1. How Doctors Document
VALUE DRIVERS in Personal
Injury Claims Today
By:
Jeffrey D. Bohn Esq.
(all graphics used with permission Mark Blane, Esq.)
San Francisco, San Jose, Walnut Creek, San Mateo, Carlsbad,
Cupertino, Palo Alto, Oakland, Pleasant Hill, Sunyvale,
Fresno, North Sacramento, South Sacramento
TEL: 559-304-1549
Email: jeffreybohn@gmail.com
www.jdbohnlaw.com

2. I. RISE OF THE COMPUTERS
 70% of auto cases in the United States are evaluated using
computer ―Claims Assessment Software‖ programs like:
 COLOSSUS
 CLAIMS OUTCOME ADVISOR
 INJURY CLAIMS EVALUATIONS
 DECISION POINT
 TEACH
 MYND
 AIM
 ICE
 InjuryIQ
 The list of companies using these programs include 16 of the Top
20 Auto Property & Casualty Insurers in the United States!

3. INFORMATION ON COLOSSUS FOR
THIS LECTURE COMES FROM:
 Dissatisfied former claims adjusters;
 Defense Attorneys;
 Information leaked from Bad Faith Trials,
Discovery, and Depositions on how
COLOSSUS is used, tuned, and entered
into analysis, etc.

4. II. THE “DAVINCI CODE” OF VALUE
IN PI CLAIMS TODAY
 The Injuries (ICD-9 Codes) +
 Frequency/Intensity, & Duration of Treatment
(CPT Codes, CPT Code interlay) +
 Frequency, & Duration of Complaints from
Injuries +
 Duties Under Duress + Loss Enjoyment of
Life + Economic Loss +
 Prognosis/Future Care + AMA 4th or 5th
Edition Impairment by a M.D. or D.O.?

5. VALUE BEGINS WITH THE INJURY
PROPERLY DOCUMENTED IN THE
CHARTNOTES
AS DOCTORS, YOU MUST DOCUMENT:
 ICD-9 CODES, with Descriptions of Injuries
 CPT CODE INTERLAY, documenting the
modalities of medical care
 DURATION and COMPLAINTS of the Injuries

6. COLOSSUS ANALYSIS
 Uses 10,600 VALUE DRIVERS on EVERY PI
claim!
 600 are Injury Codes, and 10,000 are
―factors‖ (ER visit? TENS unit used? Surgery?
D.C. care? M.D. care? Etc.)
 Begins with the ICD-9 Code and ends
whether there is an AMA impairment.

7. COLOSSUS INSPECTS FIVE
ELEMENTS IN A PI CLAIM
1. Trauma (type of accident, property
damage, etc.)
2. Impairment (must be 4th or 5th Edition
AMA)
3. Disability (known as Duties under
Duress)
4. Loss of Enjoyment of Life
5. Disfigurement (if any)

8. Insurance Companies Using COLOSSUS and Claims
Assessment Software
 AIG  Infinity (Great American)
 Allstate  Metlife
 American Family  Metropolitan
 CNA  Nationwide
 State Farm
 CSAA
 Travelers/Aetna
 Chubb
 Truck
 Farmers  USAA
 Grange  Wausau
 Hartford  Zenith

9. III. DOCUMENTING THE PATIENT
UPON THEIR ARRIVAL
 Active Care vs. Passive Care
 What did the patient ACTIVELY do before
seeing you?
 Is there a GAP in Medical Care?
No problem, document active care in your
chartnotes!

10. SOAP Notes
Subjective/Objective findings, Assessment,
and Plan
 Make daily SOAP notes
 complete
 legible
 understandable
 avoid the use of nonstandard shorthand;
 SOAP notes are one of the chief data
sources for Colossus;
 Track Prognosis periodically
(details on Prognosis later)

11. Typical Chart Notes
 Bad Example:

12. Another Typical Example of Chart
Notes
Another Bad Example:

13. Good Example of Chart Notes
 Good Example (clear):

14. IV. ICD-9 CODE & CPT CODE
INTERLAY
 ICD-9 Codes are the first to go into
computer (use descriptions with codes)
 Followed by CPT Code Interlay
 Combined, they build the foundations of
the PI Claim
 You MUST ICD-9 ALL INJURIES! Even if
injury is NOT within your specialty

15. HIERARCHY OF INJURY VALUES
 Contusion  Sprain/Strain?
 Sprain = ligament injury
 Strain = muscle injury
 Ligamentous Injury or Tear?
 Loss Motion Segment Integrity?
 Extensive Internal or External Fixation?
 Disc Bulging vs. Disc Herniation?
 Degloving  Disfigurement?

16. Disc Bulge vs. Disc Herniation
Under Colossus
 Colossus only recognizes ―Disc Bulge‖ or
―Disc Herniation‖
 Bulges and Subluxation are downcoded to
Sprain/Strain
 Severity of Bulge or Herniation should
ALWAYS be accurately documented

17. Colossus Recognizes Three
Physician Categories
1. D.C. (Doctor of Chiropractic)
2. M.D. (Medical Doctor)
3. Medical Specialist (D.O. or D.O with
specialty, Ortho, Neurologist, Neuro
Surgeon, Psychologist, or
Psychiatrist

18. MEDICAL FINDINGS UNDER
COLOSSUS
 Radiculopathy: value is only given IF it is linked
to complications of the injuries, i.e. separate
injury finding; nerve damage; surgery, etc.
 Subluxation: only accepted by Colossus if
diagnosed after 3 months post-injury! Why?
It is a potentially huge value driver because
there may be a finding of Loss Motion Segment
Integrity!

19. Continued Medical Findings under
Colossus
 Ambulance to ER: valued as a M.D. visit, UNLESS
patient ADMITTED overnight;
 then it depends on how many days admitted, value increases
 If Hospitalized
 was ICU indicated?
 Anesthetic?
 Surgery:
 How many?
 Body part?
 Reduction open/closed?
 External/internal fixation?
 Any complications?
 Immobilization of some kind applied?

20. Continued Medical Findings under
Colossus
 Therapy (PT, etc.):
 longer than 90 days?
 If so, definitely need a M.D. to support that
 Type
 Intense
 Duration
 Home traction, Bed Rest, TENS unit, Injections,
MRI or CAT Scan, or Discogram, immobility, and
hospitalization.

21. Continued Medical Findings under
Colossus
 Medication: is viewed as therapy;
 Was it prescribed?
 Longer than 30 days?
 Dosage?
 More than one prescription?
 Two or more prescriptions? (then =
intensive); D.C. or M.D. can document this!

22. Continued Medical Findings under
Colossus
 Pain Level: Only valuable if part of a
complication of injury; then pain value
increases.
 Be careful to document your pain levels as
complications of the injury. It is not
good enough to merely document the pain
level, relate it to a specific ICD-9 injury.

23. DOCUMENT ALL COMPLAINTS OF
INJURIES FOR COLOSSUS
 Range of Motion Problems (this one is huge)
 Headaches (need duration, and frequency)
 Dizziness (usually experienced right after accident; also big;
linked to visual disturbance; can be recognized as a form of
Tinnitus)
 Anxiety (linked to depression; and sleep disturbance)
 Spasms (big but depends on type of injury)
 Radiating Pain (this one is huge on any extremity or Spine)
 TMJ (linked to sleep disturbance, and also recognized as a
possible symptom of neck injuries)

24. DOCUMENT DURATION OF THE
COMPLAINTS WITH DURATION OF CARE
 Duration in Colossus in known as the
―stabilization period.‖
 Duration of the Complaints must be
documented with the Duration of Care!
 Always ―bookend‖ medical care (D.C. or
P.T.) with M.D. or D.O.
 Especially after 90 days of continued care
 Colossus will accept ANY duration period if
justified and properly documented!

25. Duration of Care
 Treatment Period: Unlike other body
parts, the neck and back require specific
treatment dates. Weight assigned with a
D.C. ―sandwiched‖ between a M.D.
increases the longer the D.C. treats.
 The same affect is realized if the D.C.
treatment is punctuated with a visit to a
specialist.

26. Massage Therapy
 Treatment by LMT’s, and MT’s is inputted
differently than either chiropractic or
medical doctor visits. The indicators for
duration of treatment for these providers
are as follows:
 Short (less than 90 days);
 Short intensive
 Prolonged (longer than 90 days);
 Prolonged Regular

27. History of Treatments (VALUE
DRIVERS) Required by Colossus
 Medication
 Home Traction
 Tens Unit
 Injections
 MRI
 Discogram
 Myleogram
 Immobilization
 Confined to bed
 Hospitalization

28. Treatments (Value Drivers)
 Medication: must be prescribed in the chartnotes.
 Duration short term or long term. Short term is less than 30
days. As expected, long term has a greater affect on value than
short term.
 Home Traction: must be documented in the
chartnotes that it is prescribed and the duration
required.
 Prescription of a Tens Unit: must be documented in
the chartnotes. It can be at home or provided in the
office.
 Duration must be documented in the chartnotes.

29. Treatments (Value Drivers)
 Injections: must be described as to TYPE and NUMBER in
the chartnotes. The number and type have an effect on
value.
 MRI, Discogram, and Myleogram: must also be
documented in the chartnotes. Each has an incremental
affect on the value of the claim.
 Immobilization: must be documented in the records as
well as the TYPE (Philadelphia collar, C-collar, Lumbar
Support, etc.), and each one has a direct weighted impact on
value.
 Duration is also important to value and must be documented in the
chartnotes.

30. Treatments (Value Drivers)
 Confined to bed: must be documented
in the records as well as duration. This
has a substantial affect on the value of the
claim.
 Hospitalization: is a very significantly
weighted factor in the value of a claim.

31. V. PROGNOSIS DOCUMENTATION AT
THE CONCLUSION OF CARE
 Document a Prognosis of the patient
periodically. Every two or three weeks is
ideal.
Is the patient:
 GOOD?
 UNDETERMINED?
 POOR?
 GUARDED?

32. Prognosis Documentation at the
Conclusion of Care (Continued)
• Is the prognosis undetermined? Why?
 Is treatment concluded and no complaints remain?
 Are there on-going complaints, but no more
treatment recommended? There should always be a
―yes‖ to this; range of motion; less headaches, but
patient still has them, etc.
 Are there on-going complaints and additional
treatment is recommended? A ―yes‖ to this = active
care, but if you are a D.C., it must be validated by a
M.D.
 Is prognosis guarded at this time?

33. Prognosis Documentation at the
Conclusion of Care (Continued)
A – Undetermined
B – No treatment recommended/no
complaints
C – Complaints/no treatment recommended
D – Complaints/treatment recommended
E – Guarded

34. VI. PRIOR INJURY, OR
SUBSEQUENT INJURY?
 Aggravation: prior injury, no symptoms,
accident, then symptoms.
 Exacerbation: prior injury, symptoms,
accident, then symptoms.
 Subsequent injury: document these carefully
and use the above terms to properly document.
These are the definitions the computers use!

35. VII. RELEASING THE PATIENT
Never release a patient ―MMI reached‖ or ―MCI
reached‖ (unless utilizing a permanent
impairment rating for a specific body part).
WHY? It is a confusing medical documentation
that tends to harm the patient; particularly if the
patient still needs to do home stretching
exercises, or future medical needed.

36. Releasing the Patient (Continued)
Keep your medical goal in mind:
REMEMBER, your goal, as
CHIROPRACTORS, and M.D.’s is to bring
the patient to a point in their medical
care, so they can start “participating in
their own recovery.”
Document this way in your Final Report!

37. VIII. FUTURE MEDICAL TREATMENT? HOW
TO DOCUMENT THIS:
 TYPE: (whether it is more chiropractic, or home exercises, or both);
 FREQUENCY/INTENSITY: (how many times per month, week, or every
two weeks, etc.);
 DURATION: (how long; 6 months, 1 year, 2 years, the computer will not
give credit beyond 3 years);
 COST: (need your medical opinion based on community standards) and
most important the:
 *Percentage of Probability: document as follows:
 0-50% POSSIBLE (computer gives no credit, too speculative; just what a jury would
do);
 51-75% PROBABLE
 76-100% DEFINITE
*How likely the patient needs future medical care

38. IX. BIO-MECHANICS OF
INJURY/PROPERTY DAMAGE
 On low initial property damage estimates,
two more estimates from independent
repair shops are always a good idea
 MIST Category (minor impact soft tissue):
goal here is to take out of this category
within 30 days

39. X. AMA PERMANENT IMPAIRMENT?
HOW TO DOCUMENT THIS:
 Concerning the issue of impairment or disability,
lamentably, Colossus will not give credence to
reports from D.C.’s They must come from a
M.D., or D.O. with Specialty.
 Ironically, the D.C.’s are the foundation of
Medical Care for most injury claims, and their
foundations help set up the eventual AMA
impairment.

40. AMA Impairment (Continued)
The BIGGEST VALUE DRIVER on a PI
claim (followed closely by the injuries
themselves, i.e. ICD-9 Codes) is the
Permanent Impairment Rating.
However, it must be done with the
following FOUR CONSIDERATIONS:

41. Four Considerations for AMA
Rating
1. M.D. or D.O (if D.O., then preferably a D.O.
with a specialty);
2. Need it to be AMA, 4th or 5th Edition;
3. Need body part that has impairment to be MMI
(only time you document MMI in a PI Case!!);
4. Needs to be at LEAST 2% WHOLE BODY
impairment.
Computer automatically assumes 2%
AMA impairment on every case and is the
first value driver to be deleted if not in
settlement demand!

42. AMA Rating
 Not every case will have an impairment rating
(about 75% will, and 25% will not because it is
not warranted), but every case should be
evaluated for one.
 Thus, it is in the patient’s best interest to have it
documented if warranted and supported by the
INJURY and BIO-MECHANICAL force of the
impact.
 Is also an area where most attorneys fail
documenting in their PI demands!

43. MAIN POINTS FOR AMA 5th EDITION
IMPAIRMENT DOCUMENTATION:
 Objective of AMA Impairment: to
provide a standardized method to assess
permanent impairment and the impact of
the permanent impairment on the ability
to perform activities of daily living (ADL).

44. How Permanent Impairment differs from
Disability:
 Disability: is how the impairment affects
and changes the person’s ability to
perform personal, social, or employment
demands;
 Impairment: is a medical assessment;
and Disability is a NON-medical
assessment.

45. Head Injury Impairments which may be
entered into Colossus are related to:
 Sight
 Hearing
 Equilibrium
 Air passage
 Mastication

46. VALUE DRIVERS Colossus Looks
For in an AMA Impairment
 The body part or system impaired;
 The degree (amount) of impairment
assigned by the M.D. (% whole person).

47. Colossus Needs Impairment to be:
 AMA (American Medical Association) derived;
 Medically documented;
 Permanent and Stationary for the patient.
Also known as stable or static:
 stable: stopped receiving treatment
 static: time has elapsed since treatment stopped
and the condition of the injury has not improved

48. Five Areas That Can Be Documented
For AMA Impairment:
 Diagnostic Related Estimate (DRE) 80% of time used.
 Range of Motion (ROM) – range of motion on Spine or
extremities; any restriction/impairment of one
movement type will often affect another type of
movement.
 Anklyosis – injury to the joint
 Amputation – loss of limb
 Diagnostic Based Estimate (DBE)

49. Five Questions for AMA
Impairment Documentation:
 Is there an area of injury?
 Was it diagnosed by a D.C., M.D., or Specialist?
 Was treatment rendered?
 Was MMI reached as to injured area?
 Were Objectable Ratable Complaints or Findings
under AMA guidelines found and documented?

50. Objectable Ratable Complaints, or Findings
under AMA Guidelines:
 Ratable Examples for Spine:
 Loss of Range of Motion (ROM)
 ROM that stays in DRE is 5% which = muscle spasm
 Muscle Weakness
 Loss of Motion Segment Integrity (LMSI)
 Residual Muscle Spasm, trigger points, splinting to
palpation
 Fracture
 Surgery (maybe ratable)
 Radiculopathy (maybe ratable)
 Need nerve study up to Category III rating, if resolved,
then it is equivalent to muscle spasm.

51. Objectable Ratable Complaints, or Findings
under AMA Guidelines:
 Ratable Examples for Extremities:
 Fusion
 Joint-space reduction
 Gait derangement
 Nerve damage
 Muscle weakness
 Loss of Range of Motion (ROM)
 ROM that stays in DRE is 5% which = muscle
spasm

52. Other Ratable Factors, or Findings under
AMA Guidelines:
 Disc Herniation
 Cord Impingement
 Spinal Stenosis
 Spondylolisthesis
 Gait problems
 Swelling/Spasm

53. For AMA Permanent Impairment rating
purposes, the Musculoskeletal System is
divided into 4 units:
 Spine
 Pelvis
 Upper Extremity (arm)
 Lower Extremity (leg)

54. AMA Documented Muscle Spasms
 Muscle Spasms: Huge Value Driver; also known as
―splinting,‖ trigger points, and myospasms
 Found by diagnostics or palpation
 Definitely Ratable
 Practice Tip: always check the paraspinals thru out Spine
for spasm, and make it a habit to check the ―SCM’s‖
(Sternum Clavicle Mastoid) for trigger points—usually a
―Sign Post‖ of Acute Whiplash

55. Subluxation a.k.a. Segmental Joint
Dysfunction under AMA
 If you diagnose this, look out for Loss Motion Segment
Integrity (LMSI)
 Why? Because LMSI is a HUGE impairment rating for
Cervical and Lumbar Spine
 25% in cervical
 20% in lumbar
 0% in thoracic (protected by rib cage)
 This is why Flex/Ext. X-rays are always necessary for
every legitimate whiplash injury!
 Every PI claim should ASSUME possible LMSI as a matter
of practice!

56. LMSI of Cervical Spine

57. LMSI of Lumbar Spine

58. Two Categories of Loss Motion
Segment Integrity:
 Angulation: does the ―motion segment‖
move at angles greater than 11 degrees? (i.e.,
one vertebrae on top of another). If yes,
LMSI diagnosis.
 Translation: does the ―motion segment‖
move forward/backward in slippage greater
than 3.5 millimeters? (i.e., one vertebrae on
top of another). If yes, LMSI diagnosis.

59. Translation Of Loss Motion Segment Integrity

60. Tips on Measuring Ratable Factors for AMA
Rating:
 Perform measurements in threes
• take average.
 Check Range of Motion
 Measure length on injured body part
 Assess Muscle Atrophy
 Conduct Manual Muscle Testing
 Examine gait derangement
 Test peripheral nerve injury

61. Tips on Measuring Ratable Factors for AMA
Rating:
Inclinometer – erroneous if not used in an
exact level position; position for Lumbar
Spine at T12/S1 for accurate
measurement.
Digitization of X-rays always a good
practice (less than 2% margin of error)
Read X-rays for possible LMSI
Take Flex/Ext. X-rays, the ―Davis 7 Series‖

62. AMA Rating Values in General:
 0% = $0.00
 5% = $5,600.00
 10% = $11,050.00
 13% = 12,050.00
 20% = 29,150.00
 28% = $30,550.00
*Values vary depending on all value drivers used on a
claim; each case is so unique it is like a thumbprint.

63. Pre-existing Impairment and New
Impairment?
Colossus will evaluate the difference
between pre-existing impairment and the
current impairment percent

64. Future Impairment?
Colossus does not consider future
treatment in its assessment that could
cause impairment; too speculative.

65. Duties Under Duress VALUE
DRIVERS
 DUD: Documenting the difficulty and the
reason for the difficulty in performing the
duties is all that is needed.
 Examples include:
 household duties
 domestic responsibilities
 job duties
These should be documented in your chartnotes.

66. Loss of Enjoyment of Life VALUE
DRIVERS
 LEOL: Is considered a permanent loss. The loss
of enjoyment of life valuation screens appears in
a Colossus consultation only in cases of
impairment and only after a certain threshold is
passed.
 Examples include loss of enjoyment of:
 Domestic duties
 Household duties
 Hobbies
 Sports
 Work

67. Real World Settlement Amounts
Utilizing VALUE DRIVERS:
 Defendant Insurance Company: State Farm
 Medical Specials: $8,500.00
 Wage Loss: $0.00 (Student)
 Injuries: Soft Tissue
 Property Damage: $8,200.00
 Gap in Care: 2.5 Month Gap in care (gap documented), just one ER
visit then began D.C. visits; Chiropractic Care term was 3-4 months;
M.D. ―bookended‖ D.C. care
 MRI of left Shoulder; Finding: completely normal! M.D.
explanation: can still have nerve irritation in whiplash injury, or
trauma/injury without compression, and still entitled to best
diagnostic tool on the market to rule out nerve impingement.
 Injections: 1 steroid injection
 AMA Impairment 5th Edition: 7% WPI, cervical spine, by M.D.
Settlement: $30,000.00

68. Real World Settlement Amounts
Utilizing VALUE DRIVERS:
 Defendant Insurance Company: Progressive
 Medical Specials: $11,000.00
 Wage Loss: $2,000.00
 Injuries: Soft Tissue with Disc protrusion, and bulge with a positive
MRI finding
 Property Damage: $15,680.00
 No Gap in Care, but patient treated with 2 chiropractors; 1 for the
1st 3-4 months, then a 1.5 month gap, and then continued with
another chiropractor for 3 more months! There was 1 ER visit, no
admittance to hospital.
 M.D. ―bookended‖ chiropractic care on the second chiropractor only,
thus no M.D. involved with first chiropractor.
 AMA Impairment 5th edition: 15% WPI (5% cerv.. 5% lumb;
5% thoracic), by M.D.
Settlement: $42,500.00, first offer was $37,000.00!
Case settled in 5 days! Offered to over-night check.

69. Two Places VALUE DRIVERS
Need To Be Located
 In your Medical Documentation
 In the Attorney Settlement Demand

70. Steps that Need to be done:
 Take legible Records;
 List every injury (utilize the VALUE
DRIVERS in this presentation);
 Record properly Chart Notes and Reports
with VALUE DRIVERS;
 Document Prognosis, DUD, and LOEL;
 Obtain AMA impairment rating
 Work with the Right Attorney

71. XI. To Summarize:
 All injuries have an injury profile
 Absent accurate information in the chartnotes,
the severity rating for an individual claim will not
reflect a reasonable value
 Thus, the above is what every doctor should
know in how to document VALUE DRIVERS in
personal injury claims

72. By:
Jeffrey D. Bohn Esq.
(all graphics used with permission)
Locations:
San Francisco, San Jose, Walnut Creek, San Mateo, Carlsbad,
Cupertino, Palo Alto, Oakland, Pleasant Hill, Sunyvale, Fresno,
North Sacramento, South Sacramento
TEL: 559-304-1549
559-485-1212
Email: jeffreybohn@gmail.com
www.jdbohnlaw.com