WSR 09-08-104




[ Filed March 31, 2009, 10:02 a.m. ]

Original Notice.

Preproposal statement of inquiry was filed as WSR 08-16-035.

Title of Rule and Other Identifying Information: Psychiatric ARNPs as providers of psychiatric services; WAC 296-20-071 Concurrent care, 296-21-270 Psychiatric services, and 296-23-241 Can advanced registered nurse practitioners independently perform the functions of an attending provider?

Hearing Location(s): Department of Labor and Industries, 7273 Linderson Way S.W., Room S117, Tumwater, WA 98501, on May 15, 2009, at 9:00 a.m.

Date of Intended Adoption: June 16, 2009.

Submit Written Comments to: Jami Lifka, Office of the Medical Director, P.O. Box 44321, Olympia, WA 98504-4321, e-mail, fax (360) 902-6315, by May 22, 2009.

Assistance for Persons with Disabilities: Contact office of information and assistance by May 1, 2009, TTY (360) 902-5797 or (360) 902-4941.

Purpose of the Proposal and Its Anticipated Effects, Including Any Changes in Existing Rules: This rule is being proposed in response to a petition for a rule change. The proposal is to allow psychiatric advanced registered nurse practitioners (ARNPs) to provide psychiatric services to injured workers. Currently only psychiatrists and psychologists can provide psychiatric services. The proposed amendments also clarify that concurrent care providers, like psychiatrists and psychiatric ARNPs, can prescribe medication while providing concurrent care. The effect of such a change is that workers will have better access to care for psychiatric services.

Reasons Supporting Proposal: See Purpose above.

Statutory Authority for Adoption: RCW 51.04.020 and 51.04.030.

Statute Being Implemented: RCW 51.04.020 and 51.04.030.

Rule is not necessitated by federal law, federal or state court decision.

Name of Proponent: Carla Weston, petitioner, private.

Name of Agency Personnel Responsible for Drafting: Jami Lifka, 7273 Linderson Way S.W., Tumwater, WA, (360) 902-4941; Implementation: Gary Franklin, MD, MPh, Office of the Medical Director, (360) 902-5020; and Enforcement: Bob Malooly, Assistant Director of Insurance Services, (360) 902-4209.

No small business economic impact statement has been prepared under chapter 19.85 RCW. The proposed changes to WAC 296-20-071, 296-21-270, and 296-23-241 will not impose any costs on businesses, therefore no small business economic impact statement is required.

A cost-benefit analysis is not required under RCW 34.05.328. The proposed changes to WAC 296-20-071, 296-21-270, and 296-23-241 will not impose any costs on businesses; therefore, no cost-benefit analysis is required.

March 31, 2009

Judy Schurke



AMENDATORY SECTION(Amending Order 86-19, filed 2/28/86, effective 4/1/86)

WAC 296-20-071   Concurrent treatment.   In some cases, treatment by more than one practitioner may be allowed. The department or self-insurer will consider concurrent treatment when the accepted conditions resulting from the injury involve more than one system and/or require specialty or multidisciplinary care.

When requesting consideration for concurrent treatment, the attending doctor must provide the department or self-insurer with the following:

The name, address, discipline, and specialty of all other practitioners assisting in the treatment of the injured worker and an outline of their responsibility in the case and an estimate of the length of the period of concurrent care.

When concurrent treatment is allowed, the department or self-insurer will recognize one primary attending ((doctor)) provider, who will be responsible for ((prescribing all medications;)) directing the over-all treatment program((;)), including monitoring or prescribing medications when appropriate, providing copies of all reports and other data received from the involved practitioners and, in time loss cases, providing adequate certification evidence of the worker's inability to work. The concurrent care provider shall provide copies of all required reports to the attending provider as well as to the department or self-insurer.

The department or self-insurer will approve concurrent care on a case-by-case basis. Consideration will be given to all factors in the case including availability of providers in the worker's geographic location.

[Statutory Authority: RCW 51.04.020(4) and 51.04.030. 86-06-032 (Order 86-19), 296-20-071, filed 2/28/86, effective 4/1/86. Statutory Authority: RCW 51.04.020(4), 51.04.030, and 51.16.120(3). 81-01-100 (Order 80-29), 296-20-071, filed 12/23/80, effective 3/1/81; Order 75-39, 296-20-071, filed 11/28/75, effective 1/1/76; Order 70-12, 296-20-071, filed 12/1/70, effective 1/1/71. Formerly WAC 296-20-060.]


AMENDATORY SECTION(Amending WSR 93-16-072, filed 8/1/93, effective 9/1/93)

WAC 296-21-270   Psychiatric services.   The following rule((s)) supplements information contained in the fee schedules regarding coverage and reimbursement for psychiatric services.

Treatment of mental conditions to workers is to be goal directed, time limited, intensive, and limited to conditions caused or aggravated by the industrial condition. Psychiatric services to workers are limited to those provided by psychiatrists ((and licensed)), psychologists, and psychiatric advanced registered nurse practitioners and according to department policy. Psychiatrists and psychiatric advanced registered nurse practitioners may prescribe medications while providing concurrent care. For purposes of this rule, the term "psychiatric" refers to treatment by psychologists ((as well as)), psychiatric advanced registered nurse practitioners, and psychiatrists.

Initial evaluation, and subsequent treatment must be authorized by department staff, as outlined by department policy. The report of initial evaluation, including test results, and treatment plan are to be sent to the worker's attending provider, as well as to the department or self-insurer. A copy of sixty-day narrative reports are to be sent to the department ((is also to be sent)) or self-insurer and to the attending provider.

All providers are bound by the medical aid rules in chapter 296-20 WAC. Reporting requirements are defined in chapter 296-20 WAC. In addition, the following are required: Testing results with scores, scales, and profiles; report of raw data sufficient to allow reassessment by a panel or independent medical examiner. Use of the current Diagnostic and Statistical Manual of the American Psychiatric Association axis format in the initial evaluation and sixty-day narrative reports, and explanation of the numerical scales are required.

A report to the department will contain, at least, the following elements:

Subjective complaints;

Objective observations;

Assessment of the worker's condition and goals accomplished; and

Plan of care.

The codes, reimbursement levels, and other policies for psychiatric services are listed in the fee schedules.

[Statutory Authority: RCW 51.04.020, 51.04.030 and 1993 c 159. 93-16-072, 296-21-270, filed 8/1/93, effective 9/1/93.]


AMENDATORY SECTION(Amending WSR 08-04-094, filed 2/5/08, effective 2/22/08)

WAC 296-23-241   Can advanced registered nurse practitioners independently perform the functions of an attending provider?   (1) Advanced registered nurse practitioners (ARNPs) may independently perform the functions of an attending provider under the Industrial Insurance Act, with the exception of rating permanent impairment. These functions are referenced in the medical aid rules as those of an attending or treating provider, and include, but are not limited to:

Completing and signing the report of accident or provider's initial report, where applicable;

Certifying time-loss compensation;

Completing and submitting all required or requested reports;

Referring workers for consultations;

Performing consultations;

Facilitating early return to work offered by and performed for the employer(s) of record;

Doing all that is possible to expedite the vocational process, including making an estimate of the worker's physical or mental capacities that affect the worker's employability.

(2) Psychiatric advanced registered nurse practitioners can provide psychiatric services as defined in WAC 296-21-270.

(3) ARNPs can state whether a worker has permanent impairment, such as on the department's activity prescription form (APF). ARNPs cannot rate permanent impairment or perform independent medical examinations (IMEs).

(((2) Advanced registered nurse practitioners cannot:

Rate permanent impairment; or

Perform independent medical examinations (IMEs).))

[Statutory Authority: 2007 c 275, RCW 51.04.020 and 51.04.030. 08-04-094, 296-23-241, filed 2/5/08, effective 2/22/08. Statutory Authority: 2004 c 65 and 2004 c 163. 04-22-085, 296-23-241, filed 11/2/04, effective 12/15/04.]

Washington State Code Reviser's Office