CM-933 Radiologic Interpretation

Radiologic Interpretation

U.S. DEPARTMENT OF LABOR

OFFICE OF WORKERS’ COMPENSATION PROGRAMS
DIVISION OF COAL MINE WORKERS’ COMPENSATION

Note: This report is authorized by law (30 USC 901 et. seq.) and required to obtain a benefit. The results of this interpretation will aid in
OMB No. 1240-0023
determining the miner’s eligibility for black lung benefits. Disclosure of a Social Security number is voluntary. The failure to disclose such
Expires: XX/XX/XXXX
number will not result in the denial of any right, benefit, or privilege to which the claimant may be entitled. This method of collecting
information complies with the Freedom of Information Act, the Privacy Act of 1974, and OMB Circular No. 108.
Please record your interpretation of a single image by placing “X” in the appropriate boxes on the form and return it promptly to the office that requested the interpretation.
The form must be completed as per instructions, signed by a physician, and contain the miner’s name, and social security number. The Department of Labor will pay
only for images of acceptable quality (1, 2 and 3). Images of inferior quality (U/R) must be retaken without cost to the Department.
1. Miner’s Name (Print)

1A. Date of X-Ray

1B. Miner’s Social Security Number

1C. Image Quality (if not Grade
1. Give Reason):
1

MO

1D. Is Image Completely Negative?
YES

□ Proceed to Section 5

NO

DAY

YR

□ Complete Section 2A

YES

□ Complete 2B and 2C

p

s

p

q

t

r

u

b. ZONES

0/-

0/0

0/1

s

1/0

1/1

1/2

q

t

2/1

2/2

2/3

r

u

3/2

3/3

3/+

R

3A. ANY PLEURAL ABNORMALITIES

Proceed to Section 3

Extent (chest wall; combined for
in profile and face on)
Up to 1/4 of lateral chest wall = 1
1/4 to 1/2 of lateral chest wall = 2

Calcification
O
R
L

Face On

O

R

L

O

R

L

O

R

L

O

R

L

O

R

Other site(s)

O

R

L

O

R

L

1

2

3C. COSTOPHRENIC ANGLE OBLITERATION

B

Proceed to
Section 3

C

O

L

1

2

3

> 10 mm = c
3

O

R

a

b

Proceed to
Section 3D

L

3D. DIFFUSE PLEURAL THICKENING (mark site, calcification, extent, and width)

c

O

L

a

b

c

Proceed to
Section 4A

NO

Up to 1/4 of lateral chest wall = 1
1/4 to 1/2 of lateral chest wall = 2
> 1/2 of lateral chest wall = 3

Width (in profile only)
(3m minimum width required)
3 to 5 mm = a
5 to 10 mm = b
> 10 mm = c
O

R

a

b

Extent (chest wall, combined for
in profile and face on)

Calcification

Proceed to
Section 4A

NO

Width (in profile only)
(3mm minimum width required)
3 to 5 mm = a
5 to 10 mm = b

> 1/2 of lateral chest wall = 3

R

Site

A

Complete Sections
3B, 3C

YES

Diaphragm

Chest wall

□

L

(mark site, calcification, extent and width)

L

O

SIZE

CONSISTENT WITH PNEUMOCONIOSIS?

Site
R

NO

c. PROFUSION

SECONDARY

O

U/R

2C. Large Opacities Consistent With Pneumoconiosis

a. SHAPE/SIZE
PRIMARY

Chest Wall
In Profile

3

2A. Any Parenchymal Abnormalities Consistent with Pneumoconiosis?

2B. Small Opacities Consistent With Pneumoconiosis

3B. PLEURAL PLAQUES

2

In Profile

O

R

L

O

R

L

O

R

Face On

O

R

L

O

R

L

1

2

3

4A. ANY OTHER ABNORMALITIES?

O

L

1

2

3

c

Complete
4B and 4C

YES

O

L

a

b

c

Proceed to
Section 5

NO

4B. OTHER SYMBOLS (OBLIGATORY)
aa

at

ax

bu

REPORT ITEMS WHICH
MAY BE OF PRESENT
CLINICAL SIGNIFICANCE
IN THIS SECTION
OTHER COMMENTS
4C

ca

cg

cn

co

cp

cv

di

(Specify od.)

OD

ef

em

es

fr

hi

ho

id

ih

kl

me

Date Personal Physician notified?

pb
M

SHOULD WORKER SEE PERSONAL PHYSICIAN BECAUSE OF COMMENTS IN SECTION 4C?
5A.

pa

YES

FACILITY PROVIDING RADIOLOGIC EXAMINATION:
DOL Medical Provider Number (if applicable):

□ Yes □

Was image taken by a registered radiographer/radiographic technologist?
Name

pi
o.

NO

px
D

ra

rp
ay

tb
Y

r.

Proceed to Section 5

No
Registration No.

State

5B. Physician Interpreting Image (Print Name): ___________________________________________________________________________________

□

□

□

□

□

□

Are you: Board-Certified Radiologist?
Yes
No.
Board-eligible radiologist?
Yes
No.
B-reader?
Yes
No Date current B-reader certification expires: _______
5C. I certify that this image has been interpreted in accordance with the instructions provided on Form CM-954a and/or 20 CFR 718. Subpart B, 718.102 and Appendix A. I also certify that the
information furnished is correct and am aware that my signature attests to the accuracy of the results reported. I am aware that any person who willfully makes any false or misleading
statements or representation in support of an application for benefits under Title 30 USC 941 shall be guilty of a misdemeanor and subject to a fine of up to $1,000, or to imprisonment for up to
one year, or both.
PHYSICIAN’S SIGNATURE ____________________________________________________________

DATE OF READING_________________________________________________
(Mo., Day, Yr.)

Public Burden Statement

We estimate that it will take an average of 5 minutes to complete this information collection, including time for reviewing instructions, searching existing data sources, gathering and maintaining the data
needed, and completing and reviewing the information. If you have any comments regarding these estimates or any other aspect of this survey, including suggestions for reducing this burden, send
them to the Division of Coal Mine Workers’ Compensation, U. S. Department of Labor, Room N-3464, 200 Constitution Avenue, N.W., Washington, D.C. 20210.
DO NOT SEND THE COMPLETED FORM TO THIS OFFICE
NOTE: Persons are not required to respond to this collection of information unless it displays a currently valid OMB control number.
CM-933 (Rev. 2014)

FEATURES
Technical Quality
Parenchymal
Abnormalities
Small Opacities

For Purpose of Coding for the Department of Labor, the following codes will be used
ILO 2000 INTERNATIONAL CLASSIFICATION OF RADIOGRAPHS OF THE PNEUMOCONIOSES
CODES
DEFINITIONS
1
Good
Acceptable,
with
no
technical
defect
likely
to impair classification of
2
the radiograph for pneumoconiosis.
3
Poor, with some technical defect but still acceptable for classification
purposes.
Unacceptable.
4
The category of profusion is based on the assessment of concentration
0/- 0/0 0/1
of opacities by comparison with the standard radiographs.
Profusion
1/0 1/1 1/2
Category 0 – small opacities absent or less profuse than the lower limit
2/1 2/2 2/3
of Category 1.
3/2 3/3 3/+
Categories 1, 2 and 3 – represent increasing profusion of small opacities as defined by the
corresponding standard radiographs.
Extent
RU RM RL
The zones in which the opacities are seen are recorded. The right (R) and
left (L) thorax are both divided into three zones – upper (U), middle (M)
LU LM LL
and lower (L).
Shape and Size
rounded

irregular
mixed

Large Opacities

The category of profusion is determined by considering the profusion as a whole over the affected
zones of the lung and by comparing this with the standard radiographs.
The letters p, q, and r denote the presence of small rounded opacities.
Three sizes are defined by the appearances on standard radiographs.

p/p q/q r/r

p = diameter up to about 1.5 mm.
q = diameter exceeding about 1.5 mm and up to about 3 mm.
r = diameter exceeding about 3 mm and up to about 10 mm.
The letters s, t and u denote the presence of small irregular opacities.
Three sizes are defined by the appearance on standard radiographs.
s = width up to about 1.5 mm.
t = width exceeding about 1.5 mm and up to about 3 mm.
u = width exceeding 3 mm and up to about 10 mm.

s/s t/t u/u
p/s p/t p/u p/q p/r
q/w q/t q/u q/p q/r
r/s r/t r/u r/p r/q
s/p s/q s/r s/t s/u
t/p t/q t/r t/s t/u
u/p u/q u/r u/s u/t

For mixed shapes (or sizes) of small opacities the predominant shape
And size is recorded first. The presence of a significant number or another shape and size is
recorded after the oblique stroke.
The categories are defined in terms of dimensions of the opacities.

ABC

Category A – an opacity having a greatest diameter exceeding about 10
mm and up to and including 50 mm, or several opacities each greater
than about 10 mm, the sum of whose greatest diameters does not
exceed 50 mm.
Category B – one or more opacities larger or more numerous
than those in category A whose combined area does not exceed the
equivalent of the right upper zone.

Pleural Abnormalities
Pleural Thickening
Chest Wall

Category C – one or more opacities whose combined area does not
exceed the equivalent of the right upper zone.

Type
Site
R
Width

Two types of pleural thickening of the chest wall are recognized:
circumscribed (plaques) and diffuse. Both types may occur together.
Pleural thickening of the chest wall is recorded separately for the
right (R) and left (L) thorax.
For pleural thickening seen along the lateral chest wall the
measurement of maximum width is made from the inner line of the
chest wall to the inner margin of the shadow seen most sharply at the
parenchymal-pleural boundary. The maximum width usually occurs at
the inner margin of the rib shadow at its outermost point.

L

ABC

a = maximum width up to about 5 mm.
b = maximum width over about 5 mm and up to about 10 mm.
c = maximum width over about 10 mm.
Face On

Y

N

Extent

1 2 3

Diaphragm

Presence

Y

N

Costophrenic Angle

Site
Presence

R
Y

L
N

Pleural Calcification

Site

R

L

Site
chest wall
diaphragm
other

R
R
R

L
L
L

extent

1

2

The presence of pleural thickening seen face-on is recorded even if it
can be seen also in profile. If pleural thickening is seen face-on only,
width can not usually be measured.
Extent of pleural thickening is defined in terms of the maximum
length of pleural involvement, or as the sum of maximum lengths,
whether seen in profile or face-on.
1 = total length equivalent up to one quarter of the projection of the
lateral chest wall.
2 = total length exceed one quarter but not one half of the projection
of the lateral chest wall.
3 = total length exceeding one half of the projection of the lateral chest
lateral chest wall
A plaque involving the diaphragmatic pleura is recorded as present (Y)
or absent (N) separately for the right (R) or left (L) thorax.
The presence (Y) or absence (N) costophrenic angle obliteration is
recorded separately from thickening over other areas for the right (R)
and left (L) thorax. The lower limit for the obliteration is defined by a
standard radiograph.
If the thickening extends up the chest wall then both costophrenic
angle obliteration and pleural thickening should be recorded.
The site and extent of pleural calcification are recorded separately for
the two lungs, and the extent defined in terms of dimensions.
“Other” includes calcification of the mediastinal and pericardial pleura.
1 = an area of calcified pleura with greatest diameter up to about 20 mm
or a number of such areas the sum of whose greatest diameters
does not exceed about 20 mm.

3

2 = an area of calcified pleura with greatest diameter exceeding about
20 mm and up to about 100 mm, or a number of such areas the
sum of whose greatest diameters exceed about 20 mm but dies not
exceed about 100 mm.
3 = an area of calcified pleura with greatest diameter exceeding about
100 mm or a number of such area whose sum of greatest diameters
exceeds about 100 mm.

Symbols

aa
at
ax
bu
ca
cg
cn
co
cp
cv
di
ef
em
es
fr

It is to be taken that the definition of such of the Symbols is preceded
by an appropriate word or phrase such as “suspect” , “pneumoconiotic
changes suggestive of“, or “opacities suggestive of “, etc.
hi
ho
id
ih
kl
me
pa
pb
pi
px
ra
rp
tb
od

- atherosclerotic
- significant apical pleural thickening
- coalescence of small pneumoconiotic opacities
- bulla(e)
- cancer of lung or pleura
- calcified non-pneumoconiotic opacities
- calcification in small pneumoconiotic opacities
- abnormality of cardiac size or shape
- cor pulmonale
- cavity
- marked distortion of the intrathoracic organs
- effusion
- definite emphysema
- eggshell calcification of hilar or mediastinal lymph nodes
- fractured rib(s) (acute or healed)

Comments

Presence

Y

N

- enlargement of hilar or mediastinal lymph nodes
- honeycomb lung
- ill-defined diaphragm
- ill-defined heart outline
- septal (kerley) lines
- mesothelioma
- plate atelectasis
- parenchymal bands
- pleural thickening in the interlobar fissure
- pneumothorax
- rounded atelactasis
- rheumatoid pneumoconiosis
- tuberculosis
- other significant abnormality
Comments should be recorded pertaining to the classification of the radiograph particularly if some
other cause is thought to be responsible for a shadow.
CM-933 PAGE 2(Rev. 2014)

Privacy Act Statement
The following statement is made in accordance with the Privacy Act of 1974, as amended (5 U.S.C. 552a). This report is authorized by law (30 USC 922 section 20 CFR
725.513). The information you furnish on this form may be routinely disclosed without your consent to another person or Government agency for purposes such as (1) to
comply with Federal laws requiring the release of information from our records; or (2) to conduct research and audit activities needed to assure the continuing integrity and
improvement of the U.S. Department of Labor representative payee program. Other routine disclosures of this information are listed in the Federal Register, which will be
made available upon request.

Accommodation Statement
If you have a substantially limiting physical or mental impairment, Federal disability nondiscrimination law gives you the right to receive help from OWCP in the form of
communication assistance, accommodation and modification to aid you in the claims process. For example, we will provide you with copies of documents in alternate formats,
communication services such as sign language interpretation, or other kinds of adjustments or changes to account for the limitations of your disability. Please contact our
office or your claims examiner to ask about this assistance.

CM-933 Page 3 (Rev. 2014)