specialists and advise the DD or RD of physicians
whose reports are consistently incomplete, unreliable, or late.
g. Provides professional opinions and technical advice in connection with
the adjudication and management of complex claims.
The DMD does not perform medical examinations or functions of a clinical nature
except for participating in evaluation of claimants who seek an award for
disfigurement of the face, head or neck (see Chapter 3-700). Moreover, while the
DMD does not act in a supervisory capacity per se, he or she does have
administrative oversight with respect to the medical functions of the district office.
3-0200-4 District Medical Adviser (DMA)
4. District Medical Adviser (DMA). The functions of the DMA (and the DMD
insofar as he or she performs medical evaluations of case files) include interpretation
of medical reports; rendering medical evaluations in his or her own right; and
providing guidance or instruction to claims staff regarding general medical issues
which are in compensation claims.
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a. Interpreting Medical Reports. The CE seeks the interpretive function of
the DMA where the medical evidence is complete and sufficient prior to such
review. In this form of review, the DMA may determine the percentage of
permanent partial impairment, evaluate test results, or "translate" technical
language. The DMA may also be asked to review reports from referee
specialists where a schedule award is at issue (see Chapter 3-600).
b. Rendering Medical Evaluations. The CE seeks advice from the DMA to
proceed with developing and weighing the medical evidence where the
report from the attending physician, second opinion or referee
specialist is not clear and well rationalized, and the DMA provides written
opinions on medical questions posed by members of the claims staff.
In this capacity, the DMA may advise whether a claimant's condition is
employment-related, whether the effects of an accepted condition continue,
and whether the claimant is receiving appropriate medical care, including
whether recommended procedures, appliances or treatment are useful or
necessary. The DMA may also be asked to comment on proper development
of the medical evidence where an unusual condition is under consideration.
The Employees' Compensation Appeals Board has addressed the role of the DMA in
its decision in the case of Carlton L. Owens, 36 ECAB 608:
The role of the Office medical adviser is to act as a consultant in reviewing
cases under the Federal Employees' Compensation Act. Claims examiners
make use of the services of medical advisers in adjudicating the issues of
causal relationship, extent of disability, degree of permanent impairment, and
suitability of work. The Office medical adviser's role is not to act in an
adjudicatory capacity or address legal issues in the case, and the Office
should carefully observe the distinction between adjudicatory questions which
are not appropriate and medical questions which are appropriate.
c. Monitoring Medical Care. While the DMA does not routinely monitor
cases to ensure adequacy of medical care, he or she is expected to recognize
issues regarding the quality of care arising in the cases he or she evaluates.
CEs may also identify cases where the propriety of medical care is in question
and should refer them to the DMA for action or advice. Issues may include:
(1) Appropriateness/Usefulness of Treatment. The criteria used in assessing the
suitability of medical care as well as Office policies regarding specific treatments and
appliances which may be authorized are discussed in Chapter 3-400.
(2) Length of Treatment. The duration or frequency of treatment appears
excessive for the condition or incompatible with the norm for the medical
community.
(3) Transfer of Medical Care. Claimants not infrequently request changes in
attending physician, but the Office seldom initiates this action. Transfers of care
should be handled according to the claimant's medical needs with due regard for
medical protocol.
A case sent to the DMA for evaluation of another matter may reveal
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issues pertaining to the suitability of medical care, and the DMA is
expected to use his or her medical expertise to recognize such
problems and bring them to the CE's attention.
3-0200-5 Medical Management Assistant (MMA)
5. Medical Management Assistant (MMA). The MMA's function is to assist the
DMD in the administration of the Medical Unit and to perform associated support
functions, which include:
a. Screening. The MMA examines incoming case files to ensure that all
necessary information is present, including a list of questions and Statement
of Accepted Facts.
b. Scheduling. The MMA schedules appointments for second opinion and
referee examinations in accordance with the Office's procurement and
rotation policies and the specific requirements of each type of examination.
c. Advising of Arrangements. The MMA prepares letters to claimants and
physicians once such examinations have been scheduled and ensure that all
necessary information and material is provided to each party.
d. Record-Keeping. The MMA maintains records concerning utilization of
physicians in each category as well as logs pertaining to prompt payment of
bills; keep records of cases out of the office and contact physicians when
reports and cases are overdue.
e. Documenting Exclusion Data. The MMA maintains information
concerning exclusion of medical providers and ensures that documentation of
alleged infractions is routed to the correct parties within the district office.
f. Keying. The MMA may key outgoing cases to other parts of the district
office. The MMA ensures that location printouts reflect only the cases actually
present in the medical unit, and initiates searches for any other cases.
3-0200-6 Staff Nurse
6. Staff Nurse. The OWCP Staff Nurse is responsible for coordinating the nurse
intervention process in the district office, which in turn is directed toward managing
disability claims to facilitate recovery and, if possible, return to work. This function
includes:
a. Selecting cases for intervention, in some district offices, and assigning
them to Field Nurses with the CEs' concurrence.
b. Acting as liaison between the Field Nurses and CEs. This function
includes answering questions from both parties, interpreting OWCP practices
to the Field Nurses, and helping the CEs to understand the nurses' role in
managing cases.
c. Procuring and selecting enough field Nurses to provide high quality
services to OWCP claimants, and managing and monitoring their activities on
a case by case basis as well as cumulatively.
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d. Training Field Nurses on intervention procedures and formal and
informal training of CEs and OWCP staff on these procedures and other
medical topics as warranted in the particular office.
e. Performing other liaison activities such as outreach to the medical
community and scheduling certain second opinion and impartial examinations
to ensure that these are performed in a timely fashion and the resulting
reports address CEs' concerns fully.
See PM 3-201 for a fuller discussion of the Staff Nurse's duties.
CHAPTER 3-0201 - STAFF NURSE SERVICES
TABLE OF CONTENTS
Paragraph and Subject Date Trans.No.
Table of Contents 11/98 99-06
1. Purpose and Scope 04/93 93-29
2. Definition 04/93 93-29
3. Nurses' Roles in the District Offices 04/93 93-29
4. Types of Nurse Interventions 04/93 93-29
5. Phases in the Intervention Process 04/93 93-29
6. Preliminary Steps 04/93 93-29
09/95 95-39
7. Performing Interventions 04/93 93-29
08/94 94-34
10/95 96-04
09/96 96-15
8. Extensions and Interruptions of Nurse Services 09/96 96-15
9. Communications Between the CE and RN 09/96 96-15
10. Tracking the Nurse Intervention 09/96 96-15
11. Liaison Activities 09/96 96-15
12. Supervising Field Nurses 09/96 96-15
13. Other Medical Management Functions of the
Staff Nurse 09/96 96-15
14. Billing by the Field Nurse 09/96 96-15
15. Functional Capacity Evaluations (FCEs) 11/98 99-06
Exhibits
1. Initial Evaluation of Claimant 12/94 95-04
2. Progress Record 12/94 95-04
3. Sample Advertisement for Nurse Services 12/94 95-04
4. General Selection Guidelines 12/94 95-04
5. Suggested Training Topics 12/94 95-04
6. Sample Letter Authorizing Nurse Services 12/94 95-04
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7. Prompt Pay Authorization (Link to Image) 12/94 95-04
3-0201-1 Purpose and Scope
1. Purpose and Scope. The role of the Staff Nurse in the FEC district offices is to
aid in managing disability cases. The Staff Nurse's role and functions in this process
are the subject of this chapter. Included in the discussion will be specific nursing
functions, intervention and liaison activities which will assist the Claims Examiner
(CE) in managing cases.
3-0201-2 Definition
2. Definition. In its broadest scope, case management is a comprehensive
approach to minimize the length and perhaps the extent of disability in some
compensation cases. In this process, nurses will play a vital role by participating in
the early, aggressive medical management of cases. The primary focus of the
nurses' activities will be to encourage recovery and the return to work through direct
interventions with the claimants, treating physicians, and employing agencies.
3-0201-3 Nurses' Roles in the District Offices
3. Nurses' Roles in the District Offices. Nurses involved in case management
may be OWCP staff members or private sector professionals working with the
program on a contractual basis. While the latter (Field Nurse) can perform only the
actual interventions, the OWCP Staff Nurse may coordinate nurse intervention as
well as actually intervening in cases.
a. The Nurse Intervenor Role. The Staff or Field Nurse functioning in this
role will be working closely with OWCP office staff and claimants, physicians in
the community, and employing agencies to assist in the return to work effort.
For clarity, a nurse acting in this role will be designated as Field Nurse
throughout this chapter.
b. The Nurse Coordinator Role. The OWCP Staff Nurse acting in this
capacity is responsible for coordinating the nurse intervention process in the
district office. This function includes:
(1) Selecting cases and assigning them to the Field Nurse(s),
(2) Managing Field Nurses and monitoring their activities on a case
by case basis as well as cumulatively,
(3) Acting as liaison between the Field Nurses and CEs,
(4) Procuring and selecting enough field Nurses to provide high
quality services to OWCP claimants,
(5) Training Field Nurses on intervention procedures and formal
and informal training of CEs and OWCP staff on these procedures and
other medical topics as warranted in the particular office, and
(6) Performing other liaison activities such as outreach to the
medical community and scheduling certain second opinion and
impartial examinations to ensure that these are performed in a timely
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fashion and the resulting reports address CEs' concerns fully.
3-0201-4 Types of Nurse Intervention
4. Types of Nurse Intervention. The nurse intervention process can be classified
according to the degree of interaction: limited, moderate or intensive. The Staff
Nurse determines the appropriate type of intervention based on the diagnosis, the
severity of the injury or illness and demographic considerations.
a. Limited intervention consists of telephone interaction only. This
method provides the ability to reach a greater number of claimants and is
most effective in uncomplicated sprains and strains with a delayed return to
work date. Phone contact is initiated with the claimant and details of the
injury are discussed. In the follow-up phone calls, the nurse reinforces the
treatment regimes of the treating physician and formulates return to work
plans with the claimant and treating physician.
While phone contacts are not restricted as to frequency, the nurse must keep
in mind that too many phone contacts may inadvertently reinforce patients
who exhibit high levels of pain and illness behavior. If contacts are set up on
an as-needed basis, patients having the most difficulty will likely get the most
contact. Intervention, to be effective, should be completed within four
months.
b. Moderate intervention combines both phone calls and face-to-face
interaction. This type of intervention begins with phone contact but as the
intervention continues, evolving circumstances may warrant face to face
contact.
For example, if in the course of phone intervention, it becomes apparent that
the claimant's physician is planning surgery, a re-operative/post-operative
visit by the nurse will assist to reinforce return to work goals. Typically, these
interventions will not exceed four months' duration. However, there will be
cases (complicated post-operative period) requiring an extension of the
nurse's time, and the CE must provide authorization for this extension.
c. Intensive intervention is reserved for catastrophic cases such as head
or spinal cord injuries with extensive functional deficits where the medical
recovery is expected to extend over long or indefinite periods of time. In
these cases, the immediate intervention is directed at the claimant's needs
during the acute phase of injury (coordinating hospital care with the variety of
specialists in the case) and continues until stabilization (e.g., placement in a
rehabilitation facility or home with modifications) has been achieved and
vocational rehabilitation can be recommended.
Usually vocational rehabilitation services do not begin until nurse services
end, but in these cases it may be important to begin vocational counseling
during the period of nurse intervention. The Field Nurse assigned to the case
is responsible for identifying cases that may benefit from vocational services.
He or she should communicate this recommendation to the CE involved in the
case.
3-0201-5 Phases in the Intervention Process
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5. Phases in the Intervention Process. The intervention process, regardless of
the type, can be divided into four stages as briefly described below. Throughout
each phase, the nurse monitors the quality of medical care rendered to the claimant
and communicates frequently with the CE regarding the claimant's progress.
a. Identification Phase. The Staff Nurse, CE or other staff identifies cases for
intervention according to standard criteria. Communication is initiated with all
parties: claimants, treating physicians and employing agencies.
b. Monitoring Phase. The Field Nurse reviews the physician's overall
treatment plan and identifies areas needing CE attention (prior authorization
for surgery, prolonged bed rest, etc.) As necessary, the nurse discusses
issues with the parties concerned and participates in updating or modifying
the treatment plan to fit the claimant's changing health status.
c. Assessment Phase. The Field Nurse determines whether return to work
is possible and whether return to work plans are available and feasible.
Collaborates with all parties (CE, physician, agency, claimant) to implement
the return to work.
d. Discharge Planning Phase. The Staff Nurse assesses the outcome of
the intervention and, as necessary, follows up in the case to ensure continuity
in its management. If the claimant has returned to work, the Field Nurse will
provide follow-up for 60 days. In cases where the nurse intervention period
has expired and the return to work has not occurred, the Staff Nurse will refer
the case to the CE with appropriate recommendations such as referral for
vocational rehabilitation services, second opinion, etc.
3-0201-6 Preliminary Steps
6. Preliminary Steps. Nurse intervention early during the period of disability is
one of the major components of the quality case management procedures. This
section details all the important aspects and steps in this process.
a. Criteria for Case Selection. Cases which have been traditionally
associated with poor outcomes in terms of return to work, cases where the
outcome is uncertain, and cases where specific medical issues need to be
clarified, should be referred for nurse intervention.
(1) Traumatic Injury Cases. Although the ideal time for nurse
intervention is from 45-90 days after the day of injury, the CE may
refer traumatic injury cases for nurse intervention regardless of the
time elapsed since the injury if:
(a) The medical evidence does not state a return to work
date;
(b) The return to work date is unrealistic (i.e., not in
keeping with the magnitude of the original injury);
(c) The return to work date is extended without clear
medical reasons;
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(d) The claimant is partially disabled but the file does not
contain a description of work limitations;
(e) The CE requires additional medical information for the
initial or continuing authorization of unusual and/or prolonged
services such as intensive home nursing, housing modifications
and extensive surgery or physical therapy.
(2) Occupational Illness Cases. These cases ordinarily require
more than 90 days to adjudicate, thus placing them outside the
optimum time frame for nurse intervention. Therefore they will not
routinely be referred for continuing nurse intervention, though they
may be referred for advice and assistance with particular issues [see
paragraph a(1)(e) above]. Referral for vocational rehabilitation
services will likely be more appropriate in most occupational illness
cases.
b. Sources of Cases for Nurse Intervention.
(1) CE Referrals. CEs are tasked with identifying cases that meet the criteria
indicated above. The CEs will identify a significant number of these cases at the time
of the authorization for the first compensation payment (excluding most leave buy-
backs and schedule awards).
(2) Automated Reports. Staff Nurses may identify cases that meet
the above criteria using automated reports of CA-7 payments or other
reports containing similar information.
(3) Other Sources. In some instances, employing agencies,
Vocational Rehabilitation Specialists, District Medical Directors or
Advisors and others can identify cases which may benefit from nurse
services. All cases referred in this fashion should be discussed with
the CE before nurse intervention is offered to the claimant since the
final authority to intervene with the claimant remains a prerogative of
the CE.
c. Work/No Work Call. The initial interaction with claimants occurs
during the initial telephone call. The purpose of this call is to ascertain the
work status of the claimant and to inform those claimants who meet the
above indicated criteria of the intended nurse intervention in his or her case.
The CE may make this call. However, in those offices where the Staff Nurse
identifies potentially eligible cases from automated reports, this call will be
the responsibility of the OWCP Staff Nurse and he or she should follow the
steps detailed below:
(1) If the claimant has returned to full duty, the nurse notifies the
CE. In most instances, the nurse recommends that further
intervention is not necessary. However, in some cases where the
nurse has reason to believe that the medical condition is unstable or
that the claimant might stop working for other reasons, he or she may
recommend a follow-up call in four weeks to verify that the claimant
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remains at work;
(2) If the claimant has returned to modified and/or part time duty,
the nurse will notify the CE, who will make a decision as to whether
the claimant is to be followed until he or she returns to full-time
employment.
(3) If the claimant has not returned to work but knows when the
return to duty will occur, and the date appears realistic according to
the medical evidence, medical matrix or MEDGUIDE in Folioviews, the
Staff Nurse sets up a call-up for the date specified and calls the
employing agency on that date to find out if the claimant has in fact
returned to work.
(4) If the claimant has not returned to work at the time of the
follow-up call, and either does not state a plan to return to duty or
offers a date inconsistent with the nature and severity of the injury,
the nurse explains the nurse intervention program to the claimant and
attempts to engage the claimant in the program.
(5) Once the call is completed, the nurse notifies the CE of the
result using a Form CA-110 and recommending appropriate action on
Form OWCP-57. Although the intervention program is voluntary,
participation should be strongly encouraged. A claimant who refuses
to be visited may nonetheless allow intervention by telephone. If the
claimant refuses to participate altogether, the nurse ends the
telephone conversation but reports this result to the CE. The nurse
should attempt to secure a medical release from the claimant so that
communication may be initiated with the attending physician.
3-0201-7 Performing Interventions
7. Performing Interventions. The Staff Nurse selects the type of intervention
needed based on the nature and severity of the claimant's condition, the claimant's
geographic location and other factors. At the same time, he or she assigns the case
to a nurse who will actually perform the intervention, and notifies the claimant,
physician, employing agency and the CE.
a. Initial Contacts.
(1) Claimant. The Field Nurse notifies the claimant that they will
be working together through the recovery stage. He or she also
advises the claimant that the treating physician will be made a part of
this collaborative return to work effort.
(2) Treating Physician. The Field Nurse will contact the treating
physician to discuss current and future treatment regimes. Emphasis
is placed on identifying and managing open-ended treatments such as
bed rest and physical therapy, as well as prolonged therapy with pain
medications. As necessary, the nurse may discuss medical issues with
the District Medical Director (DMD) or Advisor (DMA), or may
recommend a second opinion to clarify issues. Ultimately, a return to
work date and concrete work limitations, if needed, will be discussed
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and formulated using Form OWCP-5. As with the claimant, contact is
made initially by phone followed by a confirmation letter.
(3) Employing Agency. The agency will also be contacted by the
Field Nurse. Communication with the agency begins with the
claimant's supervisor or the injury compensation specialist because
this person can furnish important information regarding the job in
question as well as provide some sense of pre-existing interpersonal
issues which may affect the return to work effort.
There are a variety of reasons for the nurse to contact the employing
agency. For example, the nurse notifies the compensation specialist
that one of their employees has been contacted by a nurse, verifies
that the employee has or has not returned to work and, when
applicable, informs the agency that the physician has imposed some
physical limitations for the return to work.
b. Intervention Guidelines. The Field Nurse assigned to the case
performs the intervention. The nurse is responsible for structuring the
intervention in terms of the number, content and the length of contacts with
the claimant and other parties involved. To do so, the nurse should keep in
mind the following guidelines:
(1) The focus of the program is the return to work and the claimant
should be encouraged to participate actively in the treatment plan and
in the resolution of problems which may impact on the recovery effort.
(2) Visits or calls to the claimant should be scheduled on time-
contingent basis rather than as a response to the appearance or
exacerbation of symptoms.
(3) The treating physician should participate in this process by producing a
treatment plan and a projected length of disability which are commensurate with the
claimant's signs and symptoms. If these are not forthcoming or if the physician
refuses to communicate with the nurse, the intervention with the claimant and
employing agency should continue and the MD's refusal to participate should be
communicated to the CE.
(4) Although the Field Nurse is responsible for structuring the number, length,
content and medium (telephone, face-to-face) of the interactions with all
participants, he or she should be aware that the intervention is a finite process. The
intervention is limited to 120 days from the date of referral. In some instances,
where there is substantive evidence that the return to work will occur shortly, the CE
may authorize an additional period of 30 days. Once the period for nurse
intervention has been exhausted, the case is referred to the CE for further action.
c. Intervention Process.
(1) During the first 30 days of intervention, the Field Nurse
determines whether the physician has formulated a treatment plan
and whether the claimant's physical condition is improving. As
necessary, the nurse discusses the formulation or modification of the
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15
plan with the physician and the claimant.
As soon as the Field Nurse completes the visits with the claimant and
treating physician, the nurse discusses findings from the visits and the
subsequent plans for follow up action with the CE and the Staff Nurse.
The DMD/DMA may be consulted to ensure that the treatment is
appropriate for the claimant's condition. The CE is made aware of the
need to authorize particular therapies, and that the return to work is
part of the treatment plan.
Once the plan has been formulated, the nurse monitors the physical
progress of the claimant and obtains a return to work date from the
physician, when appropriate. If necessary, the nurse forwards a
OWCP-5 form to the treating physician to define the work restrictions
present and the level of function of the individual. He or she may
discuss the content and the use of the form by OWCP and the
employing agency with the physician.
The nurse may also recommend a second opinion examination, and
with the CE's concurrence, schedule it. However, if the physician
selected is not listed in the Physicians' Directory System, the nurse
should advise the Medical Management Assistant of the physician's
name and address so that this information can be added to the
system.
(2) The nurse works with the employing agency to ensure that the
physical demands of the job are in keeping with any restrictions
imposed by the physician, that there are no significant barriers to the
return to work, and verifies that the return to work occurs on or near
the expected date.
If the return to work is delayed, the Field Nurse communicates this to
the CE and discusses the reasons with all parties concerned as
necessary. The nurse endeavors to re-establish the return to work
emphasis, define a new date and verify that indeed the claimant
returns to work on or near the expected date.
(3) If the return to work date obtained is not within 120 days from
the beginning of the intervention, there is no significant improvement
in the condition of the claimant, or the physician does not produce a
plan, the Staff Nurse ends the intervention and refers the case to the
CE for action. Upon closing the case, the Staff or Field Nurse may
choose to offer specific recommendations such as referral for a second
opinion examination, referral to vocational rehabilitation, or change of
physician.
(4) If the claimant does not return to work on or near the return to
work date, or remains at work less than 60 days, the nurse needs to
determine the underlying reasons and take appropriate action. If a job
adjustment problem (difficulty with the employing agency) is the cause
for the continuing lack of employment or stopping work, the nurse
refers the case to the CE for further action, clearly stating the nature
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of the problem.
However, if medical problems prevent or cut short the return to work,
the nurse ensures the completion of OWCP-5 by the physician, closes
the intervention and refers the case to the CE. Where the OWCP-5
indicates that the claimant is able, or will be able, to work four hours
or more, the nurse recommends vocational rehabilitation services.
The SN may complete Form OWCP-14 to refer the case for vocational
rehabilitation services, but may not sign the form. The actual referral
remains the CE's responsibility.
If there are no job adjustment or medical problems, but the nurse has
reason to believe that there is non-cooperation on the part of the
claimant, he or she refers the case to CE for further action, presenting
well reasoned justification for his or her opinion.
(5) The CE may decide that a conference call involving the injured
worker, employing agency, Field Nurse, Staff Nurse, CE and Senior CE
will help clarify return to work issues at this point.
d. Case Closure. Nurse intervention can result in various outcomes. If
the intervention has been continuing in nature, the expected result is the
return to work. In most instances, the claimant will return to the pre-injury
position, with or without modifications, or to a light duty arrangement.
Although it is possible that the worker will return to a position outside of his
or her agency during the nurse intervention period, this is not considered
likely. In a number of cases, the return to work will not occur within the
intervention time frames. In both instances, the Staff Nurse will ultimately
close the case from the nurse intervention viewpoint and refer it to the CE for
further action.
(1) To ensure that the adjustment to work is satisfactory, contact is
made with the claimant at least three times during the course of 60
days: on the first day of work, at the end of the first month and at the
end of the 60 days. The Field Nurse will accompany the claimant to
the facility on the first day back on the job. A meeting is held by the
Field Nurse with all concerned (claimant, supervisor, injury
compensation specialist) to confirm an understanding of the basis of
the return to work requirements and to clarify roles.
Should the Field Nurse identify physical or psychological barriers,
deterioration of the medical condition, or any other indication that the
return to work may not be successful, he or she contacts all interested
parties as necessary to resolve the issues within the 60 day time
frame. Monitoring the return to work beyond this period requires CE
approval.
(2) At the end of the 60 days or later if an additional follow-up
period has been approved, the Field Nurse prepares a memorandum to
the Staff Nurse describing the intervention, the type of work accepted
by the claimant, and the date of the placement. In turn, the Staff
Nurse forwards the memorandum to the CE assigned to the case,
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17
closes the case from a nursing viewpoint and notes the return to work
in the tracking system.
(3) If the claimant does not return to work during the intervention,
does not remain at work for 60 days, or does not accept the
intervention or cooperate with the nurse, the Field Nurse prepares a
memorandum for the Staff Nurse stating the problem and
recommending closure of the case and a future course of action
(second opinion, change of physician, referral to vocational
rehabilitation, etc.) The Staff Nurse reviews the case and the Field
Nurse reports, closes the case if warranted and advises the CE of the
particular issues of the case and makes appropriate recommendations.
3-0201-8 Extensions and Interruptions of Nurse Services
8. Extensions and Interruptions of Nurse Services. The nurse intervention will
usually last 120 days or less. In catastrophic injury cases, or in cases where the
time and/or dollar limits are exceeded by small amounts and it is clear that the
claimant will return to work within a short period of time, the intervention may
extend beyond this limit if the CE authorizes extensions of time or money.
Extensions of services may also be necessary or desirable in other cases to ensure
that initial return to work is successful, or to help the claimant reach higher levels of
physical capacity, resulting if possible in return to full-time full duty. Extensions may
also be granted if work-related surgery is necessary, or if the injury is a catastrophic
one. Interruptions of services may be desirable because other medical conditions,
either work-related or not, hinder the return to work effort.
a. Extensions.
(1) Initial Return to Work. The CE may approve a 30-day
extension (60 days if requested so that the nurse can provide follow-
up services after return to work). During this period, the Field Nurse
may charge for 60 professional hours or $3,000, whichever comes
first.
(2) Increase in Duty Status. Where the claimant has not returned
to full-time full duty, the FN should stress the need to return to
maximum functioning and work potential. The FN should also continue
to pursue increases in work tolerance limitations and obtain
descriptions of them on Form OWCP-5 at periodic intervals if the
claimant does not return to full-time full duty. These attempts should
be made at approximately two to three week intervals unless the facts
of the case suggest a different plan.
After the 60-day follow-up period ends, the FN may continue to work
toward full-time full duty if the medical evidence shows that such an
outcome is likely. The FN and the Staff Nurse should recommend
additional time in increments of no more than 30 days each, up to a
total of 60 days. The CE must authorize each increment.
(3) Need for Surgery. Below are listed some common surgical
procedures and their usual recovery times. In general, the simple
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18
procedures should require no more than 8-10 hours of
professional services within the 30-day period. The moderately
complex procedures will require about 12-16 hours of services
within the 60-day period. Since the complex procedures will
typically result in work limitations which may warrant referral for
vocational rehabilitation services, the FN should work toward
stabilizing the claimant's condition and obtaining Form OWCP-5 in
these cases.
TYPE OF SURGERY PROCEDURE EXTENSION
A. Simple, Endoscopies, 30 day extension,
uncomplicated diagnostic for a maximum of
arthroscopy, 150 days
herniorrhaphy
B. Moderately Discectomies 60 day extension,
complex for a maximum of
180 days
C. Very complex Multiple Work with claimant
surgery or surgery fusions, open until stable, then
with serious heart surgery, refer for rehabili-
complications amputation tation services
of limb
b. Interruptions. Return to work may be affected by other medical
conditions (work-related or not), including pregnancy. The CE must approve
interrupted status, which should not continue more than six months. The
status code "NIN" (Nurse Interrupt) should be used.
(1) Concurrent Conditions. For a concurrent non-work-related
condition, or surgery (whether work-related or not), the SN should
determine whether continued FN services will likely be needed within
six months. If so, and the CE concurs, the SN should place the case in
interrupted status until the time of expected recovery. (Interrupted
status, rather than an extension, is appropriate since the claimant
would require little or no active involvement by the FN during this
time.)
(2) FN Actions. During the interruption, the FN should stay in
touch with the claimant to monitor medical issues and maintain a focus
on return to work. If surgery is involved, the FN will typically review
the attending physician's orders with the claimant after surgery and
monitor the claimant's course at home. Also, the FN may discuss the
post-operative plan with the physician by telephone and monitor the
claimant's compliance with these orders. The RN may perform these
services up to five hours per month.
3-0201-9 Communications between the CE and the RN
9. Communications between the CE and the RN. The Field Nurse should inform
the Staff Nurse of the medical progress of the claimant and of issues which may
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hinder the recovery process. As necessary, the nurse should provide thoughtful
recommendations for further action. An initial evaluation after the first contact with
the claimant and the treating physician, and monthly reports thereafter are
expected. For these reports, the nurse uses the Initial Evaluation and Progress
Report Form shown in Exhibits 1 and 2.
Periodically during the intervention and/or at the end of 120 days, the nurse and the
CE or Staff Nurse will confer, either by mail, written memorandum or face-to-face
meeting, to determine the next actions to be taken. The nurse is encouraged to
communicate either with the CE or the Staff Nurse informally as well as by written
report whenever this is necessary during the return to work effort.
3-0201-10 Tracking the Nurse Intervention
10. Tracking the Nurse Intervention. Using the data described below, the Staff
Nurse will be able to analyze various aspects of the program and obtain the basic
statistics necessary to manage the nurse intervention effort. These statistics
include: the numbers of claimants and nurses participating in the intervention
program at any given time, the duration and result of the intervention by case or in a
cumulative fashion in the district office, the rotation of cases among the Field Nurses
and other data.
a. Claimant Data. From the moment a claimant is selected for
intervention, the Staff Nurse or another designated individual must track the
case through the Case Management File (CMF) Tracking System and, in
district offices where it is installed, the Nurse Tracking System (NTS). The
CMF system will include the dates on which the case is referred from the CE
to the Staff Nurse and then to the Field Nurse. A return to work date is also
captured on this system.
b. Field Nurse Data. Information regarding the Field Nurses should also
be maintained, including the name of each nurse, his or her geographic
location, and hourly rate.
3-0201-11 Liaison Activities
11. Liaison Activities. By definition, case management includes the referral of
certain injured workers for second opinion and referee examinations by medical
specialists to ensure the appropriateness of the treatment plan, verify the level of
disability and address other issues related to the medical recovery. To have the
expected impact, these examinations need to occur on a timely basis.
At district office option, the Staff Nurse can assist this process by: actually
scheduling these examinations; reviewing the outgoing CE questions and assessing
the incoming medical reports; interacting with the medical community to acquaint
them with FEC policies and procedures; and enlisting their participation in second
opinions and/or referee examinations. The nurse may also coordinate with the
DMD/DMA in identifying geographical areas requiring outreach activity and in
assisting in the recruiting and retaining of physicians for second opinion referrals.
a. Scheduling Examinations. The use of the Physicians' Directory System
(PDS), an automated directory and tracking mechanism, is mandatory in
scheduling all referee examinations and is optional in the scheduling of
second opinions. Details of this system are found in PM 3-500.7. The nurse
should consult FECA PM 3-500.3 and 3-500.4 for the procedures to be used in
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scheduling second opinion and referee examinations respectively.
The CE determines the need for these examinations and prepares a list of
questions to be answered by the examining physician. He or she should
indicate the type of specialist required. Claimants are to be scheduled as
close to home as is feasible (25 miles is considered reasonable in most urban
areas). In rural areas, and in some urban areas with shortages of physicians,
the claimant will have to travel over 25 miles.
b. Reviewing Outgoing Material. The nurse may review outgoing material
for comprehensiveness of medical data and clarity of the questions posed by
the CE. He or she may recommend changes and discuss issues with CE as
necessary.
c. Tracking Second Opinion and Referee Examinations. Usually, 30 days
is a sufficient time period after the second opinion or referee examination for
the specialist to submit the report. Follow-up phone calls should be made in
cases where no report has been received in the office within 30 days of the
examination. Once received, the report should be reviewed in light of several
factors:
(1) Timeliness is an important consideration in the assessment of
the quality of medical reports. District offices may set their own
criteria in this respect or use six weeks as the standard. Reports that
are not timely should be noted in the NOTES section of the PDS for
monitoring purposes. If the physician is late in submitting the report,
the nurse contacts his or her office and appraises him or her of this
fact and obtains a copy of the report as soon as possible. However, if
no report is forthcoming after a reasonable waiting period, the nurse
notifies the CE for further action.
(2) Content is also crucial. When the report does not address all
questions posed by the CE, or contains equivocal answers, the nurse
so notifies the CE. Upon request of the CE, the nurse may notify the
physician's office of these deficiencies and request clarification or
completion of the report. This second request is also tracked and
reimbursement for the examination may be withheld until clarification
is obtained.
3-0201-12 Supervising Field Nurses
12. Supervising Field Nurses. The Staff Nurse is responsible for procuring,
training and managing Field Nurses who will work directly with OWCP claimants in
the return to work effort.
a. Procurement and Selection. The Staff Nurse develops a structure and
a timetable for the procurement and selection of Field Nurses taking into
account the geographic, volume, and operational requirements of the district
office.
(1) Once the number and location of the Field Nurses needed has
been determined, the Staff Nurse solicits the services of nurses
through advertisements placed in local newspapers, occupational
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health journals or other nursing newsletters. Advertisements may also
be distributed to local hospitals, universities, nursing schools and
vocational rehabilitation companies. A sample advertisement to
procure contact nurse services is included in Exhibit 3.
(2) Field Nurses must be selected according to standard criteria
which include educational background, licensing, clinical experience,
medical case management, and specific workers' compensation or
occupational health experience. Selection criteria guidelines are
detailed in Exhibit 4.
(3) All applicants should be appraised by the Staff Nurse and any
other staff designated by the district office. The appraisals and the
reasons for the selections must be well documented by the Staff
Nurse.
(4) After the selection of candidates, the Staff Nurse ensures that
each receives and signs a memorandum of agreement. The document
details the various responsibilities of the nurse and the time frames
within which he or she is to accomplish them. The agreement also
details the nurse's hourly professional and administrative
reimbursement.
b. Training Field Nurses. Most commonly training of Field Nurses is done
at the district office location. The training for nurses contracted for this
project should not exceed one and a half days since there is no effective way
to reimburse them for their time. One day should be devoted to discussing
various FEC policies and procedures and one half day should be allocated to
addressing the nurse functions (report compliance and completion, billing
forms and coding schemes).
In those areas where travel by the Field Nurse to the district office would
require several hours or necessitate air travel, the Staff Nurse may wish to
consider travel to cities where the Field Nurses are located. The length of
training and the agenda topics should be the same. A suggested training
outline has been enclosed as Exhibit 5.
c. Managing Field Nurses. Once Field Nurse selections have been made
and memoranda of agreements have been signed, the nurse's name, phone
and address need to be recorded into the Nurse Tracking System, where
available, or into a manual log.
(1) Referring Cases to the Field Nurses.
(a) The Staff Nurse will refer cases to the Field Nurses using
geographic rotation. However, sometimes the special needs of
the claimant rather than locale may dictate the choice of nurse
for a specific case. For example, a claimant with a psychiatric
or neurologic disorder would benefit from the intervention of a
nurse having this kind of expertise. In this instance, the case
would be referred to the nurse having these qualifications
rather than to the next nurse on the rotation.
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(b) Once the selection is made, a letter which serves as an
authorization to perform these services is forwarded to the
nurse. This authorization letter reiterates the nurse's functions,
responsibilities and reimbursement rate as listed in the
memorandum of agreement. The authorization letter also
includes the claimant's name as well as all available medical
data for use by the nurse in his or her intervention. A sample
of this authorization letter may be found in Exhibit 6.
(c) It is recommended that the Staff Nurse maintain a file
on each Field Nurse. Data pertaining only to the nurse, e.g.
memorandum of agreement, credentials, warnings or
assessments of his or her work, can be kept in this folder. Any
data pertaining to claimants must be referred to their files.
(2) Field Nurses' Reports. The Field Nurse should complete the
Initial Evaluation Form, as shown in Exhibit 1, and return it to the Staff
Nurse within 30 days after initial contact with the claimant and the
physician. The Progress Report should be submitted to the Staff Nurse
on a monthly basis. However, Field Nurses may submit verbal or
written reports at any time to the Staff Nurse if issues needing
immediate attention arise.
The Staff Nurse should have reviewed and clarified the elements of
each of these reports during the Field Nurse training session. It may
prove useful to review these data elements again when the case is
referred. A supply of these forms may be included in the initial
authorization packet or sent to the Field Nurse under separate cover
with instructions for completion.
(3) Warning and Termination Procedures. The memorandum of
agreement with FEC identifies the responsibilities of the Field Nurse.
When any of these responsibilities are not fulfilled by the Field Nurse,
the Staff Nurse needs to take immediate corrective action.
For example, the nurse's reports are consistently late or there has
been no follow up either by phone or in person with the treating
physician. Such delays may hamper possible return to work
opportunities. The staff nurse needs to issue verbal warnings to the
field nurse after the first two violations, issue written warnings to the
field nurse after the second two violations, and terminate the field
nurse's working relationship with OWCP after the fifth violation,
ensuring that there has been 30 days' prior written notice.
3-0201-13 Other Medical Management Functions of the Staff Nurse
13. Other Medical Management Functions of the Staff Nurse. While the primary
function of the Staff Nurse is to coordinate nurse services, there are other medically
related activities which require his or her expertise. These areas include:
a. Complex Medical Bills. The automated enhancements to the medical
bill processing system will suspend bills for a variety of medical issues. The
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23
nurse may be called on to evaluate such issues as: assessing the relatedness
of a procedure to the accepted condition; clarifying the need for continued
prior authorized services (physical therapy, TENS units, home nursing
services); resolving excessive charges submitted by consultant physicians;
and performing random quality control reviews of bills after payment
approval.
b. Training on Medically Related Issues. The nurse may offer training to
CEs and other district office staff on an as-needed basis using any of the
following methods:
(1) A one-on-one session would be appropriate at the time a CE
requested information pertaining to a treatment modality, i.e., a
specific drug, diagnostic examination or operative procedure.
(2) An informal group session may prove helpful if the nurse is
approached by a Supervisory CE (SCE) to assist the module in a
specific issue, e.g., formulating the questions posed to treating,
second opinion and referee physicians.
(3) Formal group sessions may be organized when the nurse
identifies the expertise of a medical consultant, either in-house
(DMD/DMA) or from outside the Office, and arranges for that doctor to
discuss his or her specialty with the CEs and other office staff.
Training by the nurse may also be initiated with new DMDs/DMAs,
contact representatives and office staff resolving bill problems.
3-0201-14 Billing by the Field Nurse
14. Billing by the Field Nurse. Billing periods are to correspond to the report
(either Initial or Progress) service periods, i.e., monthly, and the program will not
accept bills that arrive without a report. A bill must not contain charges for services
that fall outside the billing period or for unpaid balances from prior billing periods.
a. The following requirements must also be met for reimbursement
approval:
(1) Form. The only acceptable billing form will be the HCFA-1500.
(2) Codes. Only the specific internal codes with appropriate
terminology and dollar amounts designated for professional and non-
professional services will be acceptable.
(3) Submission of Bills. A HCFA-1500 needs to be completed in
duplicate for each claimant receiving nursing service. A duplicate
report (initial/progress) must also be attached to the duplicate HCFA
form. The words "PROMPT PAY" should be written at the top and
bottom of the original HCFA billing form. The envelope should also be
marked "PROMPT PAY" to the attention of a designated individual. A
sample of a correctly completed HCFA-1500 form is shown as Exhibit 7
(Link to Image).
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3-0201-15 Functional Capacity Evaluations (FCEs)
15. Functional Capacity Evaluations (FCEs). These evaluations may
be classified in two types according to their purpose, duration and
content: a general-purpose FCE, and an FCE for placement into an
Occupational Rehabilitation Program (ORP) such as Return to Work or
Work Readiness (commonly called work-hardening, work conditioning,
etc.)
a. A CE or SN may authorize a general-purpose FCE in cases
where management of disability calls for clarification of job tolerances,
job modifications, etc., and the treating physician, second opinion or
referee specialist recommends or requires this service. However, only
a Rehabilitation Specialist can authorize an FCE in connection with an
ORP (see PM 2-813).
b. Before authorizing the FCE, the CE or SN should review the
case and verify that the injury occurred more than three months ago,
the functional impairment is of moderate to high complexity, and the
services recommended by the physician exceed routine physical
performance tests and measurements (e.g. CPT 97750). More
detailed guidelines appear in Chapter 1 of MEDGUIDE.
c. The CE or SN advises the recommending physician that the FCE
is approved. Based on the severity of the case and whether or not any
complicating factors are present, up to eight hours can be approved
for a general-purpose FCE.
d. The CE or SN completes the authorization form and enters the
authorization in the "Notes" section of the Case Management File
(CMF). To ensure the accurate processing of bills for the FCE, the
following information must be included: the approved service code, the
number of hours approved, the name of the provider, and, as
necessary, the use of modifiers.
The CE or SN also notifies the Field Nurse (FN) assigned to the case of the
authorization of the FCE and provides the FN with a copy of the authorization.
3-0201 Exhibit 1: Initial Evaluation of Claimant
TO: NAME OF CE OR COORDINATOR File #:
FROM: NAME OF NURSE ICD-9 Accepted
Condition:
PHONE #: NURSE'S TELEPHONE NUMBER
Claimant Name: Address:
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Primary Physician: Address:
Phone:
Employer:
A. PERSONAL INFORMATION
Family Dynamics and Home Situation (detail only those factors
which relate to claimant's return to work):
B. JOB HISTORY
Description of Injury (including date of injury):
INITIAL EVALUATION OF CLAIMANT, Continued
C. MEDICAL HISTORY
Current Medical Status (include consulting physicians)
History of Previous Injuries
Non-Injury-Related Medical Conditions
Current Medications
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Physician(s) Contacts/Conclusions
D. NURSING CARE PLAN
Potential Problems
Recommendations
Planned Services During the Next 30 days
Planned On-site Visit to Agency/Work Site
3-0201 Exhibit 2: Progress Record
Report Date:
Claimant Name: Case File #:
Claimant Address: ICD-9 Accepted
Condition:
Name of Nurse: Phone:
A. DATES OF SERVICE
From: To:
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B. SUMMARY OF PROGRESS TO DATE
C. ACTIONS TAKEN DATES
D. NURSING CARE PLAN
Planned Services For the Next 30 Days
Potential Problems Recommendations
3-0201 Exhibit 3: Sample Advertisement for Nurse Services
The U.S. Department of Labor, Federal Employees' Compensation Program (FEC) is
currently seeking to contract with nurses to work with claimants and their treating
physicians to coordinate treatment, promote recovery and ultimately facilitate the
return to work of the claimant.
An applicant must have the following minimum qualifications to be considered for
this service: a registered nurse (R.N.) license; at least two years of general medical-
surgical clinical experience; and at least two years of case management experience.
Additional expertise desired includes: a basic knowledge of workers' compensation
injuries and illness; excellent oral and written communication skills; good
organizational and time-management skills, and proven decision-making abilities.
Selection will be based on the combination of education and expertise that best
meets the needs of the Department of Labor.
The hourly rate for a contract registered nurse is $00.00 for professional services
and $00.00 for administrative services.
If you wish to pursue this opportunity, please submit your curriculum vitae showing
the qualifications as listed above, along with a copy of your current nursing license
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to:
DISTRICT OFFICE ADDRESS
All applications must be received in this office no later than DATE.
If you need further information, you may contact:
NAME, TITLE AND PHONE NUMBER
OF DISTRICT OFFICE CONTACT
3-0201 Exhibit 4: General Selection Guidelines
GENERAL SELECTION GUIDELINES
Describe qualifications under the following categories:
A. Nursing Degree (R.N.) License Number____________
B. Clinical Experience Dates
Specialty
General Medical-Surgical
Emergency
Critical Care Unit (CCU, ICU, etc.)
Other
C. Positions Held Dates
Staff Nurse
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Team Leader
Head Nurse
Other
D. Additional Experience Factors
- demonstrates in the C.V. that he/she has medical case
management experience.
- shows workers' compensation case experience through past
positions held, e.g. with DOL, State or private sector
carrier.
3-0201 Exhibit 5: Suggested Training Topics
SUGGESTED TRAINING TOPICS
A. Introduction
- Overview of Nurse Intervention
- Objectives of the Training
B. Training Outline
The Federal Employees' Compensation Program: CA-810
and CA-550
1. Coverage of FECA
- Constituency (variety of occupations)
- Kinds of Claims--traumatic,occupational diseases
- Kinds of Benefits--compensation, medical,
vocational
rehabilitation etc.
- Philosophy of the program--non-adversarial
- Organization of program; geographical distribution,
district office structure
2. How claims are adjudicated and managed (brief description)
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- Notice of Injury
- Forms CA-1 and CA-2
- Acceptance, ICD-9 diagnoses codes
- Continuation of Pay
- Compensation, short/long term
- Reemployment and Vocational Rehabilitation
3. Nurse Intervention Process
- Roles/responsibilities
- Reporting Mechanisms
- Claimant/Physician Communication
- Billing Procedures
- Security of Files
- Schedule for additional training/problem-solving
sessions
4. Tour of the District Office
3-0201 Exhibit 6: Sample Letter Authorizing Nurse Services
Case File #:
Claimant Name:
Employing Agency:
Dear NAME OF NURSE:
This letter serves as a referral and authorization to you to provide medical
management services to the above-named injured worker. It also serves as
notification that you may contact the treating physician to coordinate the medical
treatment, and the employing agency to clarify the requirements of the injured
worker's job. As previously discussed, your hourly rate will be $00.00 for
professional services and $00.00 for non-professional charges. There is a $3,000 or
60 hours of nursing service maximum limit per case. On an exception basis, one
extension only can be authorized, so that the total services per case may not exceed
120 hours or $6,000.
In case(s) assigned to you, your responsibility will be to communicate directly with
the injured worker and his/her family as deemed necessary to explain and monitor
medical treatment and progress. As needed, you will obtain concrete work
limitations and communicate directly with physician and agency about light duty
opportunities.
Enclosed is a summary of case information and the significant medical reports for
your official and confidential use. This information must be kept in a secure location
which only you have access to. When the case is closed, please return the case
information to this office. The case information supplied to you is the property of
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OWCP and cannot be discussed with parties other than the claimant, (claims
examiner/ coordinator), physician and employing agency.
Should you have any questions or comments regarding the contents of this letter,
please contact NAME OF CE OR COORDINATOR on PHONE NUMBER.
Sincerely,
STAFF NURSE
3-0201 Exhibit 7: Prompt Pay Authorization (Link to Image)
CHAPTER 3-0202 - CONTRACT FIELD NURSE
CERTIFICATION
TABLE OF CONTENTS
Paragraph and Subject Date Trans. No.
Table of Contents 03/95 95-12
1. Purpose and Scope 03/95 95-12
2. Certification Process 03/95 95-12
3. Field Nurse Allocation 03/95 95-12
4. Recruitment 03/95 95-12
5. Nurse Selection Method 03/95 95-12
6. Interview 03/95 95-12
7. Notification To Applicants 03/95 95-12
8. Certification Training Workshop 03/95 95-12
9. Option Year Renewal 03/95 95-12
10. Contract Field Nurse Management 03/95 95-12
11. Referring Cases To The Field Nurse 03/95 95-12
12. Tracking Contract Field Nurse Intervention 03/95 95-12
13. Warning and Termination Procedures 03/95 95-12
Exhibits
1. Optional Form (OF) 612 Application
Form (Link to Image) 03/95 95-12
2. Completion Instructions for Optional Form 612 03/95 95-12
3. Scoring Instructions for Contract Field Nurse
Applications 03/95 95-12
4. Scoring Sheets 03/95 95-12
5. Sample Response to Field Nurse -- Acceptance 03/95 95-12
6. Sample Response to Field Nurse -- Denial 03/95 95-12
7. Organizational Timetable for Certification
Process 03/95 95-12
8. Contract Field Nurse Evaluation Form 03/95 95-12
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3-0202-1 Purpose and Scope
1. Purpose and Scope. The program uses contract field nurses to perform nurse
intervention in Quality Case Management (QCM) cases as well as in other case
management initiatives. This chapter describes and standardizes the Office of
Workers' Compensation Programs' (OWCP's) procedures for soliciting, recruiting and
selecting contract field nurses.
In addition, the chapter also defines the role of the staff nurse in managing and
tracking the activities of the contract field nurse.
Each district office will contract with the specific number of nurses which have been
identified as the number needed to adequately serve the injured workers within a
specific geographical area. The staff nurse will act as the coordinator at the district
office level. The National Office will assist in the certification process by coordinating
the solicitation for contract nurses on a national basis, sending out the application
packet to applicants and responding to certification questions or concerns raised by
the staff nurse or other individuals.
3-0202-2 Certification Process
2. Certification Process. The certification process provides for a standardized
approach for procuring the services of contract field nurses. This process consists of
soliciting, recruiting, selecting and contracting with registered nurses to work with
claimants. The contract or memorandum of agreement is valid for a period of two
(2) years. After this initial period, field nurse services may be renewed yearly for
three option years. National certifications of field nurses occur at five (5) year
intervals, however the individual district offices may hold local certification drives
when needed. The staff nurse determines that additional field nurses are necessary
to fulfill specific needs when:
a. Field nurses voluntarily withdraw from OWCP's program and need
replacement.
b. The number of claimants requiring the services of a field nurse
increase in a certain geographic area.
c. The performance of a field nurse (late reports, refusing case referrals)
may prompt the staff nurse to discontinue referrals to particular nurses and
require additional recruitment.
d. Option year attrition occurs.
Once the need for a local certification drive is established, the district office submits
a memo requesting additional field nurses to the Chief, Branch of Medical Standards
(BMSR) in the National Office for consideration. The letter must contain: the
anticipated dates and location of the training, the geographic areas involved by zip
code clusters, and the number of field nurses needed to satisfy the additional need.
After the request is approved, the Chief, BMSR, determines the schedule for the
additional certification training workshop and ensures the availability of adequate
support resources.
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3-0202-3 Field Nurse Allocation
3. Field Nurse Allocation. The FEC staff nurse (SN) in each district office
determines the number of field nurses (FN) needed for each geographical area and
reports the number to BMSR. The staff nurse may use the same allocation or
clustering established for the vocational rehabilitation counselors. A cluster consists
of a number of adjacent zip codes grouped together based on reasonable size, ease
of travel within the cluster, and the number of claimants located within this area.
Once the geographic unit or cluster is established, automated reports detailing the
number of claimants residing in the cluster can be obtained. The staff nurse uses
this information and her own experience to establish the number of nurses needed in
the cluster. This number is then reported to BMSR.
3-0202-4 Recruitment
4. Recruitment. Solicitation for the services of registered nurses to perform
contract field nurse activities is made both at the National and District Office levels.
a. The Chief, Branch of Medical Standards and Rehabilitation (BMSR),
places the advertisement in the Commerce Business Daily and in other
selected national publications (ANA newsletter, National Black Nurses'
Association newsletter, etc.)
b. The district office conducts advertisement at the regional level in local
nursing organization newsletters, and newspapers. The names of nurses who
have previously expressed interest in joining the program should be
maintained in a file so that they are included in the
district office solicitation. Field nurses who are currently certified also need to
be mailed a copy of the advertisement by the district office.
c. The advertisement contains the minimum qualifications required, the
geographical region(s) for which the field nurses are needed, instructions for
responding and a response due date. If the district office plans to conduct
interviews as part of the selection process, this also needs to be mentioned in
the advertisement.
d. BMSR receives the responses to the advertisement, categorizes these
responses by geographic area and distributes a list to the district offices.
BMSR sends all timely respondents an application package. Only responses
postmarked on or before the due date are processed further; late respondents
will be notified that they are not eligible for this certification but will be
notified when an advertisement is placed for the next certification. The DO
staff nurse maintains alphabetically organized late response files for this
purpose.
3-0202-5 Nurse Selection Method
5. Nurse Selection Method.
a. The Staff Nurse in each DO acts as the coordinator for the selection
process. Upon receipt of the completed application forms (OF-612 is shown
in Exhibit 1 (Link to Image)), the staff nurse, or designated district office
staff, compiles them by geographic area/cluster, ensuring that only
applications received on a timely basis are included. Late applications will not
be rated and the applicants will be sent a postcard by the district office
explaining the rejection.
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b. The Field Nurse Panel evaluates the applications from the field nurses
based on pre-determined criteria and selects qualified candidates to be part of
the OWCP nurse intervention program. The panel is composed of the district
office staff nurse and national office staff. The panel members evaluate each
application independently, and then, via telephone, reach a consensus
regarding the ranking of the field nurse candidates. As needed, a third panel
member may be used in those circumstances when a "tie-breaker" decision is
needed.
c. The panel uses the scoring sheets (see Exhibits 3 and 4) to rate each
application considering the following factors: work experience in case
management, specialized nursing skills, educational background and
certifications. The first step in the rating is to verify that the applicant meets
the minimum requirements by checking Block 13. If no R.N. license number
is listed, or if there is no photocopy of the license attached, the reviewer does
not proceed and the applicant is disqualified.
In addition, the other minimum requirements of two (2) years generalized
medical/surgical clinical experience and two (2) years in case management or
an equivalent (Block 8) need to be clearly indicated in the applicant's work
experience. Absent these factors, the applicant is disqualified. An
unsatisfactory performance evaluation should be grounds for non-selection.
d. The specific aspects of how to score experience and education are
detailed further on the instruction sheet attached to the rating form (see
Exhibit 2). Each member needs to obtain a copy of the candidates OF-612
application form and the rating sheet. Data contained on this sheet is self-
explanatory. However, it is important to document reasons for disqualifying
an applicant. It is also important to indicate the reason(s) for 0 points in any
category. When the rating process of an application is completed, panel
members total the number of points awarded in each section, sign and date
the rating form.
e. Ranking and Selection.
(1) Panel members rank the qualified applicants by the total
number of points awarded on the application form, placing the
applicant with the most points at the top of the list. In cases where
applicants receive identical scores and one is above the cut-off line but
the other is not, each is selected for certification.
(2) Once the list is completed, panel members draw a cut-off line
so that the number of applicants above the line corresponds to the
number of field nurses that the district office wants to certify.
(3) All application materials are returned to the staff nurse
coordinator.
(4) The staff nurse takes the applications of those considered
qualified and verifies the accuracy of the licenses with the applicable
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state licensing board for currency and good standing status. In
addition, the name and/or company which employs the field nurse
needs to be checked against the U.S. General Services Administration
(GSA) list of Excluded Parties From Federal Procurement Programs.
This monthly publication identifies those parties excluded throughout
the U.S. Government from receiving Federal contracts. If the nurse or
company employing the nurse appears in the book, the applicant
cannot be selected. A field nurse who is not selected for this reason
needs to be notified that his or her non-selection was based on this
information. The publication can be procured from the regional
OASAM office or electronically from G.S.A.
3-0202-6 Interview
6. Interview.
a. At this point in the selection process, the staff nurse may interview
those eligible candidates in the office's regional jurisdiction who are within a
competitive range. For the purpose of nurse certification, a competitive range
is defined as the number of nurses who are qualified and selected plus those
who are qualified but not selected. Within this group the staff nurse defines a
fair and reasonable number of nurses to interview. To do this, the staff nurse
considers her own time constraints and the availability of the candidates.
Since an interview is a subjective process, and the points earned from this
process should not substantially alter the original rating score. For this
reason, the points assigned to an interview should not exceed three (3).
b. The selecting official (staff nurse) has the authority to determine the
extent of the competitive range based on a fair and reasonable estimate. For
example, if the pre- determined number of nurses for a specific area is 10,
and 15 applicants are found qualified, the interview should include all 15.
However, if the pre-determined number for an area is 10 and 35 applicants
are eligible, it is not reasonable to interview the 25 additional applicants.
c. Questions posed during the interview must:
(1) Be the same for everyone.
(2) Relate to job performance, the strengths/ weaknesses te
applicant brings to the job, and what is expected of him or her.
(3) Be documented together with the applicant's response.
3-0202-7 Notification to Applicants
7. Notification to Applicants. At the conclusion of the rating or interview
process, whichever is the final selection factor, all nurses are notified of their
individual status. Nurses selected for the program are made aware of the selection
and given the necessary information on the certification training workshop. Those
not selected will be given reasons for this action. Sample acceptance and denial
response letters are included in Exhibits 5 and 6.
3-0202-8 Certification Training Workshop
8. Certification Training Workshop. The certification process ends with the
training workshop. Throughout the course of the certification process, the staff
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nurse prepares for the training session. A suggested organizational time table has
been developed for the staff nurses' use in planning the workshop and can be
referenced on Exhibit 7.
The training will typically last only one day since there is no effective way to
reimburse the nurses for their time. The training is divided into two parts: a
description of the FEC policies and procedures, and the contract nurse responsibilities
(e.g. report compliance and completion, billing forms and coding schemes, etc.) At
the completion of the Certification Workshop the staff nurse ensures that all newly
certified field nurses sign and date a new memorandum of agreement. It is at this
expiration date that the option years begin.
It may be necessary to conduct the workshop more than once if the number of
nurses is very large or if the geography is such that prolonged travel is required to
reach the city where the training is held.
3-0202-9 Option Year Renewal
9. Option Year Renewal. On each option year the staff nurse will need to decide
whether to renew the services of each field nurse. To do that, the staff nurse
reviews the field nurse's work performance in terms of timeliness, quality, billing
characteristics, intervention successes, compliments or complaints received from
employing agencies, claimants, FEC staff, presence or absence of verbal and/or
written warnings. This yearly evaluation is a composite of all the case-related
evaluations performed when a case is either closed or transferred to another field
nurse. A sample of this evaluation is found on Exhibit 8. Each field nurse is notified
by letter as to whether his or her contract was renewed or not for the option year.
If the contract is renewed, the field nurse signs another memorandum of agreement
providing the staff nurse with updated information (R.N.license expiration date,
home address/phone changes). The staff nurse also assesses whether another
training (abridged) session is necessary. Applicants will be notified if a training
session is planned. BMSR also needs to be made aware of the training schedule.
3-0202-10 Contract Field Nurse Management
10. Contract Field Nurse Management. Staff nurses will be responsible for the
managing of contract field nurses within their geographical jurisdiction. The staff
nurse will: maintain all manual and automated records referring field nurses,
generate case referrals, supervise their work performance and provide them with
periodic reviews, reserving the authority to terminate those field nurses whose
performance is not in keeping with OWCP policies and procedures. A more extensive
explanation of the staff nurses responsibilities in managing the field nurse activities
may be found in the FECA PM Chapter 3-0201.
3-0202-11 Referring Cases to the Field Nurses
11. Referring Cases to the Field Nurses.
a. The staff nurse will refer cases sequentially to the field nurses using a
geographic rotation. The district offices may use an automated system, i.e.,
Rehabilitation Tracking System (RTS), Nurse Tracking System (NTS) or
maintain the rotation through use of a manual log.
The rotation is based on a geographic match between the first three digits of
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injured worker's zip code and that of the field nurse. Ideally, the field nurse
should be located within 25 miles of the injured worker's residence but may
be located as far away as 50 miles. If there are no available field nurses
within a 50 mile limit, the staff nurse may refer the case to the field nurse
having the best method of access to the injured worker even if that nurse is
located in a different zip code area. This situation typically occurs when the
injured worker is on the border of one geographic cluster, it may be more
efficient in time and money to assign a field nurse from a different zip code
range or cluster since it is closer geographically.
b. Sometimes the special needs of the claimant rather than locale may
dictate the choice of a nurse on a specific case. When a particular case
requires special skills or knowledge that the next field nurse in sequence does
not possess, the staff nurse may select the field nurse out of sequence.
Documentation as to the reason for not following the rotation needs to be
maintained in whatever system is in use (manual or automated system) in
the district office.
c. Once the case assignment is made, a letter which serves as an
authorization to perform these services is forwarded to the field nurse. This
authorization letter reiterates the nurse's functions and responsibilities as
listed in the memorandum of agreement. In addition to the authorization
letter, the field nurse will also receive relevant CA forms, all available medical
data (reports and objective findings) and the Form OWCP-5.
d. The staff nurse maintains a file on each field nurse. Data pertaining to
the nurse such as a copy of memorandum of agreement, credentials,
warnings and/or assessments of his or her work can be kept in this folder.
3-0202-12 Tracking the Field Nurse Intervention
12. Tracking the Field Nurse Intervention. Using the data described below, the
staff nurse will be able to analyze various aspects of the program and obtain the
basic statistics necessary to manage the nurse intervention effort. These statistics
include: the number of claimants and nurses participating in the intervention
program at any given time, the duration and result of the intervention by case or in a
cumulative fashion, the rotation of cases among the field nurses and other data.
a. Claimant Data. From the moment a claimant is selected for nurse
intervention, data is entered by the CE on the QCM screen. The staff nurse
will also enter information on the name of the field nurse and the date the
case was referred out. A return to work date is also captured on this screen.
b. Field Nurse Data. Information regarding the field nurses should also
be maintained including the name of each nurse, home address, phone
number and geographical location.
3-0202-13 Warning and Termination Procedures
13. Warning and Termination Procedures. The memorandum of agreement with
OWCP identifies the duties and responsibilities of the field nurse. When any of these
responsibilities are not fulfilled by the field nurse, the staff nurse needs to take
immediate corrective action in the form of a warning. At any point in the
warning/termination process, the staff nurse may opt to decrease the workload of
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the field nurse as an incentive for a change in behavior. The decrease in workload
needs to be documented and maintained only for a finite time period. If the field
nurse's work improves, she is restored to the rotation. If there is no improvement,
the staff nurse proceeds with the verbal warnings. If there is a serious violation of
ethics such as breach of confidentiality, falsifying documents or other fraudulent
activities, dismissal is immediate.
The staff nurse needs to document each stage of the termination process by entering
the date and type of violation and the date and type of staff nurse response (verbal
warning, final letter etc.)
a. Verbal Warning. The staff nurse may issue a verbal warning when the
field nurse demonstrates a lack of professionalism or violates any of the
conditions in the memorandum of agreement.
b. First Termination Warning Letter. The staff nurse will send the "First
termination warning letter" after he/she has issued a verbal warning within a
twelve-month period and the field nurse continues to demonstrate a lack of
professionalism or violates the conditions of the memorandum a second time.
Copies of this letter are placed in the field nurse's file.
c. Final Termination Letter. The staff nurse will send a termination letter
when the field nurse continues to demonstrate a lack of professionalism or
violates conditions of the memorandum again within twelve months after
receiving the first termination warning letter. The staff nurse calls the field
nurse and advises that, as of the date of mailing, no further services should
be provided or billed for because his or her cases have been transferred to
another field nurse. A copy of this letter is also placed in the field nurse's file
and sent to the Regional Director and Chief, BMSR.
d. Reconsiderations and Appeals. The field nurse may request a
reconsideration or appeal within 30 days after receiving a termination letter
or, in the case of appeals, a reconsideration decision. A reconsideration
request should be accompanied by relevant evidence to support the field
nurse's arguments. The Regional Director will decide all reconsiderations
within 90 days of receiving the request. The Director, Planning, Policy and
Standards Division in the OWCP's National Office will decide all appeals based
on the evidence of record within 90 days of receiving the request.
3-0202 Exhibit 1: Optional Form (OF) 612 Application Form (Link to Image)
3-0202 Exhibit 2: Completion Instructions For Optional Form 612
INSTRUCTIONS TO APPLICANTS:
This application form is being forwarded to you in response to the OWCP solicitation
to contract with registered nurses for early intervention of injured employees.
Please complete only those items listed below and return to (Name/Address of the
District Office) postmarked no later than (Insert Date).
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The information which you submit on this OF-612 Application Form will be compared
to the minimum requirements developed by OWCP for contract field nurses. The
minimum requirements are:
1. Evidence of two years' specialized case management experience (experience
can be in workers' compensation, occupational or community health, utilization
review, discharge planning or rehabilitation nursing (Block 8).
2. Evidence of two years' general med-surgical clinical experience (Block 8).
3. Evidence of a valid, current R.N. license. Your R.N. license number(s) needs
to be present in Block 13 or a photocopy of the license needs to be attached to the
application.
4. All applications must be accompanied by your latest performance appraisal.
If this appraisal is more than five years old, please submit three letters of reference
from three clients (employers).
Failure to meet the above requirements or to return the form by the deadline date
will result in disqualification of your application.
ITEM NO. EXPLANATION
4, 5, 7 Personal data--self-explanatory.
6 Applicant's home address (NOT employer's).
8 (Include prior work with OWCP)
In describing your most recent work experience, CLEARLY indicate
evidence of:
(1) case management skills (identify experiences in workers'
compensation, occupational or community health, utilization review,
discharge planning, rehabilitation nursing.
(2) at least two years in general med-surgical nursing.
(3) any specialized clinical nursing expertise e.g. ICU, CCU,
neurology, orthopedics, psychiatry.
Additional sheets may be used if necessary
10-12 Educational Data. Self-Explanatory. This section must at a minimum
indicate that applicant attained: Associate Degree, Diploma or
Bachelor's Degree.
Graduate level degrees will be awarded points on the highest level of
college work completed.
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13 Other Qualifications.
An additional sheet may be used for this section if necessary.
** At a minimum this block MUST contain an R.N. license number(s)
or a photocopy of the R.N. license must be attached. If this info is
missing, applicant is disqualified.
Additional items to address in this area include:
(a) when applicable, certification credentials, e.g. COHN, CCM, CIRS
etc.
(b) special skills when applicable e.g. psychiatric, catastrophic nursing
expertise.
18 Signature.
This certifies that all information completed in the specific blocks is
correct.
3-0202 Exhibit 3: Scoring Instructions for Contract Field Nurse Applications
SCORING INSTRUCTIONS FOR CONTRACT FIELD NURSE APPLICATIONS
Introduction
These sheets will be used by the reviewer to score the applicant's information
submitted on the Optional Form (OF) 612 and supplemental sheets.
Information on the OF-612 will be compared to the minimum requirements
developed by OWCP for contract field nurses. The minimum requirements are:
1. Evidence of two years' specialized case
management experience (experience can be in workers'
compensation, occupational or community health,
utilization review, discharge planning or
rehabilitation nursing). (Block 8)
2. Evidence of two years' general med-surgical
clinical experience. (Block 8)
3. Evidence of a valid, current R.N. license.
R.N. license number needs to be either present in
Block 13 or a photocopy of the license needs to be
attached to the application.
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4. The latest performance appraisal. If this
appraisal is more than five years old, three letters
of reference from three clients (former employers)
MUST also be enclosed.
In scoring the application, it is important for the reviewer to first check to see if the
work experiences indicating case-management and med-surgical expertise as well as
the R.N. License Number/photocopy of license are present. If any of these factors
are NOT present, the candidate is disqualified and no further review of the
application is necessary.
3-0202 Exhibit 4: Scoring Sheets
SCORING SHEETS
The following three items reflect the minimum requirements and must be clearly
indicated on applicant's form. If any of the three items are not present, discontinue
your review, applicant is disqualified.
Block # Data Score
8 Review for Specialized Experience
Applicants must show two years' case
management work, e.g., Workers'
Compensation, Occupational/Community
Health, Utilization Review, Disc.
Plan., Rehabilitation Nursing.
** If none appear, Disqualify N= 0
If 2-3 years' experience 2
If 3 + years' experience 3
Review for Med-Surg Experience
Applicant must clearly show minimum
of two years' general med-surg. work
** If none appear, Disqualify N= 0
If 2-3 years' experience 2
If 3 + years' experience 3
13 Check for R.N. license numbers
** If no license number is indicated or
photocopy of the license is not attached,
Disqualify N= 0
R.N.#=1
The additional items are to be scored in addition to the above
requirements.
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4-7 Personal Data N= 0
8 Work Experience
Review for previous work with OWCP
- accepts cases most of the time (85%) Y= 1
N= 0
- reports/communication timely & complete Y= 1
N= 0
- billing accurate & timely (85%) Y= 1
N= 0
- works well with claimants, staff,
physicians, employing agencies Y= 1
N= 1
- no previous OWCP work experience N= 0
Review for additional areas of clinical
expertise in any of these areas,
e.g., orthopedics, neurology,neurosurgery,
psychiatry, ICU, CCU.
If 1-2 years' experience 1
If 3 + years' experience 2
10-12 Educational Background--
Review for evidence that applicant
earned at least one:
Associate Degree
Diploma
Bachelors Degree 2
Additional points will be given for
the highest level of college work
completed, e.g.:
Masters Degree 1
Ph.D Degree 2
13 In addition to R.N. license number(s),
Other Certifications related to case
management may be entered here, e.g.,
Certification in Occupational Health--COHN,
Certification in Case Management--CCM,
Certified Insurance Rehab. Spec.--CIRS.
No additional points will be given for
this now but at next certification
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additional points will be given.
Total Points=
Name of Reviewer __________________________
Date of Review ____________________________
3-0202 Exhibit 5: Sample Response To Field Nurse--Acceptance
Dear FIELD NURSE:
I am pleased to accept you as an OWCP contract field nurse. To complete the
certification process, a training workshop is planned for:
DATE:
TIME:
PLACE:
Please detach and return the lower portion of this letter to me at the above address.
Your workshop reservation must be postmarked by the following date:
.
You may contact me at - - if there are any questions on this workshop.
Sincerely,
STAFF NURSE
I will attend the workshop. I will not attend the workshop.
Please print your name:
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Home Address:
3-0202 Exhibit 6: Sample Response To Field Nurse--Denial
Dear FIELD NURSE:
Thank you for your interest in the Office of Workers' Compensation Programs'
(OWCP's) nurse intervention program. As a result of the certification process, I am
unable to select you to provide services to OWCP injured workers for the reason (s)
indicated below:
You are qualified for selection. However, we selected
the maximum number of field nurses needed to provide
services within the geographical area of the District
Office. You may be selected at a later date if we have a
need for new field nurses.
Your application did not meet our minimum
qualifications based on either case management and/or
med-surgical clinical experience.
Your application was incomplete.
Your response to our solicitation for contract field nurses to provide services to our
injured workers is appreciated.
Sincerely,
STAFF NURSE
3-0202 Exhibit 7: Organizational Timetable For Certification Process
WEEKS TO WS ACTION STATUS
10 weeks
1. Determines the number of
or earlierfield nurses, presents
geographic distribution plan
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to RD, NO.
2. Advertises Contract
Field Nurse Position in local
nursing journals, newsletters,
newspapers etc.
3. Coordinates date and
location of the workshop with
DO and NO.
9 weeks
1. Confirms attendance of
district and NO staff (BMSR)
who will deliver welcoming and
closing remarks, as well as part
of the actual training.
2. Reserves space for the
workshop, preferably in a
Federal Building.
3. Ascertains that all
necessary furniture,
equipment, and supplies will
be available.
7 weeks
1. Rejects incomplete
applications.
2. Refers completed forms to
panel for evaluation and ranking.
3. Organizes application
materials after panel
completes selection.
4. Creates folder for "Selected"
Applicants.
5. Creates additional folders
marked "Qualified-Not Selected"
and "Disqualified" Applicants.
5 weeks
1. Completes/mails acceptance
letter or earlier which includes
date/time/place of training
workshop. Include to whom form
should be returned and by what
FECA-PT3 Printed: 08/02/2011
46
date (should be no later than
three weeks before the workshop).
2. Sends notification to the
"Qualified-Not Selected" and
"Disqualified" applicants.
Advise they may discuss non-
selection with staff nurse or
file written appeal for BMSR
review.
2 weeks
1. Compiles training materials,
draws up final agenda, sends
this information to BMSR
for concurrence.
2. Makes sure all available
spaces for the workshop are
filled.
3. Prepares Workshop Attendance
Log.
4. Contacts FNs who did not
respond to the letter and verify
their attendance.
5. Notes the reason for non-
attendance on the log and replace
with field nurses from the
"Qualified-Not Selected" folder.
Confirm new FN attendance by phone
and add name on the Attendance Log
and whom he or she is replacing.
Day Before 1. Checks the physical location
Workshop and set-up of the training
facility.
2. Reminds speakers of the time/
place of the workshop.
Workshop 1. Supervises the sign-in
Day procedure for attendees.
2. Distributes materials and
acts as resource person.
3. Conducts sessions.
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47
4. Ensures all participants
complete and sign a Memorandum
of Agreement.
5. Checks that each participant
has provided you with his or her
phone number and home address.
After 1. Ensures that all pertinent FN
Workshop information is entered on either
the RTS or district office
tracking system.
3-0202 Exhibit 8: Contract Field Nurse Evaluation Form
CONTRACT FIELD NURSE EVALUATION FORM
F.N.'s Name:
I.W.'s Name:
Claim File:
Instructions: This evaluation form should be completed when the FN submits the
closure report or when the case is assigned to another field nurse or transferred to
another district office.
Did the FN: Yes No N/A
1. Respond timely to the request
for case referral?
2. Communicate timely and
effectively with IW, AP, EA,
SN, CE and other parties?
3. Identify problems which could
affect the RTW promptly and
accurately?
4. Offer good problem-solving
techniques and/or offer viable
recommendations to OWCP?
5. Only make commitments based
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48
on the written approval and
authorization of OWCP?
6. Provide and coordinate necessary
services (e.g., schedule of second
opinion exams) without delay ?
7. Follow the directions of the SN
and CE ?
8. Submit reports and bills timely
and accurately?
CHAPTER 3-0300 - AUTHORIZING EXAMINATION
AND TREATMENT
TABLE OF CONTENTS
Paragraph Subject Date Trans.No.
Table of Contents 06/00 00-07
1. Purpose 10/90 91-02
2. Requests for Authorization 09/96 96-15
3. Form CA-16, Authorization for Examination &/or
Treatment 10/90 91-02
4. Prohibited Authorizations 10/90 91-02
09/95 95-39
5. Medical Facilities Where Care May Be Authorized 10/90 91-02
6. Transfer or Termination of Authorization
for Medical Care 04/95 95-17
06/00 00-07
7. Peace Corps Cases 10/90 91-02
(Pagination only) 04/95 95-17
Exhibits
1. Authorization for Examination and/or Treatment 12/94 95-04
(Link to Image)
3-0300-1 Purpose
1. Purpose. The purpose of this chapter is to describe the circumstances under
which OWCP or, in some instances, the employing agency may authorize medical
services for injured claimants. The methods of authorization and when they should
be used are also described.
3-0300-2 Requests for Authorization
2. Requests for Authorization. While claims personnel receive the majority of
requests for examination and treatment, the Medical Unit may receive some requests
as well.
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49
a. Types of Treatment Requested.
(1) Emergency. If an emergency exists, the DMA may authorize
treatment by telephone. Otherwise, the caller should be advised that
the physician should submit a written request detailing the type of
treatment recommended and the reason it is needed.
Authorization is sometimes requested for a non-emergency procedure
scheduled for the immediate future. If the authorization cannot
properly be given by the date in question, the caller should be asked
to submit a written request as described above and advised that if the
request is approved, payment may be authorized after the fact.
(2) Surgery. Authorization for surgery should be obtained in
advance whenever possible in order to ensure payment. Even if
surgery is undertaken without OWCP approval, however, the cost may
be reimbursed if the procedure is later found to be acceptable. See
FECA PM 3-400.5b(1) for a description of the criteria used to
determine if surgery should be approved.
(3) Other Procedures. Requests will normally be handled by the
District Medical Adviser (DMA). In his or her absence, the Medical
Management Assistant (MMA) will obtain all pertinent information and,
with the concurrence of designated claims or managerial personnel,
determine whether authorization should be given.
b. Contractual Obligation. Authorization by OWCP for medical
examination and/or treatment constitutes a contractual agreement to pay for
the services regardless of whether a compensable injury or condition exists.
Moreover, any medical condition resulting from authorized examination or
treatment (such as residuals from surgery) may form the basis of a
compensation claim for impairment or disability, regardless of the
compensability of the original injury. For both of these reasons great care
must be exercised in authorizing medical examination and/or treatment.
c. Documentation. Form CA-110, Report of Telephone or Office Call, or a
memorandum to the file must be completed to document all telephone calls
concerning authorization or denial of examination and/or treatment. Verbal
authorization as well as the issuance of Form CA-16 or a telegram (usually
used only when the claimant is overseas) should always be confirmed in
writing. If the MMA gives the authorization, the DMA will confirm it in writing.
Ordinarily, copies of letters of authorization and forms addressed to
physicians and medical facilities are not sent to the official superior. They
may be provided on request to the claimant or representative as long as the
correspondence contains no sensitive medical information. A letter of
authorization will always be used to arrange for examination of an employee
and/or review of the case file by a specialist.
3-0300-3 Form CA-16, Authorization for Examination and/or Treatment
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3. Form CA-16, Authorization for Examination and/or Treatment. Form CA-16 is
the vehicle by which the employing agency authorizes examination and/or treatment
at OWCP expense. It is used primarily to refer an employee who sustains traumatic
injury to a local physician or hospital of the employee's choice. OWCP delegates this
authority to the employing agency to allow medical treatment from the time of the
injury until a claim is adjudicated.
a. Traumatic Injury.
(1) Period of Authorization. Form CA-16 (Exhibit 1 (Link to
Image)) limits to 60 days the Office's contractual obligation to pay for
medical services and instructs physicians to contact the district office
for extension of that period. (Previous versions of the form provided
for a 90-day period of treatment, and occasionally an agency will use
such a form to authorize treatment. When this occurs, the bills must
be paid until authorization is revoked.)
(2) Effect of Adjudication. Once a case is accepted, the period of
authorization is automatically extended to cover necessary services for
the accepted condition, and additional authorization is not necessary
unless requested by a provider in a specific case. If a case is denied,
however, authorization for treatment must be revoked even though 60
days have not elapsed. If the case is denied after the end of the 60
day period, the physician will be informed that the injury is not
compensable and that bills will be paid only for services rendered prior
to the end of that period.
(3) Emergency Circumstances. Form CA-16 may be used to
authorize treatment in cases of a doubtful nature, and in emergencies
or unusual circumstances, the Office may approve payment for
medical expenses incurred even if Form CA-16 has not been issued
and the claim is subsequently denied. Payment in situations meeting
these criteria must be determined on a case-by-case basis (see Val D.
Wynn, Docket No. 88-1813, issued March 10, 1989).
If Form CA-16 is inadvertently released to an excluded provider, the
bills should be paid, but a letter rescinding the authorization should be
released immediately to the claimant and provider.
b. Occupational Disease, Latent and Recurrent Disability. The employing
agency must contact OWCP for instructions on providing treatment in cases
where an occupational disease is claimed, when disability recurs more than 90
days after the claimant returns to duty, or when disability begins more than
90 days after an injury for which no report was made to OWCP. From the
employing agency and/or the employee, the Claims Examiner (CE) will
determine the nature and cause of the injury and any treatment which has
been provided for the disability. In exceptional circumstances, OWCP may
permit the employing agency to issue Form CA-16 for examination and/or
treatment, depending on the nature of the injury or alleged injury.
3-0300-4 Prohibited Authorizations
4. Prohibited Authorizations. No authorization for medical care may be given
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unless a notice of injury or occupational disease has been or is about to be filed (that
is, a notice of injury has been completed and is in possession of the employing
agency). The following kinds of authorization are prohibited:
a. Issuance to Excluded Providers. Although an employee has the right
to choose the initial treating physician, no authorization may be given for
examination and/or treatment by an excluded physician. For further
information regarding excluded providers see Chapter 3-800.
b. Issuance to Oneself. An injured employee does not have the authority
to issue an authorization for examination and/or treatment on his or her own
behalf. For example, if a postmaster sustains an injury, it is expected that
authorization will be secured from the regional office. In an emergency, the
services of the nearest physician or hospital may be utilized without prior
authorization, with the understanding that the employee will contact the
employing agency at the earliest possible time for authorization or
instructions.
c. Issuance to Minors. OWCP does not consider any person under the
age of 18 to be emancipated. Therefore, permission from the parent or
guardian will be needed to authorize treatment of any claimant under 18. If
the parent or guardian is not immediately available for signed consent it may
be necessary to arrange for a witnessed telephone call or to send a telegram
(if the claimant is overseas) to obtain consent. Any expense incurred in order
to do so is payable by OWCP.
d. Issuance to Certain Employees Prior to Separation. Certain groups of
claimants are entitled to FECA coverage by virtue of special legislation. They
include Peace Corps and VISTA volunteers as well as Job Corps enrollees.
While members of these groups are entitled to medical care for accepted
injuries at OWCP expense, authorization for treatment may not be granted
until the volunteer or enrollee is separated from the program.
e. Advance or Blanket Authorization. An authorization for treatment at
some future time, or as the need arises, shall not be issued. When such
authorization is requested the employee should be advised to contact OWCP
in writing as the need for treatment arises, or by telephone or telegram
(where the claimant lives overseas) should the need become urgent.
f. Fitness-For-Duty Examinations. The law does not provide for
examination to determine the "fitness-for-duty" status of an employee. This
is a function of the employing agency.
g. Exposure to Disease. The law does not provide for routine
examination of an employee who has been exposed to a co-worker with an
infectious disease or to hazards of the workplace. Unless there is reasonable
proof that a disease or illness has been sustained by the employee, such
examinations are the responsibility of the employing agency (however, see
PM Chapter 3-400.7a). The decision to authorize examination at OWCP
expense in these cases must be made by OWCP.
3-0300-5 Medical Facilities Where Care May Be Authorized
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5. Medical Facilities Where Care May Be Authorized. The FECA at 5 U.S.C. 8103
permits the employee an initial choice of physician. Examination and treatment may
be given in the following settings:
a. Emergency Medical Facility. Emergency medical care by private
physicians, clinics or hospitals may be authorized if such care is warranted.
The employee may seek continuing medical care from the physician who
provided the initial treatment or select another local physician.
b. Employing Agency Health Units. These facilities are equipped to
provide immediate assistance and/or to refer employees to local physicians or
emergency care facilities. When indicated, rescue squads or similarly trained
and equipped units may be used to move injured persons.
c. Physician's Office. Ordinarily, the physician selected should be located
within 25 miles of the employee's home or place of employment (in rural
areas, a provider at a greater distance may be authorized).
d. Hospital. The attending physician may arrange for care in a local
hospital. A private room may be authorized only if the condition is such that
the attending physician believes it is medically necessary and the District
Medical Advisor (DMA) concurs. If a private room is used because of the
claimant's personal preference, he or she will be required to pay the
difference in cost. Also, such personal items as television and telephone
service must remain the claimant's responsibility.
e. Federal Medical Facilities. The medical facilities of the Army, Navy, Air
Force, and Veterans Administration may be used to provide treatment if
practicable. Arrangements must be made on a case-by-case basis with the
director of the hospital or clinic (such arrangements should be documented on
Form CA-110, Report of Telephone or Office Call, or in a memorandum for the
file). Use of Federal facilities may not be required to the exclusion of the
claimant's choice of physician.
3-0300-6 Transfer or Termination of Authorization for Medical Care
6. Transfer or Termination of Authorization for Medical Care.
Any transfer of medical care should be accomplished with due regard for professional
ethics and courtesy. No transfer or termination of treatment should be made unless
it is in the best interest of the claimant and the government. The following
guidelines should be observed:
a. Request by Official Superior. The official superior of an injured
employee does not have authority to transfer medical care from one physician
to another. If adequate medical care is not available locally or the employer
feels transfer of medical care is advisable for other reasons, the official
superior should contact OWCP for instructions.
b. Request by Attending Physician. If the attending physician asks to be
relieved of responsibility in a case, the request will be granted. The physician
should be asked to provide his or her reasons for the request, report the
patient's condition at the time, and state any further medical
recommendations.
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53
c. Request by Employee. Employees who want to change attending
physicians must explain their reasons in writing, and the CE must review all
such requests.
(1) The CE may approve a change on his or her own authority
when: the original treating physician refers the claimant to another
physician for further treatment; the claimant wants to change from the
care of a general practitioner to that of a specialist in the appropriate
field, or from the care of one specialist to another in the appropriate
field; or the claimant moves more than 25 miles from the original
physician.
(2) The CE must use discretion in cases where other reasons are
presented:
(a) Denial solely on the basis that the claimant did not seek
approval of the change before consulting another physician is
improper (see Cybil L. Slade, 40 ECAB 1029). Rather, the CE
must examine the request to determine whether the treatment
was reasonable and necessary. (See Arron G. Marston, Docket
No. 88-1716, issued March 22, 1989). This assessment may
require referral of the case to the DMA.
(b) A request to change from the care of a specialist to the
care of a non-specialist may not be denied without considering
whether the treatment provided by the new physician is
reasonable and necessary. However, unless the issue has
arisen because care by a specialist is not available, the case
should be referred for opinion from the DMA.
(c) Likewise, where the claimant wishes to change from the
care of a medical doctor to that of a chiropractor, the CE should
consult the DMA to determine whether the services of the
chiropractor constitute medical treatment under the Act and if
so whether it is reasonable and necessary (see Elizabeth J.
Davis-Wright, 39 ECAB 1232).
(3) Cases involving complex medical issues should be referred for
opinion from the DMA.
(4) A second opinion examination may be in order if a claimant
requests transfer to another physician at a time when the treating
physician is recommending return to employment. If a second opinion
is necessary to address issues involving continuing medical care, the
selected physician may not become the treating physician.
d. Questions about Treatment. If the employee is under the care of a
qualified physician and a question arises concerning the physician's medical
management of the case (for instance, the prolonged use of therapeutic
measures or the use of measures of questionable value), it is proper to
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54
request the physician's comments, and the DMA may request discussion of
the medical problem involved.
e. Request for Consultation. The OWCP may seek consultation services
with experts in specialized fields, either to provide the attending physician
with guidelines or to determine a future course of action with regard to
medical care. In such cases, the attending physician must be advised of the
action contemplated and told that the findings will be made available to him
or her.
f. Transfer of Care. When it is determined that a transfer of medical care
is needed, the previous attending physician and the claimant must be notified
in writing regarding the change so that the physician may close his or her file
and submit a final bill and report. A suitable explanation should also be
furnished to the attending physician. If appropriate, the physician should be
assured that OWCP's action is not intended as a criticism of his or her
management of the case or professional ability and judgment. The claimant
as well as the physician should be advised that authorization for treatment is
being terminated.
g. Exclusion of Provider. As noted above, OWCP must terminate
authorization for treatment with excluded providers. Both the physician and
the claimant should be advised immediately that further medical treatment is
not authorized and the claimant should be advised to select another treating
physician. The claimant may continue to receive treatment from the excluded
provider at his or her own expense. Exclusion of providers is discussed in
Chapter 3-800.
3-0300-7 Peace Corps Cases
7. Peace Corps Cases. Peace Corps volunteers (including volunteer leaders and
trainees) are covered by the FECA by virtue of special legislation which affects,
among other things, the kinds of medical care which may be authorized. Peace
Corps claims are adjudicated in the National Operations Office, after which they may
be transferred to other district offices if approved. The following procedures apply to
Peace Corps volunteers:
a. Entitlement to Medical Care. A Peace Corps volunteer is entitled to
medical care for any injuries suffered while abroad (which is defined as any
area outside the United States, its territories, the Commonwealth of Puerto
Rico, and the District of Columbia). Except for the exclusions which appear in
Section 8102 of the FECA and Section 5 (d) (2) of the Peace Corps Act,
volunteers have the protection of the FECA for all injuries sustained and
diseases contracted during such service. Trainees assigned to work in the
United States, however, must meet the same burden of proof with respect to
performance of duty and causal relationship as other Federal employees.
b. Initial Authorization for Medical Care. Since these claims are
adjudicated in the National Operations Office, requests for initial authorization
of medical care should be referred there. The following procedure has been
established with regard to issuing authorization for medical care:
(1) Prior to Separation. When a volunteer is in the hospital with a
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55
prognosis which indicates that separation from the Peace Corps will be
mandatory, the Medical Unit of the National Operations Office may
verbally approve authorization by the Peace Corps for examination
and/or treatment effective the day following separation, if eligibility for
coverage is established or sufficient indications exist to show that the
condition is related to Peace Corps service, so that continuity of
medical care will be preserved.
(2) At Separation. If eligibility for coverage is established or
sufficient indications exist to show that the condition is related to
Peace Corps service, the National Operations Office may verbally
approve authorization by the Peace Corps for examination and/or
treatment near the volunteer's home.
(3) Following Separation. The Peace Corps may not issue
authorization for examination and/or treatment at OWCP expense to a
volunteer following separation. In such instances, OWCP will issue
authorization and/or instructions to the former volunteer.
(4) Emergency Situations. The Medical Unit in the National
Operations Office may approve the issuance of an authorization
effective the day following termination, prior to receipt of written
documentation, if a medical emergency exists or a delay in authorizing
medical care would seriously affect the continuity of medical
management. The record should show that the agency has completed
Form CA-1 or CA-2 or will ensure that it is initiated and submitted to
OWCP.
c. Coverage for Disease. In cases involving disease, the examining
physician or the DMA must state that the disease was contracted abroad in
order to accept it as Peace Corps related. In some situations, this
determination includes consideration of the incubation period for the disease.
The broad coverage for disease may present unusual medical problems. In
general, the following rules may be observed:
(1) Dental Disease. Caries, abscesses, etc., may be considered
contracted abroad if comparison with the pre-induction dental
examination so indicates. Unless an acute dental emergency exists,
eligibility for coverage will be established prior to issuance of
authorization for dental care. The volunteer may be instructed to
obtain an estimate from a dentist near his or her home at OWCP
expense and submit it to OWCP for consideration. The examination
may include x-rays and prophylaxis, which are payable by the Office.
(2) Mental Illness. If it is determined that the psychiatric condition
is related to Peace Corps service, treatment can be authorized until the
attending physician indicates that the condition or episode has
resolved and that no further disability exists. If a recurrence of the
mental disease is alleged, it must be determined whether the
recurrence is due to the Peace Corps experience or to other factors,
including pre-existing conditions.
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56
(3) Parasites. If the separation medical examination indicates the
presence of intestinal or other types of parasites, further examination
and treatment may be authorized. A positive serology or skin test
alone will not necessarily be considered evidence of a disease.
(4) Tuberculosis. If the separation medical examination indicates
the presence of tuberculosis, further examination and treatment may
be authorized, as may provision of INH prophylactic medication.
(5) Pregnancy. It has been determined that the Pregnancy
Discrimination Act requires that FECA coverage be extended to Peace
Corps volunteers for pregnancies which occur during Peace Corps
service overseas and continue past the date of termination. Such
pregnancies are to be considered in the same light as any covered
injury. The coverage is retroactive to April 1, 1979, the date on which
the Pregnancy Discrimination Act became applicable to fringe benefit
programs.
Peace Corps volunteers are covered for all pregnancy- related
conditions, including miscarriages, prenatal and postnatal care of the
mother. Any prenatal care is to be considered part of the treatment
for the disability (pregnancy) of the volunteer, and not preventive
treatment or treatment for the unborn child. Because FECA coverage
is limited to Peace Corps volunteers, the benefits of the Act may not
be extended to the children born of such pregnancies.
Under no circumstances, even when it involves the health of the
mother, may the OWCP pay for an abortion for a Peace Corps
volunteer. This policy is necessary because the Peace Corps is
prohibited from using its funds for abortion, and the Compensation
Fund could not be reimbursed for such expenditure.
(6) AIDS. Peace Corps volunteers are tested for HIV infection
before being sent overseas. If comparison with this test shows that
the infection has developed during the Peace Corps Service, medical
and compensation benefits for the resulting condition are payable.
3-0300 Exhibit 1: Authorization for Examination and/or Treatment (Link to
Image)
CHAPTER 3-0400 - MEDICAL SERVICES AND
SUPPLIES
TABLE OF CONTENTS
Paragraph and Subject Date Trans. No.
Table of Contents 06/00 00-07
1. Purpose 10/90 91-02
2. Statutory Authority 10/90 91-02
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57
3. Supplies and Appliances 10/90 91-02
10/95 96-04
09/95 95-39
4. Obtaining Appliances and Arranging for Repairs 10/90 91-02
04/92 92-17
5. Medical Services 04/92 92-17
04/93 93-24
6. Nursing Services 06/00 00-07
04/92 92-17
7. Other Modes of Treatment 04/92 92-17
8. Non-medical Services 04/92 92-17
09/95 95-39
9. Injury or Death While Obtaining Medical Care 04/92 92-17
10. Transportation and Expenses 04/92 92-17
3-0400-1 Purpose
1. Purpose. Many forms of treatment, including diagnostic procedures, may be
authorized by OWCP when prescribed by the attending physician. Similarly, many
supplies may be provided at the request of the attending physician or claimant. This
chapter describes the circumstances under which such treatments and supplies may
be authorized.
3-0400-2 Statutory Authority
2. Statutory Authority. While OWCP generally does not have authority to require
an injured employee to undergo treatment against his or her will, it is assumed that
employees will seek appropriate treatment to restore health and lessen the severity
of impairment. Services and supplies which meet the statutory criteria of being
"likely to cure, give relief, reduce the degree or the period of disability, or aid in
lessening the amount of the monthly compensation" (5 U.S.C. 8103(a)) may be
approved.
3-0400-3 Supplies and Appliances
3. Supplies and Appliances. Specific supplies and appliances and the conditions
under which they may be authorized are as follows:
a. Prescription and Non-Prescription Drugs. In general, drugs and
medications which are necessary to treat an injury or occupational disease
may be purchased at OWCP expense on the recommendation of the attending
physician. These include prescription as well as non-prescription medications.
Cases requiring prolonged use of narcotic preparations, tranquilizers, or
medicinal alcohol must be referred to the DMA for consideration of continued
authorization.
b. Home Medical Supplies and Appliances. Items such as rubbing
alcohol, thermometers, sun lamps, heating pads, analgesics, antacids, etc.,
will not be furnished at OWCP expense unless prescribed by the attending
physician and justified medically. Accepted conditions which may warrant
furnishing such items include such conditions as paraplegia, quadriplegia,
coma, and chronic ulcers. The Claims Examiner (CE) does not need to obtain
approval for the use of these items but may need to consult the District
Medical Adviser (DMA) to determine the frequency with which they are
needed.
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58
c. Durable Medical Equipment.
(1) Orthopedic Mattresses or Hospital Beds. These appliances may
be authorized when prescribed by the attending physician to relieve
orthopedic or other medical conditions, but less costly alternatives
such as a bed board should be considered first whenever possible.
(2) Motorized Wheelchairs. The purchase or rental of a motorized
wheelchair may be authorized when the condition necessitating it is
considered to be permanent. Recommendations for this equipment
shall be referred to the DMA for advice regarding authorization.
(3) Other Equipment. Such items as traction apparatus and
walkers for home use may be authorized upon the recommendation of
the attending physician if their use is warranted by the accepted
condition.
d. Prosthetic Devices and Other Personal Appliances.
(1) Glasses and Contact Lenses. Glasses and contact lenses for the
correction of refractive error will be furnished for a condition accepted
as work-related, and subsequent repair or replacement will be
authorized as necessary.
(a) When OWCP accepts a case for loss of vision or loss of
an eye, the purchase of glasses or contact lenses will be
authorized for correction of refractive error in the uninjured
eye.
(b) Prescription sunglasses will be authorized when
recommended by a qualified physician in cases following
cataract surgery. When recommended for another approved
condition, the opinion of the DMA should be obtained prior to
acting on the recommendation.
(c) Intraocular implant lenses are imbedded in the eye to
correct vision in some older patients when cataract surgery is
performed. They may be authorized on recommendation of the
attending ophthalmologist.
(2) Hearing Aids. Hearing aids will be authorized when hearing loss
has resulted from an accepted injury or disease if the attending
physician so recommends. Trial or rental periods should be
encouraged as many persons do not find their use satisfactory.
Maintenance of hearing aids provided by OWCP, including batteries,
repairs, and replacements, may be authorized as needed.
(3) Orthopedic Shoes. If an accepted injury to the foot modifies its
structure so that the employee cannot be fitted with ordinary shoes,
specially constructed ready-to-wear or custom built shoes may be
furnished upon the recommendation of the attending physician. If
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such shoes will be required permanently, the purchase of two pairs
may be authorized. Alterations to stock shoes usually worn by the
claimant will also be authorized if needed.
(4) Artificial Limbs and Braces. These devices may be authorized
as recommended by the attending physician.
(5) Non-medical Equipment. Items such as waterbeds, saunas,
weight-lifting sets, exercise bicycles, etc., may be authorized only if
recommended by the attending physician and if OWCP finds that the
item is likely to cure, give relief, reduce the degree or the period of
disability, or aid in lessening the amount of monthly compensation.
Procedures for developing and adjudicating requests for such
equipment are provided in PM 2-810.15.
(6) House and Vehicle Modifications. Procedures for developing
requests for modification of houses and vehicles due to the accepted
condition are provided in PM Chapter 2-1800. Requests for items such
as home wheelchair ramps, special automobile attachments, and
window air conditioning equipment should be handled in accordance
with paragraph (5) above.
3-0400-4 Obtaining Appliances and Arranging for Repairs
4. Obtaining Appliances and Arranging for Repairs. Appliances may be either
personal or non-personal in nature.
a. Personal Appliances. Devices which are specifically fitted to and worn
by the claimant, such as back braces, eyeglasses, and artificial eyes are
considered personal rather than government property. Upon the
recommendation of the attending physician, such appliances may be repaired
or replaced without advance approval when the estimated cost is less than
$500. Repairs or replacements costing more than this amount should be
approved in advance by the DMA if possible. The attending physician should
check the repaired or replaced item to ensure a proper fit.
b. Non-personal Appliances. Prior to authorizing any item of a non-
personal nature, the cost of purchase should be compared to the cost of
renting, taking into consideration the prognosis and the estimated duration of
need. Generally, the less expensive method will be used. When the item is
rented, the Medical Management Assistant (MMA) will place a six-month call-
up to assess whether the item is still needed for the accepted condition and if
rental is still less costly than purchase.
A purchased item which can be salvaged when no longer required by the
employee will be considered government property if its retail value is more
than $5000. Such items as hospital beds and wheelchairs fall into this
category, and the employee must be notified in writing at the time of
purchase that the property may be recovered by the government at a later
date. When the item is no longer needed, the MMA will contact at least one
nearby Federal medical facility and offer it for pickup at no expense to OWCP.
If the facility does not wish to acquire the item, the MMA will notify the
regional office of the General Services Administration that the item is
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available.
c. Repair and Replacement.
(1) The definition of "injury" at 20 C.F.R. 10.5(a)14 includes:
damage to or destruction of medical braces, artificial limbs, and other
prosthetic devices which shall be replaced or repaired; except that
eyeglasses and hearing aids shall not be replaced, repaired, or
otherwise compensated for, unless the damage or destruction is
incident to a personal injury requiring medical services.
(2) Medical braces, artificial limbs, and other prosthetic devices
covered under this provision can be repaired or replaced on a one-time
basis in the absence of any other medical condition resulting from a
work-related incident. OWCP can authorize repair or replacement of
property, such as eyeglasses, hearing aids, and artificial teeth, which
is damaged or destroyed while in the performance of duty only when
the damage or destruction is incident to a personal injury requiring
medical services, or when an accepted condition requires change in a
prosthesis used at the time of injury.
(3) When OWCP cannot authorize repair or replacement, the CE
should advise the claimant that under 31 U.S.C. 240-243, Federal
establishments may settle and pay claims against the United States by
its civilian employees for damage to, or loss of, personal property
incident to employment. The CE should also advise the claimant to
contact his or her supervisor to determine whether a claim may be
made under this statute.
3-0400-5 Medical Services
5. Medical Services. Services which meet the statutory criteria of being "likely
to cure, give relief, reduce the degree or the period of disability, or aid in lessening
the amount of the monthly compensation" may be authorized. The circumstances
under which various kinds of services may be authorized are described below. Any
denial of services requested by the claimant or attending physician must address
these criteria.
a. Emergency Medical Facility. Emergency medical care by private
physicians, clinics or hospitals may be authorized if such care is warranted.
b. Hospital. The attending physician may arrange for care in a local
hospital. A private room may be authorized only if the condition is such that
the attending physician believes it is medically necessary and the District
Medical Advisor (DMA) concurs. If a private room is used because of the
claimant's personal preference, he or she will be required to pay the
difference in cost. Also, such personal items as television and telephone
service must remain the claimant's responsibility.
(1) Surgery. In an elective or non-emergency situation, the file
must be reviewed by a specialist prior to authorizing surgery for a
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back condition, an organ transplant or a destructive procedure. A
second opinion examination may be obtained at Office expense prior to
authorization for surgery or any invasive procedure (see Chapter 3-
500 concerning second opinion requests). In-house review by the
consultant should occur within 21 days of receipt of the request for
surgery, and any second opinion examination required should be
accomplished within 40 days. Plastic surgery for cosmetic reasons
may not be authorized unless it is performed for a disfigurement of the
face, head or neck which has been accepted by the Office.
(2) Organ Transplants. Organ transplants, except for those which
are experimental or not generally accepted by the medical community,
may be approved upon the attending physician's recommendation and
OWCP's approval consistent with its second opinion procedures.
Ancillary treatment such as immunosuppression is also considered
compensable.
An organ donor is not considered an "employee" within the meaning of
the FECA and is not entitled to compensation for wage loss or
permanent impairment, nor is a donor entitled to benefits for any
complications resulting from the transplant. Only those medical and
related expenses of the donor which are necessary to secure treatment
for the employee are allowable.
(3) Destructive and Questionable Measures. Such procedures as
rhizotomy, injection treatment for varicose veins, chordotomy,
neurectomy, etc., will not normally be authorized solely because of
chronicity of a condition. They may be authorized as a measure of last
resort, after adequate consultation with specialists in the appropriate
field of medicine. Medical or surgical treatment of a questionable
nature will not be authorized without adequate consultations. Second
opinion examinations and OWCP approval are required for any such
procedure.
(4) Substance Abuse Treatment. Where recommended by the
treating physician, the Office may approve a one-time inpatient
substance abuse treatment program up to 28 days in length. Such a
program may be approved even if the Office has not accepted
substance abuse as related to employment in cases where the abuse is
hindering the claimant from participating in a rehabilitation program or
securing employment. The treatment facility should be located within
25 miles of the claimant's home wherever possible, and a cost
comparison between comparable facilities should be made before care
is authorized. Any request for a subsequent course of inpatient
substance abuse treatment should be forwarded to the National Office
for consideration.
Outpatient treatment may be recommended by itself or as a follow-up
measure to inpatient care. Such treatment may be authorized when
recommended by the attending physician, as may medications
prescribed to alleviate the effects of addiction (e.g., Antabuse).
Likewise, counseling in a group setting may be undertaken at OWCP
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expense.
c. Outpatient or Ambulatory Services. In addition to treatment in the
physician's office, the following may be authorized:
(1) Nursing Services. See paragraph 6 below.
(2) Physical Therapy. For any orthopedic or neurological condition,
physical therapy for a period of 90 days may be authorized if
prescribed by the attending physician. Any therapy in excess of 90
days requires additional medical justification. The time limitation does
not apply to cases involving brain and spinal cord injuries, extensive
second and third degree burns and other conditions which have
rendered the claimant bedridden. (See FECA PM 2-810.16 for a
detailed discussion of authorization of physical therapy.) Work
hardening programs may also be considered on recommendation of
the treating physician.
(3) Occupational and Speech Therapy. These services may be
authorized when recommended by the attending physician for
reasonable periods if improvement or relief of distress is likely to
result. Long term therapy without prospect of improvement shall not
be authorized. Recommendation for such therapy is usually referred
to the DMA for consideration. Occupational or speech therapy may be
authorized when performed in recognized facilities or when rendered
by private providers as long as it is prescribed by the treating
physician and he or she monitors the results.
(4) Lip-Reading Services. On recommendation of the attending
physician, the DMA may approve lip reading services if they would
likely reduce the extent of disability and aid in rehabilitation.
(5) Pain Clinics. The DMA may authorize pain clinic treatment only
if it is appropriate for the accepted condition and the clinic in question
is reputable. Whenever possible clinics connected with universities or
other teaching institutions should be used.
(6) Palliative Treatment. The DMA may authorize such treatment
for prolonged or terminal conditions when the need is adequately
supported by consultants. The therapy may consist of surgical
procedures (rhizotomy), nerve blocks, large doses of pain medications,
and the services of pain clinics or hospices.
(7) Specific Treatments. In addition to the routine diagnostic and
therapeutic services provided in an institution or professional office,
specific forms of treatment may be authorized as follows:
(a) Acupuncture. Acupuncture may be authorized when
recommended by the attending physician to provide relief.
Such treatment shall be supervised by the recommending
physician, who shall submit periodic reports to show progress
or any relief of the symptoms. If the treatment continues
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beyond six months and/or the results are questionable, the
DMA should be asked for an opinion as to whether the
treatment should continue.
(b) Chymopapaine Treatment. Serious side effects have
been reported from the injection of chymopapaine. Therefore,
any request for this form of treatment must be justified by the
attending physician and reviewed by the DMA.
(c) Hernia Treatment. Surgery is the usual treatment
authorized for a hernia. If surgery is refused or medically
contraindicated, the fitting of a truss may be authorized if
recommended by an examining physician. Injection treatments
are now very rarely used and any such request should be
referred to the DMA for opinion.
(d) Substance Abuse Treatment. Such treatment may be
authorized on the basis of the attending physician's
recommendation. Such a program may be approved even if
the Office has not accepted substance abuse as related to
employment in cases where the abuse is hindering the claimant
from participating in a rehabilitation program or securing
employment.
d. Dental Services. The law provides for repair or replacement of injured
natural and fixed artificial teeth. Except in dental emergencies, prior approval
of OWCP shall be obtained for dental repair or replacement. Before approving
dental repair or replacement, an examination including x-ray and prophylaxis
should usually be authorized and an estimate of the cost of the proposed
dental work must be obtained.
3-0400-6 Nursing Services
6. Nursing Services. OWCP uses the services of in-house Staff Nurses and
contract Field Nurses to coordinate claimants' medical care and aid them in returning
to work. The work of the Staff Nurses is discussed briefly in PM 3-200 and more
thoroughly in PM 3-201. The following guidelines pertain to requests for clinical
nursing services:
a. Licensed or Practical Nurse. The services of these nurses may be
authorized when recommended by the attending physician for therapeutic
services in the home. The services of a nurse may not be authorized to
perform housekeeping duties, however.
(1) Nursing Plans. Nursing agencies routinely develop nursing care
plans for home care which are based on the treating physician's
instructions. A copy of the plans should be obtained to verify that the
nursing care proposed is related to the accepted condition. Absent
such plans, the following questions may be posed to the attending
physician:
(a) What are the chronic sequelae of the work-related injury
and what form of treatment do they require?
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(b) Are there acute and/or recurrent complications of these
sequelae? How frequently do they appear? What form of
treatment do they require?
(c) Has the claimant required hospitalization for the
treatment of any of the chronic sequelae and/or complications?
How frequently?
(d) What is the anticipated duration of nursing services?
(2) Special Nurses. The services of special nurses may be
authorized when the attending physician certifies that such services
are necessary due to the severity of the claimant's condition. In
questionable cases, the case file should be referred to the DMA for
recommendation. A care plan should be obtained and the approval
period tailored to the needs of the claimant in accordance with the
physician's recommendation.
B Services of Relatives. The attending physician must approve the
qualifications of a relative acting as a nurse to provide the necessary services.
c. Extended Care Facilities. Care in a convalescent home, skilled nursing
facility or hospice may be authorized when the employee does not need acute
care but does require services difficult or impossible to arrange in the home
setting. The recommendation of the attending physician is required in this
situation. OWCP will pay the rates for standard accommodations according to
the requirements of the medical condition. The claimant should remain under
continuing medical supervision of a physician, who may be asked to justify
the continuing need for institutional care every three to six months according
to the severity of the claimant's medical condition.
3-0400-7 Other Modes of Treatment
7. Other Modes of Treatment.
a. Preventive (Prophylactic) Treatment. The FECA does not authorize
provision of preventive measures such as vaccines and inoculations, and in
general, preventive treatment is a responsibility of the employing agency
under the provisions of 5 U.S.C. 7901. However, preventive care can be
authorized by OWCP for the following:
(1) Complications of preventive measures which are provided or
sponsored by the agency, such as adverse reaction to prophylactic
immunization.
(2) An injury involving actual or probable exposure to a known
contaminant, thereby requiring disease-specific measures against
infection. Included among such treatments would be tetanus antitoxin
or booster toxoid injections for puncture wounds; administration of
rabies vaccine where a bite from a rabid animal, or one whose status
was unknown, is involved; or AZT where exposure to HIV virus has
occurred.
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(3) Periodic examination of the uninjured eye may be authorized
where injury to the other eye has resulted in loss of vision, so that
possible sympathetic involvement of the uninjured eye may be
detected at an early stage. The frequency of these examinations
should be determined on the basis of the attending physician's
recommendations. If sympathetic involvement of the uninjured eye is
found, appropriate medical and surgical treatment for this condition
will be authorized.
(4) Conversion of tuberculin reaction from negative to positive. In
this situation INH therapy may be authorized. Treatment is limited to
the injured employee and cannot be extended to others who may, for
example, have been exposed to an infectious agent by the employee.
b. Adjunct and Ancillary Treatment. Upon the recommendation of the
attending physician, treatment may be authorized for a concurrent ailment if
it appears that such treatment is closely related to the treatment of an injury
and would hasten the cure of the accepted condition(s). Requests for such
treatments may include such regimes as weight loss programs for claimants
with chronic back conditions as well as more traditional therapies such as
treatment of concurrent diabetes in claimants with eye or foot conditions.
The DMA must review all such requests prior to authorization.
c. Experimental Treatment and Clinical Research. All requests for
authorization of the following kinds of treatment or research should be
referred to the OWCP Medical Director following appropriate development:
(1) Experimental diagnostic and treatment modalities or those
which are not generally accepted. Experimental treatment modalities
will be considered if the accepted condition is life-threatening (e.g.,
cancer or AIDS); established therapy has been tried to no avail; and a
significant body of data supports the view that the experimental
procedure is indeed beneficial;
(2) Participation in a research protcol;
(3) Administration of questionnaires, particularly of a sociological or
psychological nature.
Such requests should not be approved or denied without advice from
the National Office.
3-0400-8 Non-medical Services
8. Non-medical Services.
a. Health Club/Spa Membership. Membership in a health club or exercise
facility, or treatment at a spa, may be authorized when recommended by the
attending physician as likely to cure or give relief. Only the facilities required
should be authorized (for example, if swimming is prescribed, the approval
should not include use of exercise equipment as well) and the least expensive
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facility in the area should be used. Procedures for developing and
adjudicating requests for health club/spa membership are provided in PM
Chapter 2-810.15.
b. Seeing Eye and Hearing Dogs. The OWCP may pay for seeing eye and
hearing dogs, as well as for their training and maintenance costs, on
prescription of the attending physician if this service is required because of
blindness in both eyes or severe deafness (at least 80 percent binaural loss)
resulting from factors of the employment.
c. Change in Locality. Where a physician recommends that an injured
employee visit or move to another climate to alleviate symptoms of the
employment-related condition, the expenses incurred may be authorized if
OWCP finds that such a move is likely to cure, give relief, reduce the degree
or period of disability, or aid in lessening the amount of monthly
compensation. After developing the evidence, the CE should refer the case
file to the DMA for opinion concerning the advisability of such a move.
3-0400-9 Injury or Death While Obtaining Medical Care
9. Injury or Death While Obtaining Medical Care.
a. Benefits Payable. When an employee is injured while traveling to or
obtaining authorized medical care or examination, he or she is entitled to
medical benefits just as if the injury had occurred in the performance of duty.
If an injured employee dies away from home while receiving medical
examination or treatment, the body may be embalmed and transported in a
hermetically sealed casket to the employee's home at OWCP expense even if
death did not result from an accepted injury. If death resulted from a
condition unrelated or questionably related to the accepted condition,
authorization for services should include a request for postmortem
examination.
b. Pathological and Postmortem Examinations. The DMA may authorize
pathological examination of removed tissue at OWCP expense if such
examination is necessary to determine the merits of a claim that has been or
will be filed. If a postmortem examination has not been ordered by the
coroner or local medical examiner, permission for such an examination must
be requested in accordance with the appropriate state law.
c. Autopsy. If an autopsy is authorized, the DMA should specify that it
be conducted by a pathologist or another physician fully qualified to perform
such services and that a complete autopsy protocol must be submitted prior
to payment of the bill. Authorization for this procedure may be given by
telephone, followed by written confirmation or by telegram (where the
medical examiner is overseas). See PM Chapter 2-700 for additional
information concerning autopsies.
3-0400-10 Transportation and Expenses
10. Transportation and Expenses. OWCP will reimburse the cost of transportation
needed for treatment or examination of the claimant for the accepted injury, unless
transportation is furnished by the government. The transportation costs may include
the services of an accompanying nurse or attendant if required (see paragraph 6a(4)
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above). Incidental expenses may also be reimbursed whether or not transportation
is furnished by the Government, but OWCP cannot advance funds to defray travel
and incidental expenses except as noted below.
a. Mode of Travel. Travel should be undertaken by the shortest route,
and if practical, by public conveyance such as bus or subway. If the medical
evidence shows that the employee is unable to use these means of
transportation, the CE may authorize travel by taxi or special conveyance.
Transportation by ambulance may also be authorized if required, and if travel
by air ambulance is indicated, or air ambulance is found to be more
economical and expeditious than ordinary commercial air transportation,
approval may be granted for this service. In all such instances the DMA will
be consulted for advice, by telephone if indicated.
b. Transportation Expenses. Standard Form 1012 and Form CA-1077
shall be sent to the injured employee whenever examination and/or
treatment is authorized. They are used to claim reimbursement for travel
expenses when the government does not furnish transportation. When the
employee must travel to secure authorized examination and/or treatment and
the travel will cost more than one hundred dollars by public transportation, a
Government Transportation Request (GTR), Standard Forms 1169 and 1169a,
may be issued. The claimant should be instructed to return a GTR which is
not used so it can be canceled.
c. Accompaniment While Traveling. If the employee requires a nurse or
an attendant to accompany him or her in securing examination and/or
treatment, this service and associated transportation and incidental costs may
be authorized. Unless a need for other arrangements is demonstrated, he or
she should be instructed to make the return trip as soon as possible so that
no unnecessary expense will be incurred.
d. Incidental Expenses. Charges for child care, pet care, and home
security may be paid when incurred in the course of securing medical services
and supplies. In each case, the record must contain a memorandum
discussing the need for the incidental expenditure and the reasonableness of
the amount claimed.
(1) Necessity and Reasonableness. Incidental expenses shall be
paid to the extent that they are necessary and reasonable. For
example, in a household consisting of the claimant, a child, and a
semi-invalid parent where the claimant must pay for care of the child
and parent while hospitalized, reasonable family care expenses would
be paid. Should additional expenses be claimed, such as a kennel for
the family dog, reasonable kennel charges would be paid only if it were
determined that other arrangements could not be made, such as pet
care by the person staying with the family.
(2) Timing of Expense. Incidental expenses are allowable only
when incurred in the course of securing medical services and supplies.
Therefore, it is necessary to distinguish between expenses connected
with securing treatment and those incurred following treatment.
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Expenses in the latter category, such as housekeeping costs while the
claimant convalesces at home, are not payable because they are not
required to obtain medical services.
CHAPTER 3-0500 - OWCP Directed Medical
Examinations
Chapter 3-0500, OWCP Directed Medical Examinations
Paragraph and Subject Date Trans. No
Table of Contents 7/11 11-06
1. Purpose 7/11 11-06
2. Statutory Requirements 7/11 11-06
3. Second Opinion Examinations 7/11 11-06
4. Referee Examinations 7/11 11-06
5. Medical Management Application 7/11 11-06
6. Medical Management Codes 7/11 11-06
1. Purpose. This chapter describes the two kinds of OWCP directed medical
examinations, second opinion and impartial referee medical examinations, and the steps
involved in scheduling these examinations.
Other Federal Employees’ Compensation Act (FECA) Procedure Manual chapters also
have relevant guidance pertaining to medical examinations and should be consulted.
Chapter 2-0810, Developing and Evaluating Medical Evidence, discusses the Claims
Examiner's (CE’s) function in evaluating medical evidence and authorizing treatment. It
has specific sections devoted to the decision-making process for obtaining second
opinion and referee examinations.
Chapter 3-0300, Authorizing Examination and Treatment, discusses the circumstances
under which OWCP or, in some instances, the employing agency may authorize medical
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services and treatment for injured claimants.
Chapter 3-0600, Requirements for Medical Reports, outlines the information that should
be included in all medical reports.
2. Statutory Requirements. The authority to schedule second opinion and referee
examinations is specifically noted in the FECA in §8123, which states:
An employee shall submit to examination by a medical officer of the United
States, or by a physician designated or approved by the Secretary of Labor, after
the injury and as frequently and at the times and places as may be reasonably
required. The employee may have a physician designated and paid by him present
to participate in the examination. If there is disagreement between the physician
making the examination for the United States and the physician of the employee,
the Secretary shall appoint a third physician who shall make an examination.
3. Second Opinion Examinations. The attending physician (AP) is the primary
source of medical evidence in most cases, and the AP is expected to provide a
rationalized medical opinion based on a complete medical and factual background in
order to resolve any pending issues in a case. In certain circumstances, such as where the
AP’s report does not meet the needs of the OWCP, OWCP may schedule a second
opinion examination (SECOP).
a. Determining the Need for Examination. The decision to refer a case for a
second opinion examination rests with the CE, though such an exam may be
recommended by a Field Nurse (FN) or District Medical Advisor (DMA), or
requested by the employing agency. A complete discussion of when a CE should
refer a case for a second opinion examination is found in PM 2-0810-9 and 2-810-
10.
Also, OWCP may send a case file for second opinion review where actual
examination is not needed, or where the employee is deceased.
b. Selection of SECOP Physician.
(1) Physicians selected to perform second opinion examinations
should be administratively qualified in the appropriate branch of medicine.
(a) Where an emotional condition is the only work-related
condition known to be present, a referral can be made to a
psychiatrist or a clinical psychologist (as long as the file contains
no indication that medication for a psychological condition is
being used). Referral to a clinical psychologist may be made even
if the attending physician is a psychiatrist, but not where
psychogenic overlay is felt to be present, as these cases presuppose
a connection between the psychological condition and its physical
manifestation which can best be addressed by a psychiatrist.
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(b) If the issue for determination is the causal relationship
between a workplace injury/factor and a claimed condition or a
claimant’s ability to perform the date of injury position or some
other type of modified work, a referral can be made to a specialist
in occupational medicine, even if the attending physician is an
orthopedist, neurologist or some other specialty. As a sub-
specialty under the Board of Preventive Medicine, occupational
medicine physicians are specialists in the field of workplace
injuries and illnesses and their causal associations. They also
specialize in assessing fitness for duty relevant to the employee’s
work environment.
(2) Second opinion examinations are generally conducted by a
physician selected by a medical referral group that has contracted with
OWCP to provide second opinion medical referrals. The method for
selecting second opinion physicians is more flexible, since a strict rotation
of physicians is not required for this type of examination.
(3) If the medical referral group is unable to schedule the necessary
appointment in accordance with the needs of OWCP, OWCP can use the
Medical Management application for this purpose (see paragraph 5
below).
c. Information Sent to Physician. The physician should be provided with the
following:
(1) Description of the reason(s) for requesting the examination and a
list of questions to be resolved, along with a blank Form OWCP-5 if
appropriate.
(2) Statement of Accepted Facts (SOAF).
(3) Copies of pertinent medical reports from the case record, including
diagnostic test results, if applicable.
d. Information Sent to Claimant and the Properly Authorized Designated
Representative. Once the appointment has been scheduled, the
claimant/representative should be notified. See Donald J. Knight, 47 ECAB 706
(1996) (where ECAB held that OWCP’s failure to notify appellant's authorized
representative of the referral to a second opinion physician effectively denied
appellant's statutory right to have a physician designated and paid by him to be
present and participate in the examination pursuant to 5 U.S.C. 8123). This may
be done by OWCP, or by the contractor on OWCP’s behalf. The claimant and
his or her designated representative should be provided with the following
information:
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(1) The name and address of the physician to whom he or she is being
referred, as well as the date and time of the appointment.
(2) The claimant's right, under section 5 U.S.C. 8123 of the FECA, to
have a physician paid by him or her present during a second opinion
examination. 20 C.F.R. § 10.320; Esther Velasquez, 45 ECAB 249 (1993)
(ECAB held that by misinforming the claimant of the purpose of the
medical referral, OWCP effectively denied her the right granted by the
FECA, and that OWCP was precluded from relying on the resulting
medical report “before affording appellant the opportunity to exercise this
statutory right.”).
Because a claimant has a right under the statute to have such a physician
attend a second opinion examination, OWCP may not re-characterize an
impartial examination as a second opinion examination in the event it
determines there was no conflict in the medical evidence; however, the
report need not be excluded and may be considered for its intrinsic value.
(3) A warning that benefits may be suspended pursuant to 5 U.S.C.
8123(d) for failure to report for examination.
(4) Information on how to claim travel expenses.
e. The employee is not entitled to have anyone present at the examination
(other than the physician identified in d(2) above), unless the case file or other
rationalized medical evidence establishes the need for someone else in the room,
or OWCP decides that exceptional circumstances exist. However, where an
employee requires an accommodation, such as where a hearing-impaired
employee needs an interpreter, the presence of an interpreter or other individual
will be allowed. Anthony H. Jackson, 53 ECAB 529 (2002) (ECAB held that a
claimant is not entitled to have anyone other than a qualified physician in
attendance at a referral medical examination unless OWCP decides that
exceptional circumstances exist); Ida L. Townsen, 45 ECAB 750, 757 (1994)
(finding that interference by appellant's representative in insisting that he be
present for a medical examination constituted obstruction under section 8123 and
supported suspension of appellant's benefits).
f. Follow-up Action. Using the SOAF (See FECA PM 2-0809 regarding
SOAF requirements) as the framework for his or her opinion, the second opinion
physician should provide a report which contains a clinical history, results of the
examination, results of any testing performed, and a reasoned opinion in response
to the questions posed. A report should be expected within 30 days of the
examination.
(1) If no medical report is received within 30 days from the date of
appointment, the CE or medical scheduler should inquire as to the status
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with the medical referral group and/or the second opinion physician. The
CE or medical scheduler may also follow up soon after the date of the
appointment to verify the claimant’s attendance at the appointment. For a
complete discussion describing the circumstances under which benefits
may be suspended under 5 U.S.C. 8123(d) for failure to attend an
appointment, see PM 2-0810-13 Suspension of Benefits.
(2) Upon receipt of the report, the CE should review the report to
ensure that the physician has adequately addressed the questions posed.
(a) If clarification or additional information is necessary, the
CE should write to the specialist to obtain it, either directly or via
the medical referral group, as appropriate.
(b) Upon receipt of any clarifying information, the CE should
again review the report to ensure that it is complete and responsive
to the questions asked.
4. Referee Examinations. Section 8123(a) of the FECA and section 10.321 of the
implementing regulations provide for the appointment of a referee physician to examine
the claimant and resolve a conflict of medical opinion in a case. This is referred to as an
impartial medical examination (IME). Because this method of resolving conflicts is
provided in the FECA, the probative value of the referee specialist's report is great and
will normally constitute the weight of the medical evidence of record. Y.A., 59 ECAB 701
(2008) (when a case is referred to an impartial medical specialist for the purpose of
resolving a conflict in medical opinion, the opinion of such specialist, if sufficiently well
rationalized and based on a proper background, must be given special weight).
a. Determining the Need for Examination. A difference in medical opinion
sufficient to be considered a conflict occurs when two reports of virtually equal
weight and rationale reach opposing conclusions. See James P. Roberts, 31
ECAB 1010 (1980). The CE makes this determination after weighing the
opinions. See PM 2-0810-6 for an extended discussion on weighing medical
evidence. A complete discussion of when a CE should refer a case for a referee
examination is found in PM 2-0810-11. 20 CFR § 10.321(a).
b. Selection of IME Physician. Unlike selection of second opinion
examining physicians, selection of referee physicians is made on a strict rotational
basis.
(1) OWCP will select a physician who is qualified in the appropriate
specialty and who has had no prior connection with the case.
(2) The Employees' Compensation Appeals Board has placed great
importance on the appearance as well as the fact of impartiality, and only
if the selection procedures which were designed to achieve this result are
carefully followed may the selected physician carry the special weight
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accorded to an "impartial specialist."
In Leonard W. Waggoner, 37 ECAB 676 (1986), ECAB remanded the
case because the physician who examined the claimant was an associate of
the physician to whom the claimant had been referred. Since the claimant
was told to report to one physician but was ultimately examined by
another, he had no opportunity to object to the choice of examiner. ECAB
did not find that the specialist in this case was in fact biased, or would
have been ineligible on any particular ground. Rather, it found that to give
special weight to a physician not selected in accordance with procedures
would "undermine the appearance of impartiality or would appear to
compromise the integrity of the system for selecting impartial specialists."
ECAB found that the physician was not entitled to the special weight
accorded to a referee specialist because the procedures designed to provide
adequate safeguards against any possible appearance of bias were not
followed.
(3) Physicians in certain roles may not be chosen to act as referees in
specific cases. When a physician is asked to act as a referee specialist, the
medical scheduler should inquire as to the nature of any previous
association with the claimant or the claimant's employing agency.
Physicians who may not be used as referees include:
(a) Those employed by, under contract to, or regularly
associated with Federal agencies. See George W. Coast, 36 ECAB
600 (1985) (ECAB held that although there was no direct evidence
of record substantiating that the physician was previously
connected with the claimant's case, the selection of a physician
involved with fitness-for-duty examinations on behalf of the
employing establishment undermined the appearance of
impartiality).
(b) Physicians previously connected with the claim or the
claimant, or physicians in partnership with those already so
connected (see Raymond E. Heathcock, 32 ECAB 2004 (1981)
(ECAB held that OWCP could not use the report of one physician
to resolve a conflict in medical evidence because he was an
associate of another physician previously connected with the case,
and therefore was not completely independent)).
(c) Physicians who have acted as a medical consultant to
OWCP (see John Clement, 35 ECAB 959 (1984)).
Note: The mere fact that a physician has conducted a second
opinion examination in connection with the FECA program does
not eliminate that physician from serving as an impartial referee
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physician in another case.
(4) In a case involving only a mental condition where a conflict exists
between two psychologists or between a psychologist and a physician who
does not specialize in treatment of mental disorders, the referee specialist
chosen to resolve the case may be either a psychiatrist or clinical
psychologist (as long as the file contains no indication that medication for
a psychological condition is being used). In those cases, however, where a
conflict has arisen between a psychologist and a psychiatrist or between
two psychiatrists, the Office will obtain a referee examination from a
psychiatrist. This practice will ensure that the referee physician carries
sufficient weight in cases where a medical doctor has been involved in
creating the conflict, and should also ensure that the full range of issues is
addressed.
(5) In a case involving a physical condition where a conflict exists
with regard to the causal relationship between a workplace injury/factor
and a claimed condition or a claimant’s ability to perform the date of
injury position or some other type of modified work, a referee examination
may be scheduled with an occupational medicine physician, even if one or
both of the physicians with conflicting opinions is not an occupational
medicine physician. As a sub-specialty under the Board of Preventive
Medicine, occupational medicine physicians are specialists in the field of
workplace injuries and illnesses and their causal associations, and they
also specialize in assessing fitness for duty relevant to the employee’s
work environment, they are qualified to provide an opinion on these issues
and may be afforded the special weight provided to referee physicians.
(6) The selection of a physician to perform a referee medical
examination is done by the district office using the Medical Management
application within the Integrated Federal Employees’ Compensation
System (iFECS). This selection process is described in detail in paragraph
5 of this chapter.
(a) The Medical Management application contains the names
of physicians who are Board-certified in certain specialties. The
database of Board-certified physicians used for referee
examinations contains over 30 specialties, including:
cardiovascular disease, dermatology, gastroenterology, internal
medicine, neurology, occupational medicine, osteopathy,
orthopedic surgery, physical medicine and others.
(b) The services of all available and qualified Board-certified
specialists will be used as far as possible to eliminate any inference
of bias or partiality. This is accomplished by selecting physicians
(in the designated specialty in the appropriate geographic area) in
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alphabetical order as listed in the roster and repeating the process
until the list is exhausted.
(c) A physician can be added to the Medical Management
application, and thereby the rotation, by the District Director, or
his/her designee after verifying that the physician meets the board-
certification requirements for a particular specialty.
(d) A physician may be eliminated from the rotation for the
following reasons, which include, but are not limited to: he or she
is not willing to perform examinations for OWCP; reports have
shown a predictable pattern amounting to bias; he or she
chronically submits inadequate reports in the face of acceptable
questions; reports are consistently submitted late; or he or she has a
signed agreement with OWCP to perform case file reviews.
OWCP may discontinue the use of a physician by properly
updating the Medical Management application and citing instances
(dates, specific case files, etc.) in which bias or inadequacies are
demonstrated. The District Director, or his/her designee, is
authorized to suspend or permanently remove a physician.
(e) Excluded providers are disqualified from serving as referee
physicians (see Chapter 3-0800).
(f) A physician who is not Board-certified may be used if he or
she has special qualifications for performing the examination, but
the scheduler must document the reasons for the selection in the
case record.
(7) Sometimes examination by more than one kind of specialist is
required in order to fully address work-related injuries and any
complications that may be associated with the injuries. If the CE has
identified the need for examination by two kinds of specialists, for
instance an orthopedist and a psychiatrist or clinical psychologist, the
scheduler will arrange two separate examinations without asking either
physician to coordinate the results.
On the other hand, a referral physician who needs to obtain information
from another provider is authorized to make subsidiary referrals as
necessary (for instance, a psychiatrist may refer a claimant to a clinical
psychologist for testing). In this case, the referral physician should submit
a summary report discussing any discrepancies among the physicians'
viewpoints so that questions posed by OWCP are fully answered.
In extremely complex cases, a panel of physicians may be asked to
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examine the claimant and render a collective opinion. The services of
such panels are most easily arranged through medical schools and
hospitals, as these institutions employ specialists in many fields of
medicine. Such referrals are rare.
c. Information Sent to Physician. The physician should be provided with the
following:
(1) Description of the reason(s) for requesting the examination,
including an indication of the conflict and a list of questions to be
resolved, along with a blank Form OWCP-5 if appropriate.
(2) Statement of Accepted Facts (SOAF).
(3) Copy of the complete case file, either in paper or electronic form.
(4) Notice that he or she is the only individual authorized to perform
the requested examination and provide the required report.
(5) Prompt payment billing information, including the code for referee
medical examination or case review.
d. Information Sent to Claimant and Properly Authorized Designated
Representative. Once the appointment has been scheduled, the
claimant/representative should be notified. See Rosita Mahana, 50 ECAB 331
(1999) (ECAB held that by not notifying appellant and her attorney of the identity
of the impartial medical specialist, OWCP deprived her of an opportunity to
present any objections to the selection of Dr. Schwarz as the impartial medical
specialist; and, accordingly, Dr. Schwarz was not properly selected as an impartial
medical specialist and her report could not be used to resolve the conflict of
medical opinion). The claimant and his or her duly appointed representative
should be provided with the following information:
(1) Notice of the existence of a conflict in the medical evidence and
the specific nature of the conflict. Notification should also be included
that the examination is being arranged under the provisions of 5 U.S.C.
8123, which provides the claimant an opportunity to raise any objection to
the selected physician prior to the examination.
(2) The name and address of the physician to whom he or she is being
referred, as well as the date and time of the appointment.
(3) A warning that benefits may be suspended pursuant to 5 U.S.C.
8123(d) for failure to report for examination.
(4) Information on how to claim travel expenses.
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e. The employee is not entitled to have anyone present at the examination
unless OWCP decides that exceptional circumstances exist. For example, an
interpreter may be allowed if a claimant is hearing-impaired. The law does not
provide for participation by a physician of the claimant's choice in a referee
examination (unlike second opinion examinations). 20 C.F.R. § 10.321(b).
f. A claimant who asks to participate in selecting the referee physician or
who objects to the selected physician should be requested to provide his or her
reason for doing so. The CE is responsible for evaluating the explanation offered.
See Miguel A. Munitz, 54 ECAB 217, 221 (2002) (ECAB held that OWCP
properly denied appellant’s request to participate in the selection of the impartial
medical specialist: “appellant's representative merely requested to participate in
the selection of the referee examiner, in an ‘attempt to assure that the claimant
receives an impartial evaluation concerning this schedule award claim.’ The
Board finds that he did not provide a valid reason for participating in the selection
and did not raise a specific objection to the selected physician.”); Terrance R.
Stath, 45 ECAB 412 (1994) (ECAB has recognized that under the OWCP’s
procedures, a claimant is entitled to participation in the selection of an impartial
specialist; however, the claimant does not possess an unqualified right to
participate. The claimant must provide a valid reason for request for participation
at the time the conflict of medical opinion is found.).
(1) Examples of circumstances under which the claimant may
participate in the selection include (but are not limited to):
(a) Documented bias by the selected physician;
(b) Documented unprofessional conduct by the selected
physician;
(c) A female claimant who requests a female physician when a
gynecological examination is required; or
(d) A claimant with a medically documented inability to travel
to the arranged appointment when an appropriate specialist may be
located closer. For instance, if the orthopedic specialist chosen
through the Medical Management application in iFECS is three
hours by automobile from the claimant's home, but an orthopedic
specialist in the nearest large city is only one hour away by
airplane, the latter physician may be chosen if the attending
physician documents that the claimant can not travel for three
hours by automobile.
(e) Simple preference for examination in a particular location
will not be considered a valid reason. See S.W., Docket No. 09-
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1110 (issued February 19, 2010) (ECAB held that appellant did not
present any evidence establishing that the impartial selection was
improper: “Although appellant’s attorney noted that the Office of
the impartial medical examiner was approximately 281 miles from
appellant's residence, the Office indicated that it would reimburse
travel expenses, including the cost of an overnight stay, if
necessary. A simple preference for examination in a particular
location is not considered a valid reason for objecting to an
impartial medical examiner.”).
(2) If the reason is considered acceptable, the scheduler will prepare a
list of three specialists available through the Medical Management
application in iFECS, including a candidate from a minority group if
indicated, and ask the claimant to choose one. This is the extent of the
intervention allowed by the claimant in the process of selection or
examination.
(3) If the reason offered is not considered valid, a formal denial on the
claimant's request, including appeal rights, may be issued if requested.
g. Follow-up Action. Using the SOAF as the framework for his or her
opinion, the referee physician should provide a report which contains a clinical
history, results of the examination, results of any testing performed, and a
reasoned opinion in response to the questions posed sufficient to resolve the
conflict. A report should be expected within 30 days of the examination.
(1) If no medical report is received within 30 days from the date of
appointment, the CE or medical scheduler should inquire as to the status
with the referee physician’s office. The CE or medical scheduler may also
follow up soon after the date of the appointment to verify the claimant’s
attendance at the appointment. For a complete discussion describing the
circumstances under which benefits may be suspended under 5 U.S.C.
8123(d) for failure to attend an appointment, see PM 2-0810-13
Suspension of Benefits.
(2) The CE must refrain from verbal contact to discuss any substantive
issue in the case with a physician who has been engaged to provide a
referee opinion. All such communication regarding these issues should be
in writing.
If a referee medical report is obtained through such substantive telephone
contact with the physician or submitted as a result of such contact, the
referee report must be excluded. See PM 2-0810-12 for further details
regarding exclusion of medical evidence.
The CE may only verify attendance at the appointment and inquire as to
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the status of the submission of the report, and should document that
verification with a CA-110.
(3) Upon receipt of the report, the CE should review the specialist's
report to ensure that it meets the requirements for a referee examination
and that it addresses all issues posed.
(a) If someone other than the selected physician examined the
claimant, the report cannot be used to resolve a conflict in medical
opinion and cannot be afforded special weight. It should be
annotated accordingly, and another referee examination must be
arranged. Moreover, any indication of interference by the
employing agency or claimant's representative will be considered
sufficient to bias the report, which will then not be considered
probative evidence.
(b) If clarification or additional information is necessary, the
CE should write to the specialist to obtain it. Under no
circumstances, however, should the CE telephone the specialist for
elaboration of the report as information obtained in this manner
cannot be considered probative medical evidence and bias may be
inferred as a result, leading to exclusion of the report. See PM 2-
0810-12 for further details regarding exclusion of medical
evidence.
(c) Upon receipt of any clarifying information, the CE should
again review the report to ensure that it is complete and pertinent
to the questions asked. When the referee's report is considered
adequate, the CE will take action without review by the DMA,
except where a referee examination was arranged to resolve a
schedule award issue. See PM 2-810-8.k. for further details
regarding DMA review of referee reports relating to schedule
award determinations.
5. Medical Management Application. The Medical Management application in
iFECS, which replaced the Physician Directory System (PDS), allows users access to a
database of Board-certified specialist physicians and is used to schedule referee
examinations and sometimes second opinion examinations if needed. This application
contains an automatic and strict rotational scheduling feature. This application provides
for consistent rotation among physicians and records the information needed to document
the selection of the physician.
a. In 2000, an updated version of the PDS standalone software was placed
into the iFECS system, replacing the previous PDS system. The directory of
medical specialists contains physician from the American Board of Medical
Specialties (ABMS). The ABMS includes the medical boards of the American
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Medical Association (AMA) that certify candidates in their respective fields of
specialization.
OWCP recognizes osteopathic doctors (D.O.) as physicians within the meaning of
the Act. As such, OWCP also accords special weight to their opinions as
impartial referee physicians, provided they are Board-certified with the American
Osteopathic Association (AOA).
b. Selection of a referee physician should be made only through the use of
the Medical Management application (absent exceptional circumstances discussed
below), and CEs may not dictate which physician will serve as a referee
examiner.
However, where exceptional circumstances exist (such as when an esoteric
specialty is required, or the Medical Management application does not contain
any physicians of the required specialty within a 200 mile radius), scheduling
outside of the Medical Management application may be appropriate. If this
occurs, the scheduler should consult an appropriate directory of medical
specialists to obtain names of suitable physicians for referral. Documentation
outlining the rationale for this decision must be placed in the case file, and the
decision must be approved by a Supervisory Claims Examiner or higher level
authority.
If an examination needs to be rescheduled with a prior referee examiner in
accordance with a remand order or where follow-up is necessary, scheduling
outside of the strict rotational guidelines may also be necessary. In these more
obvious instances, documentation must still be placed in the case file but approval
by a Supervisory Claims Examiner or higher level authority is not required.
c. When the medical scheduler inputs a claim number, the claimant’s home
zip code is automatically loaded. The medical scheduler then chooses the type of
examination (second opinion or referee) and the specialty. Information regarding
the next physician on the roster, based on medical specialty and zip code, appears
on the screen and remains on the screen until the appointment is scheduled or
until the physician is bypassed. The entire roster of physicians is invisible to the
medical scheduler, as he or she can only see and update the information pertaining
to the selected physician until a decision is made to schedule the appointment or
bypass the physician. See paragraph 6 of this chapter for a complete discussion
on the reasons for bypassing a physician.
d. The universe of physicians included in the search and available for referee
scheduling is based on the specialty chosen and the claimant’s home zip code.
Physicians are presented to the medical scheduler in alphabetical order, except
that any physician in the universe that has been either bypassed or had an
appointment scheduled will be at the bottom of the list based on the date of that
last contact. Presentation of physicians is based on the last contact, such that the
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physician in that universe who was either bypassed by the office or had an
appointment scheduled most recently will be at the bottom of the list.
e. The medical scheduler will contact the physician presented by the Medical
Management application to ascertain whether the necessary appointment can be
scheduled in a timely manner.
f. If an appointment cannot be scheduled in a timely manner (or for some
other reason such as a conflict, the physician is of the wrong specialty, etc.), the
scheduler will update the application with an appropriate bypass code. Upon
entering a bypass code, the Medical Management application will present the next
physician in the universe based on specialty and zip code. See paragraph 6 of this
chapter for more explicit information pertaining to the use of bypass codes.
g. If the physician agrees to schedule the appointment, the scheduler inputs
the appointment date and time into the Medical Management application. The
application saves the appointment information and prompts the scheduler to
prepare form ME023, Appointment Notification Report, for imaging into the case
file.
The ME023 report can only be generated through the Medical Management
application and serves as documentary evidence that the referee appointment was
scheduled through the use of the rotational system in the Medical Management
application. The medical scheduler should image a copy of the ME023 into the
case file to substantiate that the rotational system was used to select the physician.
In the event the report is not included in the file at the time of the referral and an
issue is raised concerning the IME selection later in the appeal process, a copy of
the original ME023 may be reproduced at a later date; no adjustments can be
made to the initial information, and it will include the original date.
h. If all physicians presented are bypassed and there are no physicians
available within that zip code range, the Medical Management application
prompts the medical scheduler to select a range of miles for selection of another
zip code. The scheduler incrementally chooses zip code ranges so that the closest
available appointment to the claimant’s home zip code can be scheduled.
The Medical Management application sets 200 miles as the outer limit for zip
code selection. If the scheduler reaches the 200-mile mark and still cannot find a
physician, a print screen from the application showing that there are no physicians
within that range should be placed in the case file. The scheduler will then need
to use an alternative method for scheduling the examination as outlined in 5(b) of
this chapter.
i. If a scheduled appointment has to be cancelled or rescheduled for any
reason, the file should be appropriately and clearly documented.
6. Medical Management Codes. The Medical Management application has
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numerous codes to display the disposition of physicians and appointments.
If a physician cannot or will not schedule an examination, he or she must be bypassed in
the Medical Management application so that the next physician in the rotation is available
for scheduling. Various codes are used to document the reasons for not scheduling an
examination with a physician in the rotation.
Most codes are stand-alone codes and do not require any rationale beyond their meaning
as outlined in this chapter. However, three codes, code B (Busy), code L (Location), and
code O (Other), do require a note explaining the reason for entry of the code. The note is
entered directly into the Medical Management application, without any requirement that
the imaged file be documented. Bypass notes entered must be sufficiently detailed to
explain the reason the physician was bypassed (e.g. a note like “pass” is not sufficient),
and the use of local abbreviations should be avoided. Finally, while notes are not
mandatory for all codes, if the scheduler enters a note, it should be applicable and
germane to the bypass code used.
Code A - Appointment Cancelled. This code is used when an appointment has been
cancelled by either the physician or OWCP. This code is not a bypass code option but
can be used in other portions of the Medical Management application.
Code B - Busy. This code is used when the physician cannot schedule an appointment in
a reasonable amount of time (usually within 60 days) or is on extended leave or a leave of
absence. A note is required to further explain usage of this code, e.g. “physician is on
medical leave of absence – unknown return date.” This code should NOT be used if the
telephone line is busy or if the medical receptionist indicates the physician is too busy at
the moment to take the call.
If a physician will be on a defined period for a leave of absence longer than 60 days, the
user should annotate the physician’s record in the Medical Management application in
iFECS as appropriate. This will ensure that the physician does not appear in the rotation
for the leave of absence period but will again appear in rotation once the leave of absence
has ended.
Code C - Conflict. This code is used if the physician, or his/her associate, has a previous
connection with the claim. This also includes physicians performing fitness for duty
exams for the employing agency.
Code D – Physician does not accept DOL patients. This code is used if the physician
will not accept any Department of Labor (DOL) cases, will not do IMEs, will not accept
workers’ compensation cases, or is not willing to perform examinations for OWCP.
If a physician will not accept DOL or OWCP cases for medical examinations, the
physician’s record in the Medical Management application in iFECS should be updated
so that the physician no longer appears in the rotation.
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Code E - Excluded/Lost license. This code is used if a physician is an excluded
provider or has lost required licensing. This code is not a bypass code option but can be
used in other portions of the Medical Management application.
Code L - Location is too far for claimant. This code is used when the physician’s
office is too far for the employee to travel, or the claimant may be medically unable to
travel long distances to report for examination. A note is required to further explain
usage of this code, since distance to travel is accounted for in the rotational presentation
of physicians in the Medical Management application.
Code M - Physician moved out of zip code area. This code is used when the physician
is no longer at the address shown in our database. The medical scheduler should attempt
to obtain current contact information to update the physician address in the Medical
Management application. If the physician is still within the same zip code as the address
in the Medical Management application, the address can be updated and the appointment
scheduled.
Code O - Other. This code is used when none of the other bypass reasons are
applicable. This code is appropriate to use when no one answers the phone (e.g. “phone
rings continuously with no answer”) or the phone number has been disconnected (e.g.
“phone disconnected/no other contact number noted”). A note is required to explain
usage of this code, and code O should not be used if there is another appropriate code.
Code O is also appropriate if the medical scheduler must leave a message. If a message
must be left, the medical scheduler should note the name of the person who was
contacted or that a message was left on a voice mail. While waiting for a return call, the
appointment with that particular physician should be put into a “pending” status. The
scheduler should allow the physician’s office a minimum of two business hours for a
return call (as determined by usual physician business hours). If the physician’s office
does not call back within this period of time, the physician can be bypassed with the O
code and another physician can be contacted. When the scheduler removes the “pending”
status, the bypass note should be updated with an annotation that no call back was
received. If a call back was received, and it was determined that the appointment could
not be scheduled for some other reason (related to another bypass code), the record
should be updated accordingly.
If a physician previously bypassed as non-responsive contacts the OWCP medical
scheduler prior to the scheduler finalizing an appointment with another physician,
continued efforts to arrange an examination with the second physician should cease and
the appointment should be scheduled with the previously bypassed physician, as he or she
was actually earlier in the rotation of physicians. If this occurs, the note should be
updated accordingly when the appointment is scheduled.
Code S – Subspecialty. This code is used if the case requires a different subspecialty, or
if the physician does not evaluate the specific body part or extremity. For instance, the
physician will only perform exams for back conditions but the claimant has an upper
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extremity injury.
Code U - Physician in use by another user. This code is used when the physician is in
use by another user. It is not available as a bypass option; rather, it is automatically
updated by the Medical Management application when the next physician in the rotation
is currently in use or in pending status (being contacted for an appointment) by another
user.
CHAPTER 3-0600 REQUIREMENTS FOR
MEDICAL REPORTS
TABLE OF CONTENTS
Paragraph and Subject Date Trans.No
Table of Contents 09/96 96-15
1. Purpose 10/90 91-02
2. Reports of Disability and Impairment 10/90 91-02
3. Statement of Accepted Facts (SOAF) 10/90 91-02
4. Questions for Response 10/90 91-02
5. Form of Medical Reports 10/90 91-02
6. Content of Medical Report 10/90 91-02
7. Criteria 10/90 91-02
8. Specific Conditions 10/90 91-02
09/94 94-42
09/95 95-39
9. Partial Disability 12/91 92-07
10/90 95-04
Exhibits
1 Attending Physician's Report
Form CA-20 12/94 95-04
Page 1-2
Page 3
2 Attending Physician's Supplemental
Report, Form CA-20a 12/94 95-04
Page 1-2
3 Duty Status Report, Form CA-17 12/94 95-04
Page 1-2
4 OWCP Hearing Loss Medical
Requirements 09/96 96-15
5 Outline for Otologic Evaluation, 09/94 94-42
Form CA-1332
Page 1-2
Page 3-4
6 Calibration Requirements for
Accreditation of an Audiological
Facility by the Professional
Services Board 09/94 94-42
7 OWCP Medical Examination
Requirements
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in Asbestos Disease Cases 12/94 95-04
8 Roentgenographic Interpretation 12/94 95-04
Form CM-933
Page 1
Page 2
9 Carpal Tunnel Cross-Sectional View
(Link to Image) 12/94 95-04
3-0600-1 Purpose
1. Purpose. The Office relies on written medical reports to justify awards for
compensation, support payment of medical expenses, and monitor the quality of care
being provided. This chapter will detail the type of information needed to render
proper determinations for the medical issues in each case.
3-0600-2 Reports of Disability and Impairment
2. Reports of Disability and Impairment. Reports are submitted by attending
physicians, consultant (second opinion) specialists, and referee physicians. Each
report may address one or more topics pertaining to the claimant's medical status.
Whatever the format or source of a report, the information provided in it must be
sufficiently clear and detailed so that claims and medical reviewers are certain of the
physician's findings, conclusions,
and opinions.
Under the FECA, impairment is defined as the anatomical or functional loss or
reduction of a function of an organ of the body in reference to the activities of
normal life; it pertains solely to the claimant's medical condition. Disability is
defined, on the other hand, in terms of the claimant's ability to perform the duties of
his or her job.
3-0600-3 Statement of Accepted Facts (SOAF)
3. Statement of Accepted Facts (SOAF). Where a medical opinion is needed to
resolve an issue in a case, the file is referred to the Medical Unit with a list of
questions (see paragraph 4 below). An SOAF usually accompanies the case and
provides the factual background for the physician's opinion. Only where the Claims
Examiner (CE) needs general information, for instance about the course of a disease,
will an SOAF not be included.
a. Contents. All SOAFs should include the information listed in items (1)
through (6); depending on the issue to be resolved, the information shown in
items (7) though (10) will be included as well:
(1) The claimant's name and age;
(2) The employer and the job held at the time of injury;
(3) Mechanism of injury;
(4) Conditions claimed or accepted;
(5) Work history since the injury, including the date
the claimant stopped work and returned to either light or regular duty;
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(6) A description of medical treatment since the injury, including
dates of treatment and names of physicians, and if relevant what
diagnostic tests were conducted (physicians' findings and conclusions
should not, however, be discussed in the SOAF);
(7) Relevant medical history;
(8) Specific description of injury or exposure factors, particularly in
cases involving occupational disease;
(9) The claimant's hobbies or activities outside of work;
(10) Physical or mental demands of claimant's regular or light duty
job, or of light duty job offered.
Detailed instructions for CEs concerning the preparation of SOAFs are
contained in PM Chapter 2-809.
The CE is responsible for ensuring that the SOAF is correct, complete,
unequivocal, and specific. When the DMA, second opinion specialist or
referee physician renders a medical opinion based on an SOAF which is
incomplete or inaccurate or does not use the SOAF as the framework
in forming his or her opinion, the probative value of the opinion is
seriously diminished or negated altogether.
3-0600-4 Questions for Response
4. Questions for Response. Files referred to the Medical Unit
will contain a list of question composed by the CE for response by the physician
(DMA, second opinion or referee) to answer. In reviewing case files, the DMA should
ensure that he or she addresses each of the questions posed, preferably in the order
given, and that the response is:
a. Complete and accurate in addressing all of the questions posed and in
addressing them thoroughly. In some instances the DMA may identify
medical issues which the CE has not addressed. It is perfectly appropriate to
discuss such issues and provide information in addition to what the CE has
requested as long as medical rather than adjudicatory questions are the
subject of the discussion.
b. Responsive to the material provided in the SOAF. If the physician
whose reports are under review has based his or her opinion on other factual
material, the DMA should take account of this in reaching an opinion.
c. Well rationalized in discussing the opinion reached. Because the quality
of the Office's adjudicatory functions depends heavily on well reasoned
medical evidence, it is very important to provide clear rationale for the
opinion given.
d. Neutral with respect to adjudicatory issues. It is not appropriate for
the DMA to offer opinions as to whether a case or medical condition should be
accepted. Doing so may adversely affect the outcome of the case since it
may suggest bias to a later reviewer.
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3-0600-5 Form of Medical Reports
5. Form of Medical Reports. The DMA will be expected to review, interpret, or
evaluate a variety of medical reports ranging from simple form reports to detailed
narrative reports (it should be noted that the use of an OWCP form is never required
in making reports). Descriptions of OWCP forms are as follows:
a. Form CA-16, Form CA-20, and Form CA-20a, Attending Physician's
Report. An initial or preliminary report may be submitted on either Form CA-
16 (Exhibit 1, Chapter 3-300 (Link to Image)) or Form CA-20 (Exhibit 1 Pages
1-2( Link to Image); Page 3 (Link to Image)), while a supplementary report
may be submitted on Form CA-20a (Exhibit 2 (Link to Image)). A completed
Form CA-16 or CA-20 represents sufficient medical evidence for adjudication
of most traumatic injury claims, although additional evidence in narrative
form may be required to justify payment of continuing benefits.
b. Form CA-17, Duty Status Report. The CA-17 (Exhibit 3 (Link to
Image)) is used by the employing agency to obtain information from the
attending physician about the claimant's work restrictions. A copy of the form
may be sent to OWCP to aid in evaluating the extent of disability remaining.
Reports submitted by the employing agency generally do not address all
pertinent issues such as the causal relationship between current disability and
factors of Federal employment. Therefore, these reports are usually
considered as supplemental information although some narrative fitness-for-
duty reports may be sufficiently probative in and of themselves.
c. Narrative Report. A narrative medical report may be required if
disability continues or complex issues such as a pre-existing medical condition
are present. In addition, narrative reports are necessary in almost all
occupational disease cases. In any case where the injury causes disability for
work for an extended period or requires lengthy treatment, reports describing
the clinical course, prognosis, and recommendations for further medical care
must be furnished as needed.
3-0600-6 Content of Medical Report
6. Content of Medical Report. Regardless of the form a medical report takes, the
following information will usually be required:
a. Dates of examination or treatment;
b. Clinical history given to the physician;
c. Detailed description of physical findings;
d. Results of any x-ray or laboratory tests;
e. Diagnosis;
f. Prognosis;
g. Description of impairment, if any;
h. Specific limitations for work;
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i. Clinical course of treatment followed;
j. The physician's reasoned opinion as to the relationship between the
condition found and factors of Federal employment. (Causal relationship is
discussed in PM Chapter 2-805.)
In addition, a detailed description of the employee's work tolerance limitations
is required in any case where the issue is the claimant's ability to return to
duty, and a detailed description of anatomical impairment in accordance with
the AMA Guides is required in any claim for schedule award.
3-0600-7 Criteria
7. Criteria. Guidelines for weighing the value of medical reports are provided in
PM Chapter 2-810. The Office uses the following criteria in evaluating medical
opinions:
(1) Physician's Qualifications. The opinion of a specialist in the
appropriate field of medicine often carries greater weight than the
opinion of a non-specialist or a specialist in an unrelated field. The
opinion of a Board-certified specialist or a specialist of professorial
rank will carry added weight.
(2) Medical Rationale. Opinion supported by a medical explanation
is required in most cases.
(3) Accuracy and Completeness. The factual and medical
background reflected in the report must be correct and complete in
accordance with the facts of the case and the medical information
reflected in other reports in file.
(4) Comprehensiveness. A comprehensive report is one which
reflects that all testing and analysis necessary to support the
physician's conclusions have been performed.
(5) Consistency. The physical findings must substantiate the
medical opinion.
(6) Decisiveness. Opinions containing unclear or vague language
can be characterized as equivocal, speculative or conjectural. Terms
such as "could", "may", or "might be" indicate speculation and/or
equivocation and are assigned less probative value than positively
expressed medical opinions. The term "probably" is considered less
speculative than the above terms and therefore has greater probative
value.
The DMA should render his or her opinion using the Statement of Accepted Facts
(SOAF), which the CE prepares (see Chapter 3-500 for a discussion of the SOAF).
The opinion should be based on the medical evidence of record (except for any
reports annotated with the word "excluded" because the evidence which they contain
was improperly obtained.) The DMA should avoid commenting on legal issues when
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rendering a medical opinion. If the DMA disagrees with the opinion of the treating
physician, a clear and thorough medical explanation must be included.
3-0600-8 Specific Conditions
8. Specific Conditions. OWCP has developed checklists for use by claimants and
their official superiors in order to better identify and gather the information required
to support a claim for occupational disease. These checklists address the following
conditions: hearing loss, asbestos, coronary/vascular conditions, skin diseases,
pulmonary disease other than asbestos, psychiatric illness, and carpal tunnel
syndrome. A general checklist is also available for use in claims for occupational
diseases not enumerated above.
Occupational disease claims in general are discussed in PM Chapter 2-806. The
following guidance is provided with respect to specific medical conditions
encountered in OWCP claims:
a. Hearing Loss. Refer to "Medical Management of Claims under the
FECA" for a discussion of development of such cases. It is generally accepted
that hearing loss may result from prolonged exposure to noise levels above
85 decibels. Acoustic trauma may, however, result from decibel levels below
85 decibels if exposure is sufficiently prolonged. OWCP therefore does not
require that the claimant show exposure to injurious noise in excess of 85
decibels as a condition to approval of the claim.
(1) After obtaining all pertinent factual evidence, the CE will
prepare a Statement of Accepted Facts. Unless the case file already
contains a reliable medical report which fully meets OWCP
requirements, the CE should refer the claimant for audiological
evaluation and otological examination which addresses the relationship
of any hearing loss to the employment and the degree of any
permanent impairment.
The audiological evaluation and the otological examination are to be
performed by different individuals as a method of evaluating the
reliability of the findings through independent observations. If
possible, the two consultations should occur on the same day. The
usual information sent to consultants, as outlined in PM 3-500.3c,
should be forwarded to both the audiologist and otolaryngologist.
(2) The audiological testing is to be performed by persons
possessing certification in audiology from the American Speech-
Language-Hearing Association (ASHA), or State licensure as an
audiologist. The audiological testing should precede the visit to the
otolaryngologist since the latter should have the audiological findings
at the time of the examination. The audiological examination should
be conducted in accordance with OWCP requirements, which are
described in Form CA-1087 (Exhibit 4).
(3) The medical examination should be performed by an
otolaryngologist certified (or eligible for certification) by the American
Board of Otolaryngology. The physician should be instructed to
conduct additional tests or retests in those cases where the initial tests
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were inadequate or there is reason to believe the claimant is
malingering. Form CA-1331 and Form CA-1332 can be used to obtain
the required report.(Exhibit 5) Pages 1-2 (Link to Image); Pages 3-4
(Link to Image))
(4) Audiological equipment used for testing must meet the
calibration protocol embodied in the Professional Services Board
Manual of the ASHA (see Exhibit 6). Each audiologist or physician who
conducts hearing tests must certify that at the time of examination the
equipment used for testing met the standards for accreditation of an
audiological facility by ASHA (ANSI S 3.6 (1969) and 3.1 (1977),
respectively).
(5) Where the employee is deceased, the following procedures are
to be followed according to the stage of development of the medical
evidence:
(a) Where an audiogram meeting the requirements set forth
in Form CA-1087, either alone or in conjunction with
audiograms that do not meet OWCP requirements, appears in
the file, the audiogram may be used as the basis of an award if
it is medically determined to be internally consistent (the
various measurements of the components of hearing are in
substantial agreement) and the evidence shows a causal
relationship between the hearing loss and employment.
(b) Where no audiogram meets the requirements of Form
CA-1087, an audiologist should review all audiograms in the
case to ascertain whether they are internally consistent with
each other and whether the hearing loss was causally related to
employment. If so, an appropriate audiogram should be
selected as the basis for an award. If not, every effort should
be made to determine an equitable award. Where an award is
made based on evidence which does not fully meet the OWCP's
requirements, the CE should prepare a detailed memorandum
to the file which explains how the award was determined. Such
decisions should be signed at the level of the Senior CE or
above.
(6) The DMA calculates the percentage of hearing loss using Form
CA-51 (see Exhibit 3 of PM 3-700 (Link to Image,)) if a schedule award
is at issue. The DMA provides opinion regarding the causal
relationship between any hearing loss and the employment and
verifies the calculations of the audiologist.
b. Asbestos-Related Diseases. Refer to "Medical Management of Claims
under the FECA" for a discussion of development of such cases. It is accepted
that asbestos- related disease may result from occupational exposure in
excess of two fibers/cc (moderate or heavy) during the course of Federal
employment, or the presence of asbestos dust on work surfaces, even if
invisible.
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(1) After obtaining all pertinent factual evidence, the CE should
consider referral to a pulmonary specialist.
(a) If the level of exposure indicated above has been met
and a medical report indicates the possible existence of an
asbestos-related abnormality, such as X-ray report of pleural or
parenchymal abnormality or report of pulmonary fibrosis, the
CE should prepare a Statement of Accepted Facts and arrange
for referral of the claimant to a pulmonary specialist for
complete evaluation in accordance with the requirements
shown in Exhibit 7, OWCP Medical Examination Requirements in
Asbestos Disease Cases.
(b) If the level of exposure indicated above has been met
but no medical report indicates the possible existence of an
asbestos-related abnormality, the claimant shall be instructed
to arrange for submission of a current medical report from his
or her treating physician which meets all of the requirements
shown in Exhibit 7, OWCP Medical Examination Requirements
for Asbestos Disease Cases. If the submitted report satisfies
OWCP requirements and the case is accepted, the cost of the
examination is reimbursable.
In addition to the usual materials sent to consultants (see PM 3-
500.3), the physician selected should be sent copies of Form CM-933
(Exhibit 8, Page 1 (Link to Image), Page 2 (Link to Image)) and the
job description.
(2) Where the employee is deceased, the CE should evaluate the
available medical evidence for completeness and refer the file for
medical evaluation (with Statement of Accepted Facts) to a pulmonary
specialist.
(3) The DMA or consultant acting in that capacity, preferably a
Board-certified pulmonary specialist, should review the report once the
CE determines that it is complete. The medical specialist should be
asked to consider the following issues:
(a) Diagnosis. Are the laboratory and physical
findings adequately supportive?
(b) Work-Relatedness. Has Federal occupational exposure
contributed to development of diagnosed conditions by direct
cause, aggravation, acceleration or precipitation?
(c) Impairment. With reference to the AMA Guides, what
percent of pulmonary impairment is indicated?
(d) Disability. Is the evidence sufficient to allow a
determination of the extent and degree of disability for normal
work (current or last) as a result of the diagnosed condition? Is
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the disability partial or total, temporary or permanent?
(e) Treatment. Is the recommended treatment appropriate?
(f) Follow-up. When should the next pulmonary evaluation
be performed?
(g) Employment. If the claimant is still employed and
exposed to asbestos, should employment continue based on
current medical findings, medical knowledge, and documented
working conditions?
c. Carpal Tunnel Syndrome. This condition involves the compression of
the medial nerve between the longitudinal tendons of the wrist musculature
and the transverse superficial carpal ligament along the palmer aspect of the
wrist (see Exhibit 9 (Link to Image)). Symptoms resulting from this
compression include pain, numbness, tingling, and weakness of the affected
hand (usually the dominant one, though bilateral involvement does occur).
Causes which may be work-related include constant exertion and/or repetitive
motion with the wrist flexed or extended against resistance, and acute
trauma. The medical report should contain clear evidence that the disease is
present. Among the clinical findings are:
(1) Phalen's Sign. This test is positive if maintenance of forced
hyperflexion for one minute precipitates pain and paresthesia.
(2) Tinel's Sign. This test is positive if tapping over the medial
nerve at the wrist produces pain.
(3) Neurological Abnormalities. These include decreased sensation
over the palmar aspect of the end joints of the same three and one
half digits and atrophy of the thenar eminence in severe cases.
(4) Decreased nerve conduction velocity (NCV) as measured during
nerve conduction test. The test results should include an evaluation as
to whether the velocities obtained are normal or not.
(5) Decreased muscle motor activity as measured by
electromyography (EMG). The test results should clearly indicate
whether the results are within normal limits or are abnormal. An
opinion as to the cause of the abnormality may also be present.
3-0600-9 Partial Disability
9. Partial Disability. When employment-related injury or disease permanently
prevents a return to regular duties, the Office and the employing agency work
together to reemploy the claimant within his or her work restrictions if possible. If
not, OWCP will offer rehabilitation services to the employee with the goal of
reemployment in the general work force.
a. Loss of Wage-Earning Capacity (LWEC). The CE monitors medical
reports to determine the extent of disability resulting from an employment-
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related injury or disease. When an attending physician's report indicates the
claimant is no longer totally disabled for all work, the physician is sent Form
CA-1302, Request for Medical Progress Report (or narrative equivalent)
and/or Form OWCP-5, Work Tolerance limitations. When this information is
received, the DMA will review it in conjunction with the description of the
position under consideration in order to determine the claimant's ability to
perform the duties involved, if that position has been identified by using the
Dictionary of Occupational Titles (that is, the position is not one which has
actually been offered to the claimant).
Occasionally the DMA will be asked to complete the Form OWCP-5 based on
the examining physician's findings. In doing so, the DMA should consider any
disability which existed prior to the injury as well as any disability resulting
from the employment injury. Subsequently acquired conditions unrelated to
the injury are excluded from consideration in determining the claimant's
LWEC but are included when considering suitability of an offered position.
b. End of Schedule Awards. As with disability, permanent impairment
does not always result in a loss of wage-earning capacity. In some cases,
however, the claimant cannot return to the kind of work performed at the
time of injury, and when this happens, compensation may be awarded based
on the claimant's LWEC. Prior to the expiration of the schedule award, the CE
may request a current medical report to determine whether a claimant has
any LWEC due to the employment injury. To make a proper determination,
the DMA must review the claimant's job description, including its physical
requirements, and compare the claimant's current work tolerance limitations
with the position description.
3-0600 Exhibit 1: Attending Physician's Report, Form CA-20
Page 1-2 (Link to Image)
Page 3 (Link to Image)
3-0600 Exhibit 2: Attending Physician's Supplemental Report, Form CA-20a
Pages 1-2 (Link to Image)
3-0600 Exhibit 3: Duty Status Report, Form CA-17 (Link to Image)
3-0600 Exhibit 4: OWCP Hearing Loss Medical Requirements
OWCP HEARING LOSS MEDICAL REQUIREMENTS
Each employee should be seen for audiological and otological examination. The
audiological testing should precede the visit to the otologist; the otologist should
have the audiological findings at the time of the examination; and, to the extent
possible, these two consultations should occur on the same day. It is also required
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that the audiological and otological examinations be performed by different
individuals.
Any tests administered as part of an audiological battery must be conducted by a
person possessing certification in audiology from the American Speech-Language-
Hearing Association (ASHA) or State licensure as an audiologist. The medical
examination must be performed by an otolaryngologist certified (or eligible for
certification) by the American Academy of Otolaryngology. All tests comprising the
battery administered in the audiological evaluation must be performed in an
environment meeting the specifications of ANSI S3.1 (1977). Facilities which are
accredited by the Professional Service Board of the ASHA meet this requirement.
Testing equipment must be calibrated in accordance with the protocol contained in
the accreditation manual of ASHA's Professional Service Board (ANSI S3.6-1969).
Audiometric tests must include the following:
1. Pure-tone air conduction thresholds should be obtained for each ear at 500,
1000, 2000, 3000, 4000, 6000 and 8000 Hz. Bone conduction thresholds should be
obtained for the specified frequencies from 500 to 4000 Hz, inclusive. Appropriate
masking should be employed as necessary and the use of masking should be
denoted on the audiogram. The symbols used in recording thresholds should be in
accordance with the most recent ASHA recommendations.
2. Impedence audiometry should be done on both ears as a means of determining
the reliability of air-bone conduction threshold relationships and for any contribution
it might otherwise make to differential diagnosis by the physician.
3. Speech reception thresholds for each ear should be established, using test
procedures and spondaic words which conform to guidelines (ASHA Committee on
Audiometric Evaluation, 1979). Standardized recorded materials should be used
rather than live voices.
4. Monaural discrimination scores should be obtained; masking should be used when
necessary. Standardized recorded word lists should serve as the stimuli and the
discrimination scores for the full list should be reported for each ear.
Reports must include, as appropriate:
1. Date and hour of examination.
2. Date and hour of employee's last exposure to loud noise. (If the employee was
exposed to noise within the last 16 hours, do not proceed with testing.)
3. History of injury.
4. The physician's rationalized medical opinion regarding the relation of the hearing
loss to employment-related noise exposure.
5. The physician's recommendation for treatment.
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6. A certification must accompany each audiological battery indicating that
instrument calibration and the environment in which the tests were conducted met
the accreditation standards of the Professional Services Board of ASHA (ANSI S3.6
(1969) and S3.1 (1977), respectively). A copy of the calibration standards are
attached for your convenience.
7. A statement commenting on the reliability of the tests.
3-0600 Exhibit 5: Outline for Otologic Evaluation, Form CA-1332
Pages 1-2 (Link to Image)
Pages 3-4 (Link to Image)
3-0600 Exhibit 6: Calibration Requirements for Accreditation of an
Audiological Facility by the Professional Services Board
CALIBRATION REQUIREMENTS FOR ACCREDITATION OF AN
AUDIOLOGICAL FACILITY BY THE PROFESSIONAL SERVICES BOARD
7.3.4. Calibration: The program shall establish and follow
7.3.4.1. The program shall keep an accurate record of all
audiometric calibrations performed. The record
shall include at least:
a. Type of calibration--biological, electroacoustic,.
b. Date performed.
C All meausurements obtained.
d. Name of observer.
e. Equipment calibrated (make, model,serial#).
f. Calibration equipment used (make, model,
serial#).
7.3.4.2. Diagnostic audiometers and/or audiometers used in
fixed locations shall meet ANSI S3.6-1969
specifications for wide-range audiometers and shall
be calibrated according to the following schedule:
A Daily: A brief biological check of the
audiometer to ensure proper operating order shall
be made each day the audiometer is in use.
B Monthly:
(1) A detailed biological check of the
audiometer which includes a careful listening
test of earphones and bone vibrator shall be
performed to ensure that the audiometer
displays no evidence of:
(i) Cross talk.
(ii) Signal distortion.
(iii) Abnormal noise.
(2) An electroacoustic calibration check of
non-solid-state audiometers shall be made
once a month which includes at least the
following measurements:
(i) The accuracy of the sound presure
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levels for all pure tones in both
earphones.
(ii) The accuracy of the sound pressure
levels for all masking noises in both
earphones.
(iii) The accuracy of the sound pressure
levels for speech signals in both
earphones.
(iv) The accuracy of the sound pressure
levels for speech signals in all sound field
loudspeakers.
c. Quarterly: An electroacoustic calibration check
of solid-state audiometers shall be made once
every three months which includes at least the
measurements specified in section
7.3.4.2.(2)(i)through (iv).
d. Annually: An electroacoustic calibration check
of all audiometer shall be made every 12
months which includes at least the following
measurements:
(1) The accuracy of output levels for all pure
tones in bone vibrator(s).
(2) The accuracy of the frequency
calibration for pure tones.
(3) The accuracy of rise/decay time for all
pure tones.
(4) Harmonic distortion for pure tones.
(5) Signal-to-noise ratio for all outputs.
(6) Accuracy of attenuator linearity.
(7) Accuracy of signal parameters utilized in
special diagnostic tests, including
impedance/admittance.
(8) Freedom from shock hazard.
3-0600 Exhibit 7: OWCP Medical Examination Requirements in Asbestos
Disease Cases
OWCP MEDICAL EXAMINATION REQUIREMENTS IN ASBESTOS DISEASE CASES
1. Occupational History. Chronological summary of the individual's job history
which includes a description of the frequency, degree, and duration of occupational
exposures to asbestos with emphasis on exposure in Federal civilian employment,
but which includes exposure in non-Federal employment. Include other dusts or
toxins and any non-occupational exposure.
2. Medical History. Chronological summary which includes references to any
previous injuries or illnesses, pulmonary problems and the development of
pulmonary symptoms. Summary of pulmonary symptoms. Complete smoking
history. Family medical history.
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3. Physical Examination. To include description of all the following:
a. General appearance and performance.
b. Sex, age, height and weight.
c. General examination denoting the presence or absence of cyanosis,
clubbing, nicotine stains, edema, hepatomegaly, ascites and other signs
ascribable to the pulmonary and cardiovascular systems.
d. The pattern and rate of claimant's breathing (presence and degree of
dyspnea, etc.); the presence of any exertional changes.
e. Results of cardiac examination.
f. The results of chest examination, including configuration, findings on
percussion and ausculation (i.e., the presence or absence of rales and/or
other abnormal sounds).
4. Chest X-rays and CAT Scans. Minimum of AP, lateral and R and L oblique
views. A full size x-ray shall be taken under the supervision of a Board-certified
radiologist and read by either a Board-certified radiologist or pulmonary specialist.
This reading must include a description of the quality of the film and all radiographic
findings. The examining physician will also review the film for these same purposes.
The x-ray interpretation must include a description of any abnormality or pathology
present with special attention given to evidence of pulmonary hypertension, fibrosis,
carcinoma, or mesothelioma. If any abnormality or pathology is present, the
description must include the following information:
a. Presence or absence of opacities described by type, size, shape,
distribution and profusion.
b. Presence or absence of plural thickening, plaques or calcification, with
description of site and extent.
c. Presence or absence of ill-defined diaphragmatic or cardiac outlines
with description of extent.
d. Any other pertinent findings of a chronic or acute nature.
X-rays should be kept available for review but should not be sent to this Office
unless requested. Additional views may be obtained at the discretion of the
physician.
In lieu of x-rays, the physician may elect to perform computerized axial tomography
(CAT scan) of the thorax, which can provide a more definitive view of the lungs and
the presence or absence of asbestosis.
5. Pulmonary Function Studies. To include measurement of the following
functions (the report of the results of the FVC, FEV(1), and diffusing capacity must
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include actual recorded values, the percent of predicted normal, and identification of
the normal standard applied for tests conducted before and/or after the use of
bronchodilators). These studies should be performed under the supervision or
direction of a Board-certified pulmonary specialist.
a. Forced Vital Capacity (FVC) and Forced Expiratory Volume in One
Second (FEV(1)) measured in liters and representing the best of three efforts
and the FEV(1)/FVC Ratio (FEV(1)%) computed from these results. Also
include total lung capacity (TLC). Report of the results of these tests must
include:
(1) Date and time of the test.
(2) Name, file number, sex, age, weight, and height of the patient.
(3) The names of the technician performing and the physician
supervising the test, if different from the referring physician.
(4) A description of the patient's ability to understand and follow
instructions and the degree of cooperation in performing the test.
(5) The paper speed (if applicable) and the name of the
instrument used.
(6) The date of last calibration of the instrument.
(7) Whether and why a bronchodilator was used and its impact on
test results.
The report must be accompanied by appropriately labeled spirometric
tracings (for all tests) showing distance per second on the abscissa
and distance per liter on the ordinate.
b. Carbon Monoxide Diffusing Capacity (Single Breath Method). The
results must be reported in ml/mm/mmHg. The report of the test must
include estimated alveolar volume (based on measured FRC), the barometric
pressure at the time of the test, the name of the technician performing the
test and the instrument used, and the date of last calibration.
c. Arterial Blood Gas Study, administered at rest. A blood gas study may
be done during exercise only if not medically contraindicated and if, in the
opinion of the examining physician, it is necessary for diagnostic purposes.
Report of the ABG study must include recorded values for pCO(2), pO(2), and
pH collected simultaneously; the date and time of the test; the altitude and
barometric pressure at which the test was conducted; the name of the
technician and supervising physician; the pulse rate at the time the blood
sample was drawn; the time elapsed between drawing and analysis of the
sample and whether the specimen was iced; the duration and time of exercise
(if appropriate); and a statement indicating that the equipment was calibrated
before and after each test.
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6. Electrocardiogram results submitted with tracings.
7. Complete Blood Count.
8. Medical Impression and Opinion which includes:
a. Diagnosis of all pulmonary conditions present.
b. Diagnosis of any other relevant disease condition present.
c. Recommendations regarding indicated course of treatment to improve
the level of pulmonary function.
d. A discussion of the findings regarding the indicated degree of
pulmonary impairment and exertional limitations (with reference to the
enclosed job description).
e. Discussion of work-relatedness, including a detailed discussion of other
possible etiological factors for each of the diagnosed conditions.
3-0600 Exhibit 8: Roentgenographic Interpretation
Page 1 (Link to Image)
Page 2 (Link to Image)
3-0600 Exhibit 9: Carpal Tunnel Cross-Sectional View (Link to Image)
CHAPTER 3-0700 - SCHEDULE AWARDS
TABLE OF CONTENTS
Paragraph and Subject Date Trans. No.
Table of Contents 01/10 10-04
1. Purpose 01/10 10-04
2. Definition and Standards for Evaluation 01/10 10-04
3. Determining Schedule Awards 01/10 10-04
4. Special Determinations 01/10 10-04
5. Disfigurement 01/10 10-04
* (ENTIRE CHAPTER REISSUED 01/10, TRANSMITTAL NO. 10-04)
Exhibits
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1. Use of the Sixth Edition of AMA Guides to The
Evaluation of Permanent Impairment 01/10 10-04
2. Percentage Table of Schedule Awards, Form CA-699 01/10 10-04
3. Hearing Loss Medical Opinion, Form CA-51 01/10 10-04
4. "Rating Spinal Nerve Extremity Impairment Using
the Sixth Edition" from July/August 2009 edition of The
Guides Newsletter, Published by the AMA 01/10 10-04
3-0700-1 Purpose
1. Purpose. The FECA provides that compensation may be paid for total or
partial loss, or loss of use of, certain parts of the body which are specified in the
FECA itself and in the regulations. The purpose of this chapter is to describe the
procedures involved in medical evaluation of claims for such awards.
3-0700-2 Definition and Standards for Evaluation
2. Definition and Standards for Evaluation. The phrase "permanent disability" in
5 U.S.C. 8107(a) is interpreted to mean "permanent physical impairment." The same
standards for evaluating such impairment are applied in all cases. The AMA Guides to
the Evaluation of Permanent Impairment is used in order to provide a consistent
method of calculating impairment. Exhibit 1 addresses calculations according to the
Sixth Edition of the Guides.
Since the Sixth Edition of the Guides is diagnosis based, the main factor in
determining impairment is the diagnosis itself. Each diagnosis grid is divided into five
classes of impairment severity, ranked from ‘0’ (no impairment) to ‘4’ (very severe).
Raters distinguish the level of severity using criteria separated into key factors and
non-key factors. These criteria consist of: (1) history of clinical presentation; (2)
physical findings; (3) clinical studies or objective test results; and (4) functional
history. All of these various factors affect the total amount of impairment awarded to
an individual.
3-0700-3 Determining Schedule Awards
3. Determining Schedule Awards. Development of cases for schedule awards is
discussed in PM Chapter 2-808. The Claims Examiner (CE) will ask the District
Medical Advisor (DMA) to evaluate a case when it appears to be in posture for
schedule award determination. The DMA is responsible for reviewing the file,
particularly the medical report on which the award is to be based, and then
calculating the award. A table showing the number of weeks of compensation
payable for various percentages of loss is shown as Exhibit 2.
a. Evaluating the Medical Report. The DMA should review the report of
the physician estimating impairment with respect to the following factors:
(1) Maximum Medical Improvement. Before an award may be
made, it must be medically determined that no further improvement
can be anticipated and the impairment must reach a fixed and
permanent state, which is known as Maximum Medical Improvement
(MMI).
(a) While additional medical treatment (such as surgery)
may be recommended in order to improve the claimant's
condition, the claimant is not required to undergo such
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treatment. See Santo Panzica, 13 ECAB 458 (1964). The Office
must calculate the percentage of the award as if no further
improvement were possible if the claimant declines such
intervention.
(b) It is well settled that maximum medical improvement
arises at the point at which an injury has stabilized and will not
improve further. This determination is factual in nature and
depends primarily on the medical evidence. See Peter C.
Belkind, 56 ECAB 580 (2005). Neither temporary nor future
impairment may be rated. Impairment should not be rated
permanent until sufficient time has passed for healing and
recovery, which may vary substantially depending on the
condition and the claimant. Clinical findings must indicate the
medical condition has stabilized. See Franklin Armfield, 28
ECAB 445 (1977). A schedule award may be payable based on
contemporaneous medical evidence of record showing a peak or
plateau in the claimant’s recovery status, even if the claimant's
condition is likely to deteriorate. Payment of an increased
award based on additional impairment may be considered at a
later date.
(c) In the absence of evidence to the contrary or a conflict
in the medical evidence requiring resolution under 5 U.S.C.
8123, the date of MMI is usually considered to be the date of
the attending physician’s evaluation that is accepted as
definitive by the Office.
(2) Description of Impairment. The attending physician should
describe the impairment in sufficient detail to permit clear visualization
of the impairment and the restrictions and limitations which have
resulted. The description should include the loss in degrees of active
and passive motion of the affected member or function, the amount of
any atrophy or deformity, disturbance of sensation, or other pertinent
description of the impairment. Under the Sixth Edition of the AMA
Guides, clinical history is also important in the diagnosis-based grid
that ranks impairment within classes of severity.
(3) Percentage of Impairment. Impairment evaluation results are
provided in terms of percentage of loss of use to the affected member
or function of the body (not the body as a whole, except where
impairment to the lungs and other bodily organs is at issue; see
paragraph 4 below). The percentage should include those conditions
accepted by OWCP as job-related and any pre-existing permanent
impairment of the same member or function. If the work-related injury
has affected any residual usefulness in whole or in part, a schedule
award may be appropriate. There are no provisions for apportionment
under the Act. Rated impairment should reflect the total loss as
evaluated for the schedule member at the time of the rating exam.
See Raymond E. Gwynn, 35 ECAB 247, 253 (1983) [In determining
the amount of a schedule award for a member of the body, pre-
existing impairments are to be included, citing Larson for the
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proposition that “the employer takes the employee as he finds him.”]
b. Calculation. The DMA should use the method of calculation set forth in
the AMA Guides. If it is necessary to deviate from the AMA Guides in
calculating an award, the record should reflect the basis for the deviation,
particularly when the use of a different table or evaluation materially affects
the percentage of the award. The policy of the Office is to round the
calculated percentage of impairment to the nearest whole point. Results
should be rounded down for figures less than .5 and up for .5 and over.
3-0700-4 Special Determinations
4. Special Determinations. Following are guidelines under §8107 of the Act for
calculating schedule awards for specific conditions:
a. Loss of Digits. While the percentage of impairment to the fingers is
generally computed in accordance with the AMA Guides, special computations
may be
required. In general, loss of more than one digit should be computed in
terms of
impairment to the whole hand or foot. The impairment computed for loss of
two or more digits occasionally exceeds the percentage for the hand or foot,
however, and in such instances the award should reflect the computation
most favorable to the claimant.
(1) Loss of Less Than One Phalanx. If less than one-half of a
phalanx has been amputated but some loss of bone or bony tuft has
occurred, the award shall be one-half of the amount payable for the
loss of the first phalanx or for 25 percent of the digit. If more than
half of a phalanx is lost, the award shall be for the entire loss of the
first phalanx, or for 50 percent of the digit.
Where significant amputation of the soft tissue of the tip of the first
phalanx has occurred with no loss of bone or bony tuft, the award shall
be one-fourth the amount payable for the loss of the first phalanx or
13 percent of the digit.
If the injury has caused impairment such as loss of flexion or
extension, swelling, gross deformity and/or changes in sensation in
addition to the amputation, the additional impairment must be
considered in the overall determination.
(2) Loss of Two or More Digits of a Hand or Foot. When there is a
loss of two or more digits, or one or more phalanges of each of two or
more digits, the award is proportional to the loss of use of the hand or
foot.
By statute, the loss of one phalanx will be considered equal to 50
percent of the digit and loss of more than one phalanx will be
considered equal to 100 percent of the digit. See 5 U.S.C. 8107 (15).
The value of each digit lost will then be applied to the hand or foot in
accordance with the AMA Guides. If the injury has caused impairment
such as nerve or palm involvement in addition to the amputation, such
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impairment must be considered in the determination. The DMA will
calculate the impairment of each digit separately and combine them
for a total percentage of loss to the hand or foot. Where the
cumulative allowances for the individual digits are greater than the
percentage of loss for the entire hand or foot, the higher percentage
should be used.
b. Loss of Hearing. After a complete report is received, the percentage of
hearing loss is calculated using Form CA-51 (Exhibit 3). The DMA will then
verify the calculation and the CE will certify the correctness of the DMA’s
computations. Adjudications based on just one audiogram should be avoided.
(1) Air vs. Bone Conduction. Air conduction studies provide a
complete picture of how well an individual can actually hear, while
bone conduction studies show what part of the hearing loss resulted
from nerve damage. While it is not unusual for air conduction studies
to show a greater hearing loss than bone conduction, the opposite
results are medically inconsistent and render the audiogram useless.
Therefore, while all audiograms must show test results for bone
conduction and pure tone air conduction studies, a schedule award
may not be based on the results of bone conduction studies.
(2) Computation. Effective February 24, 1986, hearing loss awards
are based on the formula contained in the AMA Guides. (FECA
Program Memoranda Nos. 162, 181, and 217 describe the previous
frequencies and computation methods.) Awards are computed as
follows:
(a) Monaural Loss. The average of decibel loss in the
frequencies of 500, 1000, 2000 and 3000 cps should first be
determined. From this amount 15 decibels should be
subtracted if ASA calibration was used and 25 decibels if ISO-
ANSI calibration was used. The result should be multiplied by a
factor of 1.5 to determine the percentage of loss.
(b) Binaural Loss. The monaural loss for each ear should
first be computed as described above. The percentage of loss
in the better ear should then be multiplied by five and the
result added to the percentage of loss in the worse ear. This
sum should then be divided by six to determine the percentage
of binaural loss. Percentages should not be rounded until the
final percent for award purposes is obtained. Fractions should
be rounded down from .49 or up from .50.
Between March 7, 1977 and February 23, 1986, the OWCP used only
the frequencies of 1000, 2000, and 3000 cps to determine an award
for hearing loss.
(3) Progression. Noise-induced hearing loss does not typically
progress after exposure to noise ceases. A claim with an audiogram
showing less than a 25 decibel loss soon after exposure ceases and a
second audiogram showing a ratable loss may be denied if the DMA
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provides a well-reasoned opinion. Other benefits are still payable if
any employment related hearing loss exists.
c. Loss of Vision. The percentage of impairment continues to be based on
best uncorrected vision. See 5 U.S.C. 8107 (19). Loss of binocular vision or
for loss of 80 percent or more is the same as for loss of the eye. See 5
U.S.C. 8107 (14).
d. Loss of Function of Bodily Organs. The FECA provides for award of
compensation due to permanent impairment to the extremities and organs.
However, most impairment ratings under the Sixth Edition of the AMA Guides
evaluate impairment based on injury or disease. Therefore, special
calculations are required to interpret certain ratings completed using the AMA
Guides into figures usable under the Act.
(1) Lung Impairment. All claims involving impairment of the lungs
where exposure occurred during Federal employment on or after
September 7, 1974 (see Program Memorandum No. 269) will be
evaluated for schedule
award purposes. The class of respiratory impairment should first be
established, following the AMA Guides as far as possible.
(a) While pulmonary function varies from day to day and
from environment to environment, impairment exists for
compensation purposes when the pulmonary function testing
reveals Class 1 or greater impairment severity as defined by
the AMA Guides.
(b) A Class 0 respiratory impairment equates to zero
percent impairment of the whole person. An individual in this
category would be considered to have no ratable loss and would
not be entitled to compensation under the Act.
(c) Awards are based on the loss of use of both lungs, and
the percentage for the particular class of whole person
respiratory impairment will be multiplied by 312 weeks (twice
the award for loss of function of one lung) to obtain the number
of weeks payable.
(d) In cases of anatomical loss by traumatic injury or
surgery, evaluation will also be based on loss of lung tissue (by
weight or volume). If the percentage of loss using this method
is higher than the percentage based on loss of respiratory
function, the award shall be made on the basis of loss of lung
tissue. Anatomical evaluations will be made only with regard to
the injured lung and will be based on a 156-week maximum
award for each lung. Anatomical loss awards can be made for
both lungs if the injury caused loss in both, but each lung must
be evaluated separately.
(2) Loss of Function of Other Organs. While the AMA Guides
express the impairment of bodily organs in terms of the whole person
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due to a particular injury or medical condition, a schedule award under
the FECA is based on the percentage of impairment of the particular
organ.
(a) Whole person impairment measurements can be directly
translated into organ ratings in the case of vital organs, such as
the lungs, where the total impairment of the organ(s) produces
100% impairment of the whole person. When the maximum
whole person rating of the organ is less than 100%, direct
translation of the whole person measurement into a percentage
of impairment to the organ is not valid. In these cases, to
obtain the percentage of impairment to an organ corresponding
to a given whole person impairment, the following
mathematical ratio should be used:
(A) = (X)
(B) 100
In this equation:
(A) = Actual whole person impairment of the claimant,
(B) = Maximum whole person impairment for the injury or
condition of the organ, and
(X) = Organ rating to be determined.
For example, if the maximum whole person impairment for an
injury or disease of an organ is 25% and the actual whole
person impairment of the claimant is 10%, then:
10 = (X)
25 100
(X) = 1000
25
(X) = 40% impairment of the organ
(b) For certain schedule organs which have more than one
physiologic function, the AMA Guides provide whole person
impairment scores for each affected system within that organ.
When calculating the impairment of these organs, the DMA
must consider all affected organ systems as instructed in the
AMA Guides.
In these cases, the maximum whole person impairment
ascribed to the particular organ injury or condition (B) is
obtained by combining the maximum levels for all functions
using the Combined Values Chart in the current edition of the
AMA Guides. The actual whole person impairment (A) is
obtained by combining all functional impairments found using
the Combined Values Chart in the Guides.
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For example, a claimant with an injury to the penis has a Class
3 penile (sexual) whole person impairment amounting to 15%,
and Class 2 urethral impairment of 10%. A 15% whole person
impairment combined with a 10% whole person impairment
results in a whole person impairment of 24%. The maximum
whole person impairment for the sexual function is 15% and
urethral function is 28%. Using the Combined Values Chart,
this amounts to 39% total whole person impairment. Then:
24 = X
39 100
X = 2400
39
X = 62% impairment of the penis
(c) In addition to the loss of use, the statute compensates
for loss of an organ. If there is total loss of a single
paired organ (such as a kidney, breast, testicle or
ovary), the schedule award is generally based on the
loss of the organ. In this situation, it is immaterial
whether the remaining organ compensates functionally
for the loss.
3-0700-5 Disfigurement
5. Disfigurement. The FECA [§8107(c)(21)] provides for payment of
compensation not to exceed $3500 for disfigurement of the face, head or neck which
is likely to handicap the claimant in securing or maintaining employment. The DMA
will be asked to review such claims and to evaluate the employee’s disfigurement. If
the DMA finds that maximum medical improvement has occurred, the DMA will
review the photographs submitted along with the medical evidence of record. The
concurrence of the Assistant District Director (ADD) or the District Director (DD)
must be obtained. Following the file review, the DMA and ADD or DD will write a
memorandum to the file which contains a complete description of the disfigurement.
If the DMA does not find that maximum medical improvement has occurred, but has
submitted a statement as to whether plastic surgery may improve the appearance
and decrease the degree of disfigurement and the claimant is amenable, the DMA
should include in his or her statement information concerning arrangements for
treatment.
3-0700 Exhibit 1: USE OF SIXTH EDITION OF AMA GUIDES
Effective May 1, 2009, OWCP began using the Sixth Edition of the AMA Guides. This
edition is significantly different from previous editions. There are extensive changes
affecting the calculations of schedule awards for FECA claimants.
The biggest adjustment from previous editions involves the rating of permanent
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impairment based on a specific diagnosis rather than the extremity or organ system.
In previous editions an impairment rating may have included multiple diagnoses
within an organ or extremity. Under the Sixth Edition most ratings will consider only
the diagnosis with the most impact on the rated bodily region. In the Fifth Edition of
the Guides impairment ratings relied heavily on loss of range of motion and strength
in comparison to a paired extremity. The Sixth Edition only incorporates these
findings as they relate to the specific diagnosis evaluated.
1. The Sixth Edition of the Guides implements a paradigm shift in the way
impairment evaluations are conducted. The stated vision of the Sixth Edition is
based on five axioms, including: (1) Adoption of terminology and conceptual
framework of disablement outlined by the World Health Organization’s (WHO’s)
International Classification of Functioning, Disability, and Health (ICF); (2) Becoming
more diagnosis-based and basing the diagnoses in evidence; (3) Optimizing rater
reliability through simplicity, ease of application, and following precedent; (4) Rating
percentages are functionally based to the fullest extent possible; and (5) Stressing
conceptual methodological congruity within and between organ rating systems.
2. The evaluation methodology used in the Sixth Edition substantially revises the
methods used in previous editions. The Guides characterize the objective of the new
methodology to be consistent, enhance relevancy, promote precision, and
standardize the rating process. The foundation of the new methodology is the
diagnosis-based grid used for each organ
system and chapter. Evaluators will rate impairment according to the diagnosis
representing the source of the most impairment in the given bodily region. If there
is more than one ratable diagnosis in an affected extremity, the rater should
combine all regional impairments for a final impairment at the extremity level.
Each diagnosis grid is divided into five classes of impairment severity, ranked from
‘0’ (no impairment) to ‘4’ (very severe). Within each class are five severity grades
categorized ‘A’ through ‘E’ (default ‘C’) with corresponding impairment percentages.
Raters distinguish the level of severity using criteria separated into key factors and
non-key factors. These criteria consist of: history of clinical presentation, physical
examination or physical findings, clinical studies or objective test results, and
functional history. In most organ systems or disease processes, clinical history is the
key factor which will determine the impairment class. However, objective test
results or physical findings may serve as the key factor in select organ system
evaluations. The evaluator will adjust the severity grade
based on the results of the remaining criteria. These adjustments cannot exceed
the percentage of impairment within the range specified by the designated class.
3. The Sixth Edition of the AMA Guides consists of seventeen chapters, one less than
the Fifth Edition. Two cardiovascular chapters in the Fifth Edition are consolidated
into one chapter in the Sixth.
4. Musculoskeletal regions in the Sixth Edition of the Guides consist of the upper
extremities (Chapter 15), lower extremities (Chapter 16), and the spine and pelvis
(Chapter 17). The upper extremity is divided into four separate regions, including
digits and hand, wrist, elbow, and shoulder. The lower extremity is divided into
three regions consisting of foot and ankle, knee, and hip. The spine and pelvis is
divided into four regions, including cervical, thoracic, and lumbar regions, and the
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pelvis, consisting of the ilium, ischium, pubis, sacrum and coccyx. Diagnosis classes
for the upper and lower extremities are broken into the following categories: Soft
tissue; muscle and tendon; ligament; and bone and joint. If impairment scores are
calculated in whole person ratings, they should be adjusted to individual extremity or
organ system percentages using conversion charts or rates.
5. Impairment to the upper or lower extremities that is caused by a spinal injury
should be rated consistent with the article “Rating Spinal Nerve Extremity
Impairment Using the Sixth Edition” in the July/August 2009 edition of The Guides
Newsletter published by AMA. The Guides Newsletter article (July/August publication
by the AMA) titled “Rating Spinal Nerve Extremity Impairment Using the Sixth
Edition” is Exhibit 4 in this chapter, and has been reproduced with permission from
the AMA.
6. The chapter on impairments due to pain (Chapter 3) has been updated. As with
the Fifth Edition, the Sixth Edition allows for a maximum 3% impairment rating for
non-specific pain that cannot be attributed to a condition addressed elsewhere in the
Guides. According to Section 3.3b:
Patients’ responses on functional assessment instruments will act as modifiers
of the percentage impairment they are awarded, the awards will, in general,
primarily reflect objective factors. This is in keeping with the general strategy
of the Guides to consider PRI [Pain-related impairment] but to limit the
amount of impairment that is awarded for subjective factors. In no
circumstances should the PRIs developed using this chapter be considered as
an add-on to impairment determinations based on the criteria listed in
Chapters 4 to 17. In essence, the PRIs derived according to this chapter are
determined in a stand-alone fashion.
7. Entrapment neuropathy of the upper extremities (e.g. carpal tunnel, cubital
tunnel, etc.) (Section 15.4f) must be documented with nerve conduction velocity
(NCV) testing in order to consider ratable impairment. If testing was not conducted
or does not meet the criteria outlined by the Guides, no ratable impairment may be
considered. Only pre-operative testing is used for rating impairment in this section.
Optimal rating time following surgical intervention is between nine months and 2
years. When evaluating multiple simultaneous neuropathies, the first (or most
impairing) is rated at 100%, the second is rated at 50%, and the third is rated at
0%. If there are more than three neuropathies, the neurology chapter should be
used rather than Chapter 15.
8. The Guides stipulate only permanent impairment may be rated, and only after
the claimant has reached a point of “maximum medical improvement” (MMI). The
Guides do not afford the rating of future impairment. Impairment should not be
rated permanent until sufficient time has passed for healing and recovery, which
may vary substantially depending on the condition and the claimant’s profile. The
clinical findings must indicate that the medical condition is stabilized for the claimant
to have reached MMI. The Guides define MMI as “a status where patients are as
good as they are going to be from the medical and surgical treatment available to
them.”
In cases where a claimant declines surgery or other curative treatment, an MMI
determination may still be reached. The evaluating physician should make a written
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109
note in the report discussing the appropriateness of the prescribed treatment and the
basis of the claimant’s declination. The physician should also indicate that the
individual is at MMI in lieu of additional treatment.
Claimants not at MMI, but with potential for future progression of their disease, can
be rated for permanent impairment on the current findings; MMI does not preclude
the worsening of a condition that is expected with the passage of time or due to the
aging process.
Exhibit 2: Percentage Table of Schedule Awards, Form CA-699
PERCENTAGE TABLE OF SCHEDULE AWARDS
(W = weeks; D = days)
MEMBER 01% 02%
03%
04%
05%
10% 15% 20%
Arm W 3.12 6.24
9.36
12.48
15.60
31.20 46.80 62.40
D 21.84 43.68
65.52
87.36
109.20
218.40 327.60 436.80
Leg W 2.88 5.76
8.64
11.52
14.40
28.80 43.20 57.60
D 20.16 40.32
60.48
80.64
100.80
201.60 302.40 403.20
Hand W 2.44 4.88
7.32
9.76
12.20
24.40 36.60 48.80
D 17.08 34.16
51.24
68.32
85.40
170.80 256.20 341.60
Foot/Penis W 2.05 4.10
6.15
8.20
10.25
20.50 30.75 41.00
D 14.35 28.70
43.05
57.40
71.75
143.50 215.25 287.00
Vulva/Vagina
Uterus/Cervix W 2.05 4.10
6.15
8.20
10.25
20.50 30.75 41.00
D 14.35 28.70
43.05
57.40
71.75
143.50 215.25 287.00
Larynx/
Tongue W 1.60 3.20
4.80
6.40
8.00
16.00 24.00 32.00
D 11.20 22.40
33.60
44.80
56.00
112.00 168.00 224.00
Eye W 1.60 3.20
4.80
6.40
8.00
16.00 24.00 32.00
D 11.20 22.40
33.60
44.80
56.00
112.00 168.00 224.00
Kidney/
Lung W 1.56 3.12
4.68
6.24
7.80
15.60 23.40 31.20
D 10.92 21.84
32.76
43.68
54.60
109.20 163.80 218.40
Thumb W .75 1.50
2.25
3.00
3.75
7.50 11.25 15.00
D 5.25 10.50
15.75
21.00
26.25
52.50 78.75 105.00
1st Finger W .46 .92
1.38
1.84
2.30
4.60 6.90 9.20
D 3.22 6.44
9.66
12.88
16.10
32.20 48.30 64.40
Great Toe W .38 .76
1.14
1.52
1.90
3.80 5.70 7.60
D 2.66 5.32
7.98
10.64
13.30
26.60 39.90 53.20
2nd Finger W .30 .60
.90
1.20
1.50
3.00 4.50 6.00
D 2.10 4.20
6.30
8.40
10.50
21.00 31.50 42.00
3rd Finger W .25 .50
.75
1.00
1.25
2.50 3.75 5.00
D 1.75 3.50
5.25
7.00
8.75
17.50 26.25 35.00
Toe other
Great Toe W .16 .32
.48
.64
.80
1.60 2.40 3.20
D 1.12 2.24
3.36
4.48
5.60
11.20 16.80 22.40
4th Finger W .15 .30
.45
.60
.75
1.50 2.25 3.00
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110
D 1.05 2.10
3.15
4.20
5.25
10.50 15.75 21.00
Hearing
(1 ear) W .52 1.04
1.56
2.08
2.60
5.20 7.80 10.40
D 3.64 7.28
10.92
14.56
18.20
36.40 54.60 72.80
Testicle/
Breast/Ovary* W 52 1.04
1.56
2.08
2.60
5.20 7.80 10.40
D 3.64 7.28
10.92
14.56
18.20
36.40 54.60 72.80
Hearing
(Both ears) W 2.00 4.00
6.00
8.00
10.00
20.00 30.00 40.00
D 14.00 28.00
42.00
56.00
70.00
140.00 210.00 280.00
* Includes Fallopian tube
(W = weeks; D = days)
MEMBER 25% 30%
35%
40%
45%
50% 55%
60%
Arm W 78.00 93.60
109.20
124.80
140.40
156.00 171.60
187.20
D 546.00 655.20
764.40
873.60
982.80
1092.00 1201.20
1310.40
Leg W 72.00 86.40
100.80
115.20
129.60
144.00 158.40
172.80
D 504.00 604.80
705.60
806.40
907.20
1008.00 1108.80
1209.60
Hand W 61.00 73.20
85.40
97.60
109.80
122.00 134.20
146.40
D 427.00 512.40
597.80
683.20
768.60
854.00 939.40
1024.80
Foot/ Penis/ W 51.25 61.50
71.75
82.00
92.25
102.50 112.75
123.00
D 358.75 430.50
502.25
574.00
645.75
717.50 789.25
861.00
Vulva/Vagina
Uterus/Cervix W 51.25 61.50
71.75
82.00
92.25
102.50 112.75
123.00
D 358.75 430.50
502.25
574.00
645.75
717.50 789.25
861.00
Larynx/
Tongue W 40.00 48.00
56.00
64.00
72.00
80.00 88.00
96.00
D 280.00 336.00
392.00
448.00
504.00
560.00 616.00
672.00
Eye W 40.00 48.00
56.00
64.00
72.00
80.00 88.00
96.00
D 280.00 336.00
392.00
448.00
504.00
560.00 616.00
672.00
Kidney/ Lung W 39.00 46.80
54.60
62.40
70.20
78.00 85.80
93.60
D 273.00 327.60
382.20
36.80
491.40
546.00 600.60
655.20
Thumb W 18.75 22.50
26.25
30.00
33.75
37.50 41.25
45.00
D 131.25 157.50
183.75
210.00
236.25
262.50 288.75
315.00
1st Finger W 11.50 13.80
16.10
18.40
20.70
23.00 25.30
27.60
D 80.50 96.60
112.70
128.80
144.90
161.00 177.10
193.20
Great Toe W 9.50 11.40
13.30
15.20
17.10
19.00 20.90
22.80
D 66.50 79.80
93.101
106.40
119.70
133.00 146.30
159.60
2nd Finger W 7.50 9.00
10.50
12.00
13.50
15.00 16.50
18.00
D 52.50 63.00
73.50
84.00
94.50
105.00 115.50
26.00
3rd Finger W 6.25 7.50
8.75
10.00
11.25
12.50 13.75
15.00
D 43.75 52.50
61.25
70.00
78.75
87.50 96.25
105.00
Toe (No
Great Toe) W 4.00 4.8
5.60
6.40
7.20
8.00 8.80
9.60
D 28.00 33.60
39.20
44.80
50.40
56.00 61.60
67.20
4th Finger W 3.75 4.50
5.25
6.00
6.75
7.50 8.25
9.00
D 26.25 31.50
36.75
42.00
47.25