WSR 15-12-087
[Filed June 2, 2015, 8:54 a.m.]
Original Notice.
Preproposal statement of inquiry was filed as WSR 14-16-089.
Title of Rule and Other Identifying Information: Implementation of the Fifth Edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5).
In 2013, The American Psychiatric Association released the Fifth Edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5). The department of labor and industries (L&I) is proposing to amend rules in order to aid in the implementation and consistent use of new DSM versions within Washington state's workers' compensation program.
Amended rules: WAC 296-14-300, 296-20-330, and 296-21-270.
Hearing Location(s): L&I, Tumwater Headquarters Building, S117, 7273 Linderson Way S.W., Tumwater, WA 98501, on July 13, 2015, at 1:00 p.m.
Date of Intended Adoption: September 1, 2015.
Submit Written Comments to: Jami Lifka, P.O. Box 44321, Olympia, WA 98504-4321 or e-mail or fax (360) 902-6315. Written comments must be received no later than 5 p.m., July 13, 2015.
Assistance for Persons with Disabilities: Contact Jami Lifka by July 1, 2015, TTY at 711 for (360) 902-4941 or directly to (360) 902-4941.
Purpose of the Proposal and Its Anticipated Effects, Including Any Changes in Existing Rules: The purpose of this rule making is limited to changes necessary to implement the DSM-5 and will include the following:
Amending existing rules that refer to the DSM-IV or its required classification method (axis system) or its assessment instruments, and
Clarifying how the DSM-5 is implemented within Title 51 RCW.
Reasons Supporting Proposal: Many federal and state health care purchasing agencies will use the DSM-5 for coding diagnoses for mental disorders as referenced in the federal Health Insurance Portability and Accountability Act (HIPAA) requirements. Washington's workers' compensation program is not mandated to follow HIPAA requirements, but does so to be consistent with other payors and the provider community.
Statutory Authority for Adoption: RCW 51.04.020, 51.04.030, and 51.08.142.
Statute Being Implemented: RCW 51.04.020, 51.04.030, and 51.08.142.
Rule is not necessitated by federal law, federal or state court decision.
Agency Comments or Recommendations, if any, as to Statutory Language, Implementation, Enforcement, and Fiscal Matters: The DSM-5 represents industry standards for diagnostic criteria for mental disorders. L&I is governed by Title 51 RCW, Washington's Industrial Insurance Act. The proposed rule changes will clarify how the DSM-5 is implemented within the limitations of that act. No other state or federal agencies are responsible for interpreting and enforcing the provisions of this act.
Name of Proponent: L&I, governmental.
Name of Agency Personnel Responsible for Drafting: Jami Lifka, Office of the Medical Director, (360) 902-4941; Implementation: Leah Hole-Marshall, Medical Administrator, Office of the Medical Director, (360) 902-4996; and Enforcement: Vickie Kennedy, Assistant Director, Insurance Services, (360) 902-4997.
No small business economic impact statement has been prepared under chapter 19.85 RCW. The proposed language does not disproportionately impact small businesses. L&I will not be requiring small businesses to do anything that they will not already be doing. L&I's adoption of the DSM-5 is consistent with industry standards in the health care provider and payer communities for diagnosing mental disorders and the new bill coding standards included in the DSM-5 (ICD-10) that will be implemented nationwide October 1, 2015.
A cost-benefit analysis is not required under RCW 34.05.328. The proposed rule is a procedural and interpretive rule that will allow for the consistent use of an updated reference manual for the diagnosis of mental disorders (DSM-5). As such, no cost-benefit analysis is required. In accordance with RCW 34.05.328 (5)(c)(i) and (ii), this rule making proposes amending language that pertains to ensuring consistent internal operations of an agency and interprets Washington state's Industrial Insurance Act as it relates to the implementation of the DSM-5, the violation of which does not subject a person to a penalty or sanction.
June 2, 2015
Joel Sacks
AMENDATORY SECTION (Amending WSR 88-14-011, filed 6/24/88)
WAC 296-14-300 Mental condition/mental disabilities.
(1) Claims based on mental conditions or mental disabilities caused by stress do not fall within the definition of an occupational disease in RCW 51.08.140.
Examples of mental conditions or mental disabilities caused by stress that do not fall within occupational disease shall include, but are not limited to, those conditions and disabilities resulting from:
(a) Change of employment duties;
(b) Conflicts with a supervisor;
(c) Actual or perceived threat of loss of a job, demotion, or disciplinary action;
(d) Relationships with supervisors, coworkers, or the public;
(e) Specific or general job dissatisfaction;
(f) Work load pressures;
(g) Subjective perceptions of employment conditions or environment;
(h) Loss of job or demotion for whatever reason;
(i) Fear of exposure to chemicals, radiation biohazards, or other perceived hazards;
(j) Objective or subjective stresses of employment;
(k) Personnel decisions;
(l) Actual, perceived, or anticipated financial reversals or difficulties occurring to the businesses of self-employed individuals or corporate officers.
(2)(a) Stress resulting from extreme exposure to a single traumatic event will be adjudicated ((with reference to)) as an industrial injury. See RCW 51.08.100.
(b) Examples of extreme single traumatic events include: Actual or threatened death, actual or threatened physical assault, actual or threatened sexual assault, and life-threatening traumatic injury.
(c) These exposures must occur in one of the following ways:
(i) Directly experiencing the traumatic event; or
(ii) Witnessing, in person, the event as it occurred to others.
(d) Repeated exposure to aversive details of traumatic events, none of which rises to the level of extreme exposure, is not an industrial injury (see RCW 51.08.100) or an occupational disease (see RCW 51.08.140 and 51.08.142).
(3) Claims based on mental conditions or mental disabilities that specify pain primarily as a psychiatric condition (e.g., somatic symptom disorder, with predominant pain), or that are characterized by excessive or abnormal thoughts, feelings, behaviors or neurological symptoms (e.g., conversion disorder, factitious disorder) are not industrial injuries (see RCW 51.08.100) or occupational diseases (see RCW 51.08.140 and 51.08.142).
AMENDATORY SECTION (Amending Order 74-32, filed 6/21/74, effective 10/1/74)
WAC 296-20-330 Impairments of mental health.
(((1))) Rules for evaluation of permanent impairment of mental health:
(((a))) (1) Mental illness means malfunction of the psychic apparatus that significantly interferes with ordinary living.
(((b))) (2) Each person has a pattern of adjustment to life. The pattern of adjustment before the industrial injury or occupational disease serves as a base line for all assessments of whether there has been a permanent impairment due to the industrial injury or occupational disease.
(((c))) (3) To determine the preinjury pattern of adjustment, all evaluations of mental health shall contain a complete preinjury history including, but not necessarily limited to: Family background and the relationships with parents or other nurturing figures; extent of education and reaction to it; military experience, if any; problems with civil authorities; any history of prolonged illness, and difficulty with recovery; any history of drug abuse or alcoholism; employment history, the extent of and reaction to responsibility, and relationships with others at work; capacity to make and retain friends; relationships with spouses and children; nature of daily activities, including recreation and hobbies; and lastly, some summary statement about the sources of the patient's self-esteem and sense of identity. Both strengths and vulnerabilities of the person shall be included.
(((d))) (4) Differences in adjustment patterns before and after the industrial injury or occupational disease shall be described, and the report shall contain the examining physician's opinion as to whether any differences:
(((1))) (a) Are the result of the industrial injury or occupational disease and its sequelae, in the sense they would not have occurred had there not been the industrial injury or occupational disease;
(((2))) (b) Are permanent or temporary;
(((3))) (c) Are more than the normal, self-correcting and expectable response to the stress of the industrial injury or occupational disease;
(((4))) (d) Constitute an impairment psychosocially or physiologically; and
(((5))) (e) Are susceptible to treatment, and, if so, what kind. The presence of any unrelated or coincidental mental impairment shall always be mentioned.
(((e))) (5) All reports of mental health evaluations shall use the diagnostic terminology listed in the edition of the Diagnostic and Statistical Manual of Mental Disorders ((of the American Psychiatric Association)) (DSM) designated by the department.
(((f))) (6) No classification of impairment shall be made for complaints where the quality of daily life does not differ substantially from the preinjury pattern. A patient not currently employed may not engage in the same activities as when working, but the level and variety of his activities and zest for them shall distinguish the purely situational difference from cases of regression and withdrawal. In cases where some loss of use of body member is claimed, no category or impairment shall be assigned unless there are objective findings of physiologic regression or consistent evidence of altered adaptability.
(((g))) (7) The physician shall identify the ((schizoid, antisocial, inadequate, sociopathic, passive, hysterical, paranoid, or dependent personality types)) personality disorders as defined in the edition of the DSM designated by the department. Patients with these longstanding character disorders may show problem behavior that seems more related to current stress than it is, sometimes unconsciously insinuating themselves into difficult situations of which they then complain. Emotional reactions to an injury and subsequent events must be carefully evaluated in these patients. It must be medically probable that such reactions are permanent before a category of impairment can be attributed to the injury; temporary reactions or preexisting psychopathology must be differentiated.
AMENDATORY SECTION (Amending WSR 09-14-104, filed 6/30/09, effective 7/31/09)
WAC 296-21-270 ((Psychiatric)) Mental health services.
(1) The following rule supplements information contained in the fee schedules regarding coverage and reimbursement for ((psychiatric)) mental health services.
(2) Treatment of mental conditions to workers is to be goal directed, time limited, intensive, targeted on specific symptoms and functional status and limited to conditions caused or aggravated by the industrial condition. ((Psychiatric)) Specific functional goals of treatment must be identified and treatment must have an emphasis on functional, measurable improvement towards the specific goals.
(3) Mental health services to workers are limited to those provided by psychiatrists, doctoral level clinical ((PhD)) psychologists (e.g., PhD and PsyD), 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)) mental health services" refers to treatment by psychologists, psychiatric advanced registered nurse practitioners, and psychiatrists.
(4) 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)) is to be sent to the worker's attending provider, as well as to the department or self-insurer. A copy of the sixty-day narrative reports are to be sent to the department or self-insurer and to the attending provider.
(5)(a) 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)) Explanation of the numerical scales is required.
(b) Providers must use the ((current)) edition of the Diagnostic and Statistical Manual of Mental Disorders of the American Psychiatric Association ((axis format)) designated by the department in the initial evaluation, follow-up evaluations and sixty-day narrative reports((, and explanation of the numerical scales are required)).
(c) A report to the department will contain, at least, the following elements:
(i) Subjective complaints;
(ii) Objective observations;
(iii) Identification and measurement of target symptoms and functional status;
(iv) Assessment of the worker's condition and goals accomplished in relation to the target symptoms and functional status; and
(v) Plan of care.
(6) The codes, reimbursement levels, and other policies for ((psychiatric)) mental health services are listed in the fee schedules.
(7) When providing mental health services, providers must track and document the worker's functional status using validated instruments such as the World Health Organization Disability Assessment Schedule (WHODAS) or other substantially equivalent validated instruments recommended by the department. A copy of the completed functional assessment instrument must be sent to the attending provider and the department or self-insurer, as required by department policy or treatment guideline.