The Importance of Distinguishing between a Strain and a Sprain
It is not uncommon when reviewing a file to see a purported diagnosis of a “sprain/strain.” Doctors do it. Lawyers do it. Claims professionals do it. We should all stop doing it. Here’s why.
The meaning of this diagnosis is uncertain.
The slash ( / ), also known as the virgule, has several meanings. Using it can mean: “and”, “or”, “also used as”, or “per.” The lowly virgule can signify a fraction when placed between two numbers. It can signify a connection to or conflict between two objects. It can even assist in forming an abbreviation.
The meaning of a virgule has formed the basis for a dispute that went all the way to the Texas Supreme Court, where the court wrote:
The symbol “/” (a slash, or virgule), itself ambiguous and frowned upon, often indicates alternatives. Garner, supra, at §§ 1.80, 1.81(d). Many style guides translate the phrase “A and/or B” to mean “A or B or both.” See Strunk & White, supra, at 40; Wilson Follett, Modern American Usage 64–65 (Jacques Barzun et al. eds., 1966). Thus, the trial court’s actual reasons might have been any of the first three, all four of them, or just “in the interest of justice and fairness” by itself.
In re United Scaffolding, Inc., 377 S.W.3d 685, 690 (Tex. 2012).
If a strain and a sprain were the same diagnosis, the use by doctors of a virgule between them might be considered a minor issue. But a strain and a sprain are not the same things. In fact, these two words represent two decidedly different diagnoses.
• A sprain is an injury to a ligament or a joint.
• A strain is an injury to the tendon or a muscle unit.
If you have an injury to a ligament and a muscle, there are two diagnoses: a sprain and a strain. If you have an injury that is limited to a ligament, you only have a sprain. If you are dealing only with a muscle injury, that injury is a strain.
Moreover, the ICD-10 now separates sprains and strains into two separate code ranges and makes the description specific to the injured structure. There is no ICD-10 code for a “sprain/strain.” The diagnosis cannot be billed and if it cannot be billed, it should not be paid.
The URAs and medical bill processing vendors that you use should be made aware of this distinction. So should your peer review physicians and your consulting experts. The American Academy of Orthopedic Surgeons has created a primer on the differences between ICD-9 coding and ICD-10 coding when dealing with sprains and strains. This document was primarily created to educate orthopedic surgeons and their staffs. It should be distributed widely within your organization. Call it to the attention of the doctors upon whose advice you rely. Bring it to the attention of your claims representatives.
It is important that you be able to identify which diagnoses you consider to be compensable and which ones you do not consider to be compensable on any given claim. Acceptance of a “sprain/strain” makes this more difficult. Instead, understand the difference between the two diagnoses and make every reasonable effort to determine which of the two conditions you believe to be a part of the claim. If you believe that both conditions are compensable, then the correct diagnoses for the compensable injuries would be both a strain and a sprain.
This helps you clarify your medical obligation. It also makes everything clearer when the claim reaches the MMI and IR stage. Accurately identifying the correct diagnosis helps conserve time and expense when you begin to deal with the concepts of MMI and the assignment of an impairment rating. We all know that disputes involving maximum medical improvement, impairment rating, and extent of injury frequently arise together. These cases present especially complex and time-consuming challenges to the parties and the Division.
Where a doctor fails to rate the entire compensable injury, his MMI and IR certifications cannot be adopted. See Appeals Panel Decision140166, decided March 28, 2014; Appeals Panel Decision 110463, decided June 13, 2011; and Appeals Panel Decision 101567, decided December 20, 2010. See also Rule 130.1(c). The only exception to this is if the MMI and IR certification has become final under the 90-day rule. See Appeals Panel Decision 132594-s.
Identifying the extent of the compensable injury is a threshold determination for the assessment of MMI and IR. Often the parties must obtain and present a variety of alternate certifications based on different potential outcomes of extent of injury. Failure to do so runs the risk that they will have presented no MMI or IR certification to match the Hearing Officer’s determination on extent of injury. This may result in the need for an additional CCH setting.
The likelihood that this will happen on one of your claims increases when you or a system participant utilizes the diagnosis of “strain/sprain.” Accordingly, we recommend that you seek to avoid the use of that term on your claims.
FOLIO
