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Washington F252-006-000: Lumbar Impairment Worksheet

Washington attending physicians can use this worksheet to rate permanent impairment of the dorso-lumbar or lumbosacral spine under the category system in WAC 296-20-280, which L&I says can avoid the need for an IME. After confirming maximum medical improvement and permanent impairment, the doctor circles one box in each of four findings columns, averages them and certifies an exam within the last 8 weeks.

Who completes it

The attending physician, or a consultant performing the rating, completes and signs it. L&I lets MDs, DOs, dentists and podiatrists rate as AP or consultant, while chiropractors must be L&I-approved IME examiners.

Submitting and payment

How to submit it
Send the worksheet to L&I with the chart notes and history and physical that support it; the last page is designed to tear off and mail in a window envelope. Keep a photocopy for your records.
Who pays
Impairment ratings are billed under L&I's current Chapter 11 codes, such as 1191M for an attending physician's rating of 1-3 body areas, because the worksheet's printed code 1190M now covers comprehensive hearing loss exams.

Good to know

  • The four columns are muscle weakness with atrophy or EMG changes, reflex loss, imaging findings, and other findings such as dermatomal sensory loss or reduced range of motion, each with a required explanation.
  • Oswestry and other pain scales are not considered; pain counts only when it is reflected in findings such as decreased range of motion.
  • Do not rate if a pre-existing condition was not permanently aggravated by the injury, or if the condition is still deteriorating; give treatment recommendations instead.
  • If you prefer, copy the circled box numbers into the calculation boxes and let L&I compute the average rating.

Get the official form

Download the current version from the source each time; forms change without notice.

Doctor's Worksheet for Rating Dorso-Lumbar & Lumbo-Sacral Impairment

Official pagePDF

Fill it with Vero

If your copy of the form is a fillable PDF, upload it once and Vero Documents fills it from the visit note and the chart, ready for you to review and sign. Download, print, or email the finished form, with the patient’s consent.

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Frequently asked questions

Who can use Washington's lumbar impairment worksheet?

Attending physicians rating their own patients, or consultants when the AP cannot or will not. L&I's policy lets MDs, DOs, dentists and podiatrists rate within their scope; chiropractors need L&I-approved IME examiner status, while physician assistants, nurse practitioners and naturopaths cannot rate impairment.

How is the lumbar category calculated?

Circle one box in each column, A through D, add the four box numbers, divide by 4 and round to the nearest whole number (1.1 becomes 1, 1.5 becomes 2). That number is the rating. Weakness grades are defined on the form: mild 4/5, moderate 3/5, marked 2/5 to 0/5.