Form 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 20 CFR 718.102). The results of this interpretation will aid in determining the claimant’s eligibility for black lung benefits. This method of collecting information complies with the Freedom of Information Act, the Privacy Act of 1974, and OMB Circular No. 108.

OMB No. 1240-0023 Expires 11/30/2026

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 DOL’s Case ID 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. DOL’s Case ID Number

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

1

2

3

U/R

MO

DAY

YR

1D. Is Image Completely Negative? YES □ Proceed to Section 5 NO □ Complete Section 2A

2A. Any Parenchymal Abnormalities Consistent with Pneumoconiosis? YES □ Complete 2B and 2C NO □ Proceed to Section 3

2B. Small Opacities Consistent With Pneumoconiosis

2C. Large Opacities Consistent With Pneumoconiosis

a. SHAPE/SIZE

c. PROFUSION

PRIMARY

SECONDARY

b. ZONES

0/-

0/0

0/1

p

s

p

s

1/0

1/1

1/2

q

t

q

t

2/1

2/2

2/3

SIZE

O

A

B

C

Proceed to Section 3

r

u

r

u

3/2

3/3

3/+

R

L

3A. ANY PLEURAL ABNORMALITIES

CONSISTENT WITH PNEUMOCONIOSIS? YES

Complete Sections

NO

Proceed to

3B, 3C

Section 4A

3B. PLEURAL PLAQUES (mark site, calcification, extent and width)

Extent (chest wall; combined for

Width (in profile only)

in profile and face on)

(3mm minimum width required)

Chest Wall

Site

Calcification

Up to 1/4 of lateral chest wall = 1

3 to 5 mm = a

In Profile

O

R

L

O

R

L

1/4 to 1/2 of lateral chest wall = 2

5 to 10 mm = b

Face On

O

R

L

O

R

L

> 1/2 of lateral chest wall = 3

> 10 mm = c

Diaphragm

O

R

L

O

R

L

O

R

O

L

O

R

O

L

Other site(s)

O

R

L

O

R

L

1

2

3

1

2

3

a

b

c

a

b

c

3C. COSTOPHRENIC ANGLE OBLITERATION

R

L

Proceed to Section 3D

NO

Proceed to Section 4A

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

Extent (chest wall, combined for

Width (in profile only)

in profile and face on)

(3mm minimum width required)

Up to 1/4 of lateral chest wall = 1

3 to 5 mm = a

1/4 to 1/2 of lateral chest wall = 2

5 to 10 mm = b

Chest wall

Site

Calcification

> 1/2 of lateral chest wall = 3

> 10 mm = c

In Profile

O

R

L

O

R

L

O

R

O

L

O

R

O

L

Face On

O

R

L

O

R

L

1

2

3

1

2

3

a

b

c

a

b

c

4A. ANY OTHER ABNORMALITIES?

YES

Complete

NO

Proceed to

4B and 4C

Section 5

4B. OTHER SYMBOLS (OBLIGATORY)

aa

at

ax

bu

ca

cg

cn

co

cp

cv

di

ef

em

es

fr

hi

ho

id

ih

kl

me

pa

pb

pi

px

ra

rp

tb

REPORT ITEMS WHICH

MAY BE OF PRESENT

OD

(Specify od.)

Date Personal Physician notified?

M

M

D

D

Y

Y

CLINICAL SIGNIFICANCE

IN THIS SECTION

4C

OTHER COMMENTS

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

YES

NO

Proceed to Section 5

5A.

FACILITY PROVIDING RADIOLOGIC EXAMINATION:

DOL Medical Provider Number (if applicable):

Was image taken by a registered radiographer/radiographic technologist?

□ Yes □ No

State

Name

Registration No.

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 statement or representation in support of an application for benefits shall be guilty of a misdemeanor under 30 USC 941 and, on conviction, 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.)

CM-933 (Rev. April 2020)

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 information collection, including suggestions for reducing this burden, send them to the Division of Coal Mine Workers’ Compensation, U. S. Department of Labor, 200 Constitution Avenue, N.W., Suite C3520-DCMWC Washington, D.C. 20210. DO NOT SEND THE COMPLETED FORM TO THIS OFFICE.

PRIVACY ACT NOTICE

In accordance with the Privacy Act of 1974, as amended (5 U.S.C. 552a), you are hereby notified that: (1) the Black Lung Benefits Act (BLBA) (30 U.S.C. 901

et seq.), as amended, is administered by the Office of Workers' Compensation Programs (OWCP) of the U.S. Department of Labor, which receives and

maintains personal information, relative to this application, on claimants and their immediate families; (2) information obtained by OWCP will be used to

determine eligibility for benefits payable under the BLBA; (3) information may be given to other government agencies, coal mine operators potentially liable for

payment of the claim or to the insurance carrier or other entity which secured the operator's compensation liability, contractors providing automated data

processing services to the Department of Labor; and representatives of the parties to the claim; (4) information may be given to physicians or other medical

service providers for use in providing treatment, making evaluations and for other purposes relating to the medical management of the claim; (5) information

may be given to the Department of Labor's Office of Administrative Law Judges, or other person, board or organization, which is authorized or required to

render decisions with respect to the claim or other matters arising in connection with the claim; (6) information may be given to Federal, state or local agencies

for law enforcement purposes, to obtain information relevant to a decision under the BLBA, to determine whether benefits are being or have been paid properly,

and where appropriate, to pursue administrative offset and/or debt collection actions required or permitted by law; (7) disclosure of the claimant's or deceased

miner's Social Security Number (SSN) or tax identifying number (TIN) on this form is voluntary, and the SSN and/or TIN and other information maintained by

the OWCP may be used for identification and for other purposes authorized by law; (8) failure to disclose all requested information, may delay the processing of this claim or the payment of benefits, or may result in an unfavorable decision or reduced level of benefits; and (9) this information is included in a System of

Records, DOL/OWCP-2 published at 81 Federal Register 25765, 25858 (April 29, 2016) or as updated and republished.

NOTICE

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 the claims examiner to ask about this assistance.

NOTE: Persons are not required to respond to this collection of information unless it displays a currently valid OMB control number

TWO FILING OPTIONS:

1. To file electronically, submit completed form to the COAL Mine Portal:

https://coalmine.dol.gov

2. To file by mail, send completed form to:

US Department of Labor

OWCP/DCMWC

PO Box 8307

London, KY 40742-8307

For Further Information call TOLL FREE: 1-800-347-2502

CM-933 (Rev. April of 2020)

2

For Purpose of Coding for the Department of Labor, the following codes will be used

ILO 2011 INTERNATIONAL CLASSIFICATION OF RADIOGRAPHS OF THE PNEUMOCONIOSES

FEATURES				CODES		DEFINITIONS
Technical Quality				1			Good Acceptable, with no technical defect likely to impair classification of the radiograph for pneumoconiosis. Acceptable, with some technical defect but still acceptable for classification purposes. Unacceptable. The category of profusion is based on the assessment of concentration of opacities by comparison with the standard radiographs. Category 0 – small opacities absent or less profuse than the lower limit of Category 1. Categories 1, 2 and 3 – represent increasing profusion of small opacities as defined by the corresponding standard radiographs. 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) and lower (L). 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 = 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. 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.
				2
Parenchymal				3
Abnormalities Small Opacities				U/R
			Profusion	0/- 0/0 0/1 1/0 1/1 1/2 2/1 2/2 2/3 3/2 3/3 3/+
			Zones	RU RM RL LU LM LL
			Shape and Size
			rounded	p/p q/q r/r
			irregular mixed	s/s t/t u/u p/s p/t p/u p/q p/r q/s 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
Large Opacities Pleural Abnormalities Pleural Thickening Chest Wall			Type Site	A B C			The categories are defined in terms of dimensions of the opacities. 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. Category C – one or more opacities whose combined area exceed the equivalent of the right upper zone. Two types of pleural thickening of the chest wall are recognized: circumscribed (plaques) and diffuse. Both types may occur together.
				R L			Pleural thickening of the chest wall is recorded separately for the right (R) and left (L) thorax.
			Width	A B C			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. 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			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 cannot usually be measured.
			Extent	1 2 3			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
Diaphragm Costophrenic Angle Pleural Calcification Symbols			Presence Site Presence Site Site chest wall diaphragm other extent	Y N R L Y N R L R L R L R L 1 2 3			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 showing profusion subcategory 1/1 t/t. 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. 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. 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.
aa	- atherosclerotic				hi		- enlargement of non-calcified hilar or mediastinal lymph nodes
at	- significant apical pleural thickening				ho		- honeycomb lung
ax	- coalescence of small pneumoconiotic opacities				id		- ill-defined diaphragm border
bu	- bulla(e)				ih		- ill-defined heart border
ca	- cancer thoracic malignancies excluding mesothelioma				kl		- septal (Kerley) lines
cg	- calcified non-pneumoconiotic nodules (e.g. granuloma) or nodes				me		- mesothelioma
cn	- calcification in small pneumoconiotic opacities				pa		- plate atelectasis
co	- abnormality of cardiac size or shape				pb		- parenchymal bands
cp	- cor pulmonale				pi		- pleural thickening of an interlobar fissure
cv	- cavity				px		- pneumothorax
di	- marked distortion of an intrathoracic structure				ra		- rounded atelectasis
ef	- pleural effusion				rp		- rheumatoid pneumoconiosis
em	- emphysema				tb		- tuberculosis
es	- eggshell calcification of hilar or mediastinal lymph nodes				od		- other disease or significant abnormality
fr	- fractured rib(s) (acute or healed)
Comments			Presence	Y N			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 (Rev. August 2020)

3