ICD-10 Conditions for Workers' Comp QME Evaluations

Diplopia

head brain · 5-20% WPI based on severity and compensability

Blindness, one eye, low vision other eye, unspecified eyes

head brain · 25-40% WPI for monocular blindness

Blindness, one eye, unspecified eye

head brain · 24-28% WPI for monocular blindness with normal other eye

Benign paroxysmal positional vertigo, unspecified ear

head brain · 0-10% WPI for persistent vestibular dysfunction

Noise effects on inner ear, unspecified ear

head brain · 0-35% WPI based on hearing levels

Sensorineural hearing loss, bilateral

head brain · 0-35% WPI based on binaural hearing level and speech discrimination

Unspecified sensorineural hearing loss

head brain · 0-35% WPI

Unspecified hearing loss, unspecified ear

head brain · 0-35% WPI

Tinnitus, unspecified ear

head brain · Up to 5% added to hearing impairment (combined not to exceed 35% WPI)

Unspecified injury of unspecified eye and orbit, initial encounter

head brain · 0-40% WPI depending on visual acuity and field loss

Anemia, unspecified

head brain · 0-15% WPI based on severity and treatment response

Hypothyroidism, unspecified

head brain · 0-10% WPI if symptomatic despite treatment

Thyrotoxicosis, unspecified without thyrotoxic crisis or storm

head brain · 0-10% WPI based on control

Type 2 diabetes mellitus with diabetic neuropathy, unspecified

ankle foot · 10-30% WPI combined endocrine and neurological

Type 2 diabetes mellitus without complications

lumbar spine · 5-20% WPI based on control and end-organ damage

Sleep apnea, unspecified

head brain · 0-10% WPI for poorly controlled OSA

Essential (primary) hypertension

head brain · 0-20% WPI based on end-organ damage

Hypertensive heart disease without heart failure

head brain · 10-35% WPI

Acute myocardial infarction, unspecified

head brain · 15-65% WPI based on EF and functional class

Atherosclerotic heart disease of native coronary artery without angina pectoris

head brain · 10-50% WPI based on functional class and exercise tolerance

Heart failure, unspecified

head brain · 30-65% WPI depending on NYHA class

Gastro-esophageal reflux disease with esophagitis

lumbar spine · 0-10% WPI

Gastric ulcer, unspecified as acute or chronic, without hemorrhage or perforation

lumbar spine · 0-10% WPI

Toxic liver disease with cholestasis

lumbar spine · 10-40% WPI based on liver function and progression

Fatty (change of) liver, not elsewhere classified

lumbar spine · 0-15% WPI based on liver function

Chronic kidney disease, stage 3 (moderate)

lumbar spine · 10-30% WPI

Toxic effect of unspecified substance, accidental (unintentional), initial encounter

lumbar spine · Varies widely based on affected organ systems

Primary osteoarthritis, right hip

hip · 15-40% LE (6-16% WPI); higher with total hip arthroplasty

Primary osteoarthritis, left hip

hip · 15-40% LE (6-16% WPI)

Primary osteoarthritis, right knee

knee · 10-37% LE (4-15% WPI); higher with total knee arthroplasty

Primary osteoarthritis, left knee

knee · 10-37% LE (4-15% WPI)

Primary osteoarthritis, right shoulder

shoulder · 10-25% UE (6-15% WPI) based on ROM loss and arthroplasty status

Primary osteoarthritis, left shoulder

shoulder · 10-25% UE (6-15% WPI)

Primary osteoarthritis, right elbow

elbow · 5-15% UE (3-9% WPI)

Primary osteoarthritis, right wrist

wrist hand · 5-15% UE (3-9% WPI)

Primary osteoarthritis, right ankle and foot

ankle foot · 7-20% LE (3-8% WPI); higher with ankle fusion or replacement

Chondromalacia patellae, unspecified knee

knee · 3-10% LE (1-4% WPI)

Other meniscus derangements, unspecified meniscus, unspecified knee

knee · 5-15% LE (2-6% WPI)

Chronic instability of knee, unspecified knee

knee · 5-20% LE (2-8% WPI) based on instability grade

Recurrent dislocation, right shoulder

shoulder · 10-20% UE (6-12% WPI)

Contracture, right elbow

elbow · 5-15% UE (3-9% WPI) based on ROM loss

Other instability, right knee

knee · 5-20% LE (2-8% WPI) based on instability grade

Pain in right shoulder

shoulder · 5-15% UE (3-9% WPI)

Pain in right hip

hip · 5-15% LE (2-6% WPI)

Pain in right knee

knee · 3-10% LE (1-4% WPI)

Pain in right ankle and joints of right foot

ankle foot · 5-15% LE (2-6% WPI)

Spondylolysis, lumbar region

lumbar spine · 5-15% WPI; DRE Category II-III

Spondylolisthesis, lumbar region

lumbar spine · 10-28% WPI; DRE Category III-V

Discitis, unspecified, lumbar region

lumbar spine · 15-30% WPI when chronic

Spondylosis without myelopathy or radiculopathy, cervical region

cervical spine · 5-15% WPI with apportionment consideration

Spondylosis without myelopathy or radiculopathy, lumbar region

lumbar spine · 5-15% WPI; apportionment often applied

Spondylosis without myelopathy or radiculopathy, lumbosacral region

lumbar spine · 5-15% WPI with apportionment

Other spondylosis, lumbar region

lumbar spine · 5-20% WPI depending on functional loss

Spinal stenosis, cervical region

cervical spine · 10-35% WPI; higher with myelopathy

Spinal stenosis, lumbar region

lumbar spine · 10-28% WPI; higher with surgical fusion

Spinal stenosis, lumbosacral region

lumbar spine · 10-28% WPI

Cervical disc disorder with myelopathy, unspecified cervical region

cervical spine · 20-38% WPI per DRE Category IV-V

Cervical disc disorder with radiculopathy, unspecified cervical region

cervical spine · 10-28% WPI per DRE Category III-V

Cervical disc disorder with radiculopathy, high cervical region

cervical spine · 10-25% WPI per DRE Category III-IV

Cervical disc disorder with radiculopathy, mid-cervical region

cervical spine · 10-28% WPI per DRE Category III-V

Cervical disc disorder with radiculopathy, cervicothoracic region

cervical spine · 10-28% WPI per DRE Category III-V

Intervertebral disc disorders with myelopathy, lumbar region

lumbar spine · 20-35% WPI per DRE Category IV-V

Intervertebral disc disorders with radiculopathy, thoracic region

thoracic spine · 10-20% WPI

Intervertebral disc disorders with radiculopathy, lumbar region

lumbar spine · 10-28% WPI per DRE Category III-V

Intervertebral disc disorders with radiculopathy, lumbosacral region

lumbar spine · 10-28% WPI per DRE Category III-V

Cervicobrachial syndrome

cervical spine · 10-25% WPI combining spine and UE impairment

Cervicalgia

cervical spine · 5-25% WPI depending on DRE category

Lumbago with sciatica, right side

lumbar spine · 10-25% WPI per DRE Category II-IV

Lumbago with sciatica, left side

lumbar spine · 10-25% WPI per DRE Category II-IV

Low back pain

lumbar spine · 5-25% WPI depending on DRE category or ROM deficit

Low back pain, unspecified

lumbar spine · 5-25% WPI depending on DRE category or ROM deficit

Vertebrogenic low back pain

lumbar spine · 5-15% WPI per DRE Category II-III

Other low back pain

lumbar spine · 5-20% WPI

Pain in thoracic spine

thoracic spine · 5-15% WPI

Muscle spasm of back

lumbar spine · Contributes to DRE categorization; not independently rated

Trigger finger, unspecified finger

wrist hand · 2-8% UE (1-5% WPI) per affected digit

Radial styloid tenosynovitis (de Quervain)

wrist hand · 3-8% UE (2-5% WPI)

Spontaneous rupture of extensor tendons, right lower leg

ankle foot · 3-10% LE (1-4% WPI)

Palmar fascial fibromatosis (Dupuytren)

wrist hand · 3-12% UE (2-7% WPI) based on contracture severity

Plantar fascial fibromatosis (plantar fasciitis)

ankle foot · 3-7% LE (1-3% WPI)

Adhesive capsulitis of unspecified shoulder

shoulder · 10-20% UE (6-12% WPI) based on ROM deficit

Rotator cuff tear or rupture of unspecified shoulder, not specified as traumatic

shoulder · 7-20% UE (3-12% WPI) depending on tear size and functional loss

Incomplete rotator cuff tear or rupture of right shoulder, not specified as traumatic

shoulder · 5-15% UE (3-9% WPI)

Incomplete rotator cuff tear or rupture of left shoulder, not specified as traumatic

shoulder · 5-15% UE (3-9% WPI)

Calcific tendinitis of unspecified shoulder

shoulder · 3-10% UE (2-6% WPI)

Impingement syndrome of unspecified shoulder

shoulder · 5-12% UE (3-7% WPI)

Achilles tendinitis, unspecified leg

ankle foot · 3-10% LE (1-4% WPI)

Lateral epicondylitis, unspecified elbow

elbow · 3-8% UE (2-5% WPI)

Lateral epicondylitis, right elbow

elbow · 3-8% UE (2-5% WPI)

Medial epicondylitis, unspecified elbow

elbow · 3-8% UE (2-5% WPI)

Panniculitis, unspecified

lumbar spine · 0-5% WPI

Pain in right lower leg

ankle foot · 3-10% LE (1-4% WPI)

Pain in right upper arm

shoulder · 3-10% UE (2-6% WPI)

Pain in right hand

wrist hand · 3-10% UE (2-6% WPI)

Age-related osteoporosis without current pathological fracture

lumbar spine · Not independently rated; contributes to fracture apportionment

Postlaminectomy syndrome, not elsewhere classified

lumbar spine · 15-30% WPI; often DRE Category IV-V

Unspecified displaced fracture of first cervical vertebra, initial encounter

cervical spine · 20-35% WPI per DRE Category IV-V

Wedge compression fracture of unspecified thoracic vertebra, initial encounter

thoracic spine · 10-20% WPI per DRE category

Wedge compression fracture of unspecified lumbar vertebra, initial encounter

lumbar spine · 10-25% WPI per DRE Category III-IV

Fracture of unspecified part of right clavicle, initial encounter

shoulder · 3-10% UE (2-6% WPI)

Unspecified fracture of upper end of right humerus, initial encounter

shoulder · 10-25% UE (6-15% WPI)

Unspecified dislocation of right acromioclavicular joint, initial encounter

shoulder · 3-12% UE (2-7% WPI) depending on grade

Unspecified sprain of right shoulder joint, initial encounter

shoulder · 3-10% UE (2-6% WPI)

Strain of muscle(s) and tendon(s) of the rotator cuff of right shoulder, initial encounter

shoulder · 5-15% UE (3-9% WPI)

Unspecified fracture of the lower end of right radius, initial encounter

wrist hand · 5-18% UE (3-11% WPI) depending on healing and ROM loss

Unspecified fracture of navicular [scaphoid] bone of right wrist, initial encounter

wrist hand · 5-15% UE (3-9% WPI) depending on healing and secondary arthrosis

Fracture of unspecified carpal bone, right wrist, initial encounter

wrist hand · 3-12% UE (2-7% WPI)

Fracture of unspecified phalanx of right index finger, initial encounter

wrist hand · 2-8% UE (1-5% WPI) per affected digit

Fracture of unspecified part of neck of right femur, initial encounter

hip · 15-40% LE (6-16% WPI); higher with arthroplasty

Unspecified sprain of right hip, initial encounter

hip · 3-15% LE (1-6% WPI)

Unspecified fracture of right patella, initial encounter

knee · 5-15% LE (2-6% WPI)

Unspecified fracture of upper end of right tibia, initial encounter

knee · 10-25% LE (4-10% WPI)

Other fracture of lower leg, right, initial encounter

ankle foot · 5-20% LE (2-8% WPI)

Unspecified subluxation of right knee, initial encounter

knee · 5-15% LE (2-6% WPI)

Bucket-handle tear of medial meniscus, current injury, right knee, initial encounter

knee · 5-15% LE (2-6% WPI)

Sprain of anterior cruciate ligament of right knee, initial encounter

knee · 10-25% LE (4-10% WPI) post-reconstruction

Strain of right Achilles tendon, initial encounter

ankle foot · 5-15% LE (2-6% WPI)

Unspecified fracture of right calcaneus, initial encounter

ankle foot · 10-25% LE (4-10% WPI); higher with subtalar fusion

Sprain of unspecified ligament of right ankle, initial encounter

ankle foot · 3-10% LE (1-4% WPI)

Postconcussional syndrome

head brain · 5-29% WPI for persistent cognitive deficits

Epilepsy, unspecified, not intractable, without status epilepticus

head brain · 10-40% WPI based on seizure frequency and control

Migraine, unspecified, not intractable, without status migrainosus

head brain · 0-14% WPI based on frequency and medication responsiveness

Post-traumatic headache, unspecified, not intractable

head brain · 0-14% WPI based on headache frequency and treatment response

Brachial plexus disorders

shoulder · 10-60% UE (6-36% WPI) depending on trunk involvement and motor deficit

Lumbosacral plexus disorders

lumbar spine · 10-40% LE (4-16% WPI) depending on deficit severity

Lumbosacral root disorders, not elsewhere classified

lumbar spine · 10-25% WPI depending on nerve root involvement and deficit severity

Carpal tunnel syndrome, unspecified upper limb

wrist hand · 5-15% UE (3-9% WPI) based on sensory/motor deficit severity

Carpal tunnel syndrome, right upper limb

wrist hand · 5-15% UE (3-9% WPI)

Carpal tunnel syndrome, left upper limb

wrist hand · 5-15% UE (3-9% WPI)

Other lesions of median nerve, unspecified upper limb

wrist hand · 5-20% UE (3-12% WPI) depending on deficit type

Lesion of ulnar nerve, unspecified upper limb

elbow · 5-25% UE (3-15% WPI) depending on motor involvement

Lesion of radial nerve, unspecified upper limb

elbow · 5-30% UE (3-18% WPI) depending on wrist drop severity

Other specified mononeuropathies of unspecified upper limb

wrist hand · 5-15% UE (3-9% WPI)

Lesion of sciatic nerve, unspecified lower limb

hip · 10-40% LE (4-16% WPI) depending on motor and sensory deficit

Lesion of lateral popliteal nerve, unspecified lower limb

knee · 10-25% LE (4-10% WPI) depending on foot drop severity

Tarsal tunnel syndrome, unspecified lower limb

ankle foot · 3-10% LE (1-4% WPI)

Other specified mononeuropathies of unspecified lower limb

ankle foot · 5-15% LE (2-6% WPI)

Mononeuropathy, unspecified

wrist hand · 5-25% depending on nerve and severity

Drug-induced polyneuropathy

ankle foot · 5-20% based on deficit severity

Alcoholic polyneuropathy

ankle foot · 5-20%; subject to apportionment

Polyneuropathy, unspecified

ankle foot · 5-30% LE (2-12% WPI) depending on severity

Muscular dystrophy, unspecified

lumbar spine · Varies; non-industrial condition used for apportionment

Cauda equina syndrome

lumbar spine · 25-40% WPI; DRE Category V plus potential bowel/bladder impairment

Radiculopathy, site unspecified

lumbar spine · 10-25% WPI per DRE Category III-IV

Radiculopathy, cervical region

cervical spine · 10-28% WPI per DRE Category III-V

Radiculopathy, lumbar region

lumbar spine · 10-28% WPI per DRE Category III-V

Radiculopathy, lumbosacral region

lumbar spine · 10-28% WPI per DRE Category III-V

Concussion without loss of consciousness, initial encounter

head brain · 0-14% WPI; most concussions resolve fully

Concussion with loss of consciousness of 30 minutes or less, initial encounter

head brain · 0-29% WPI depending on persistent cognitive deficits

Unspecified focal traumatic brain injury without loss of consciousness

head brain · 5-29% WPI for persistent deficits

Traumatic subdural hemorrhage without loss of consciousness, initial encounter

head brain · 15-65% WPI depending on residual deficits

Traumatic subarachnoid hemorrhage without loss of consciousness, initial encounter

head brain · 15-65% WPI depending on residual deficits

Injury of brachial plexus, initial encounter

shoulder · 15-60% UE (9-36% WPI) depending on severity

Primary insomnia

head brain · 0-5% WPI as contributing factor to primary condition

Rheumatoid arthritis, unspecified

wrist hand · Varies; typically apportioned away from industrial cause

Gout, unspecified

ankle foot · Varies; typically apportioned away from industrial cause

Muscle weakness (generalized)

lumbar spine · Rated as part of primary condition

Other specified soft tissue disorders

lumbar spine · 0-10% WPI depending on specific condition and functional impact

Pathological fracture, unspecified site, initial encounter for fracture

lumbar spine · Varies; significant apportionment for underlying bone disease

Ataxic gait

head brain · 10-30% WPI depending on severity and underlying cause

Repeated falls

ankle foot · Not independently rated; supports gait and balance impairment

Sprain of ligaments of cervical spine, initial encounter

cervical spine · 0-15% WPI; DRE Category I-III

Strain of muscle, fascia and tendon at neck level, initial encounter

cervical spine · 0-8% WPI; DRE Category I if resolved, Category II if persistent

Sprain of ligaments of lumbar spine, initial encounter

lumbar spine · 0-8% WPI; DRE Category I-II

Strain of muscle, fascia and tendon of lower back, initial encounter

lumbar spine · 0-8% WPI; DRE Category I (0%) if resolved, Category II (5-8%) if persistent

Contusion of right shoulder, initial encounter

shoulder · 0% WPI if resolved; investigate further if persistent

Contusion of right knee, initial encounter

knee · 0% WPI if resolved; investigate further if persistent

Injury, unspecified, initial encounter

lumbar spine · Dependent on specific injury identified

Infection following a procedure, initial encounter

lumbar spine · Varies based on residual effects; consequential to primary industrial injury

Personal history of other musculoskeletal disorders

lumbar spine · Not independently rated; used for apportionment documentation

Presence of intraocular lens

head brain · 0-10% WPI depending on residual visual acuity

Presence of right artificial knee joint

knee · 17-37% LE (7-15% WPI) minimum for total knee replacement

Presence of right artificial hip joint

hip · 20-40% LE (8-16% WPI) minimum for total hip replacement

Central pain syndrome

head brain · Varies based on underlying condition; pain add-on up to 3% WPI

Chronic pain due to trauma

lumbar spine · Up to 3% WPI add-on for pain

Other chronic pain

lumbar spine · Up to 3% WPI add-on for chronic pain per Chapter 18

Chronic pain syndrome

lumbar spine · Up to 3% WPI add-on for pain; additional psychiatric impairment may apply

Complex regional pain syndrome I, unspecified

wrist hand · 10-50% UE or LE depending on severity and extremity involved

Complex regional pain syndrome I of right upper limb

wrist hand · 15-60% UE (9-36% WPI)

Complex regional pain syndrome I of right lower limb

ankle foot · 15-50% LE (6-20% WPI)

Complex regional pain syndrome I of other specified site

wrist hand · 10-50% depending on affected region

Myalgia, unspecified site

lumbar spine · Contributes to primary condition rating; not independently rated

Fibromyalgia

lumbar spine · 0-3% WPI if accepted as industrial; often disputed

Pain, unspecified

lumbar spine · Up to 3% WPI add-on; usually paired with specific diagnosis

Alcohol dependence, uncomplicated

head brain · Subject to apportionment analysis; not typically rated as industrial

Major depressive disorder, single episode, mild

head brain · 5-15% WPI

Major depressive disorder, single episode, moderate

head brain · 15-30% WPI

Major depressive disorder, single episode, severe without psychotic features

head brain · 30-50% WPI

Major depressive disorder, recurrent, moderate

head brain · 15-35% WPI with apportionment

Panic disorder [episodic paroxysmal anxiety]

head brain · 10-30% WPI based on frequency and avoidance behavior

Generalized anxiety disorder

head brain · 10-30% WPI

Post-traumatic stress disorder, unspecified

head brain · 10-50% WPI per Chapter 14 psychiatric impairment categories

Post-traumatic stress disorder, acute

head brain · 10-35% WPI; may resolve or progress to chronic

Post-traumatic stress disorder, chronic

head brain · 20-50% WPI for chronic PTSD

Adjustment disorder, unspecified

head brain · 5-15% WPI

Adjustment disorder with depressed mood

head brain · 5-20% WPI

Adjustment disorder with anxiety

head brain · 5-20% WPI

Adjustment disorder with mixed anxiety and depressed mood

head brain · 5-25% WPI

Pain disorder with related psychological factors

head brain · 5-20% WPI psychiatric component

Depersonalization-derealization syndrome

head brain · 10-30% WPI

Mesothelioma of pleura

head brain · 50-100% WPI given terminal diagnosis

Chronic obstructive pulmonary disease with (acute) exacerbation

head brain · 15-65% WPI based on GOLD staging and PFT results

Chronic obstructive pulmonary disease, unspecified

head brain · 10-65% WPI based on PFT severity

Mild intermittent asthma, uncomplicated

head brain · 5-15% WPI

Mild persistent asthma, uncomplicated

head brain · 10-20% WPI

Moderate persistent asthma, uncomplicated

head brain · 15-30% WPI

Severe persistent asthma, uncomplicated

head brain · 25-50% WPI

Pneumoconiosis due to asbestos and other mineral fibers

head brain · 10-50% WPI based on PFT results and functional limitation

Pneumoconiosis due to other dust containing silica (silicosis)

head brain · 10-65% WPI depending on disease stage and PFT impairment

Hypersensitivity pneumonitis due to unspecified organic dust

head brain · 10-40% WPI based on PFT impairment

Chemical bronchitis

head brain · 10-35% WPI based on PFT impairment

Chronic respiratory conditions due to chemicals, gases, fumes and vapors

head brain · 15-50% WPI based on PFT results

Pulmonary fibrosis, unspecified

head brain · 20-65% WPI depending on PFT severity

Pleural plaque with presence of asbestos

head brain · 0-10% WPI; higher if PFTs affected

Other and unspecified malignant neoplasm of skin, unspecified

head brain · 5-30% WPI depending on type, staging, and treatment effects

Allergic contact dermatitis due to metals

wrist hand · 0-15% WPI based on severity and chronicity

Allergic contact dermatitis due to other chemical products

wrist hand · 0-15% WPI

Irritant contact dermatitis due to detergents

wrist hand · 0-10% WPI

Irritant contact dermatitis due to other chemical products

wrist hand · 0-15% WPI

Unspecified contact dermatitis, unspecified cause

wrist hand · 0-10% WPI

Actinic keratosis

head brain · 0-5% WPI

Scar conditions and fibrosis of skin

wrist hand · 0-15% WPI for disfigurement; additional for functional limitation

Burn of unspecified degree of head, face, and neck, unspecified site, initial encounter

head brain · 5-40% WPI depending on burn severity, scarring, and contracture

Burn of unspecified degree of right shoulder and upper limb, except wrist and hand, initial encounter

shoulder · 5-30% WPI depending on burn extent and ROM limitation

Burn of unspecified degree of right hand, unspecified site, initial encounter

wrist hand · 5-30% UE (3-18% WPI) depending on burn extent and digit involvement