Authorization Requirements
Initial psychiatric evaluation and ongoing treatment of a psychiatric condition both require prior approval from the department or self-insured employer (WAC 296-21-270). Authorization for psychiatric treatment may be granted for periods of 90 days or less. Subsequent authorization periods of 90 days or less are contingent on documented progress in psychiatric treatment.
Claim managers may authorize payment for treatment of psychiatric conditions that are retarding recovery from an industrial injury, even though the injury did not cause the psychiatric condition or aggravate a preexisting psychiatric condition. Claim managers can also authorize payment for treatment of psychiatric conditions when they have been caused or aggravated by an industrial injury.
If authorization for psychiatric treatment is requested following an initial psychiatric evaluation, it is the claim manager's responsibility to make a determination as to the relationship between the industrial injury and the psychiatric condition based on the information provided. For this reason, it is very important for the psychiatrist or psychologist to clearly indicate their opinion, and the basis for their opinion, whether:
- The injured worker's psychiatric condition was not caused or aggravated by the industrial injury, but it creates a barrier to recovery from a condition for which the department has accepted liability.
- The injured worker's psychiatric condition was caused by the industrial injury.
- The injured worker's psychiatric condition is a preexisting condition that was aggravated by the industrial injury.
- The injured worker's psychiatric condition was neither caused nor aggravated by the industrial injury, nor is it creating a barrier to recovery from a condition for which the department has accepted liability.
Elements of a Comprehensive Psychiatric Plan
Elements of a comprehensive psychiatric treatment plan would include formulation of a psychiatric diagnosis; identification of barriers to recovery; development of an intensive, goal-directed plan; and recommendation for duration of therapy.
Diagnosis of a Psychiatric Condition
Diagnosis is an essential first step to the development of a plan for treatment of psychiatric conditions. Diagnoses should be specific, and should use the nomenclature and numerical identification of the Diagnostic and Statistical Manual of Mental Disorders, 4th edition (DSM-IV) (or current edition). The diagnostic section of the initial report, and all subsequent reports, should address all five axes described in the DSM-IV (or current edition). Diagnoses should be based on all relevant historical information. Specific inquiry should be made into the patients’ preinjury and current medical, psychosocial, and psychological status. Whenever possible, prior medical records should be reviewed to screen for the presence of diagnostically important information and for information that may be useful in the creation of a treatment plan. Carefully document any pertinent positive or negative historical information.
Consideration should be given to the use of standardized measuring tools, such as the Rollins® or Beck® scales, and the use of individualized visual analog scales. Such measurements provide both support for diagnoses and benchmarks against which progress in treatment can be measured.
Identification of Barriers to Recovery from an Industrial Injury
Each diagnosed psychiatric condition should be assessed to determine whether it is retarding a patient's recovery from an industrial injury. Any such barriers should be clearly identified and the report should provide an explanation that links the psychiatric condition to an observable, measurable behavior that interferes with recovery from an industrial injury. (Refer to the original guideline document for an example.)
Specific inquiry should be made to determine whether there are employment-related risk factors that should be addressed in a health care setting. For example, anger towards the employer, supervisor, or coworkers may need to be addressed. Economic disincentives and employment-related loss of self-esteem can each contribute to the failure of a worker to make expected progress in recovery. Feelings of victimization may delay a return to a normal lifestyle. Such risk factors should be carefully identified and documented.
Formulation of a Psychiatric Treatment Plan
The psychiatrist or psychologist evaluating a worker with a psychiatric condition should create a treatment plan that addresses each diagnosed psychiatric condition and any identified barriers to recovery. The treatment plan must include intensive, goal-directed treatment and include a recommended duration of treatment. The treatment plan should be included in the evaluation report and updated throughout treatment.
Objectively determinable measurements of recovery should be identified for each condition for which treatment is proposed. Objective measurements should be individualized so that each patient's progress or lack of progress will be accurately assessed. Examples of such measurements include documentation of the level of physical activity; improved participation in physical therapy, occupational therapy, work hardening, or vocational counseling programs; normalization of common behavior patterns such as sleep cycles and eating disorders; and changes in medication usage. To the extent that a treatment plan may recommend medications, the plan should include a discussion of any predictable drug interactions the recommended medications might have with medications the worker is currently taking. (Refer to the original guideline document for an example of a treatment plan.)
Identification of the measured variable should include a description of what will be measured, the intervals and duration during which the variable will be measured, the anticipated endpoint, and the anticipated progress to that endpoint at each interval measurement. When appropriate, use standardized measurements such as the Rollins® or Beck® scales to document the extent of recovery. Each variable to be measured should be explained to the injured worker before treatment is actually commenced. If necessary, the patient should be instructed in how to complete diaries that document such variables as pain, activity, medication use, etc.
In the event that the psychiatric treatment plan includes measurements of indicators that are outside the practice of the psychiatrist or psychologist, prior arrangements to obtain such measurements should be made by the psychiatrist or psychologist with the attending doctor. Such measurements should be available to the psychiatrist or psychologist at the time each respective progress note is created. (Refer to the original guideline document for an example of measurements arranged by the psychiatrist or psychologist and the attending doctor.)
Assessment of Psychiatric Treatment and Recommendations
A progress note should be prepared following each clinic visit. Per WAC 296-20-06101, legible copies of progress notes must be submitted to the department for all treatment. The progress note should document the patient's interval history and should summarize any pertinent positive or negative findings. Indicators that are measured to assess progress should be documented along with measurements obtained during the interval period. An assessment should be made as to whether the measurements reflect the expected progress.
A visual analog scale can be a useful tool in assessing a patient’s perception. Generally, such scales consist of a 10-cm horizontal line with words at opposite ends of the spectrum. Studies have shown that visual analog scales are most accurately representative of that which they seek to measure when the horizontal line contains no arbitrary divisions such as numbers, interval marks, etc. The patient is instructed to place a vertical mark at the point on the line that seems most appropriate to the patient.
Should expected progress not be made, the report of the psychiatrist or psychologist should contain a discussion concerning the postulated reasons for lack of progress. If necessary, the treatment plan should be reassessed, and any necessary modifications made. (Refer to the original guideline document for an example of a progress note.)
What are the Reporting Requirements?
All reports should be written in a legible style that can be understood by nonmedical personnel. Each report must contain at least a summary of subjective complaints, objective observations, assessment of progress toward meeting goals, updated treatment plan, and DSM-IV (or current edition) axis format assessment (WAC 296-21-270). The use of specific examples of a patient's behavior may be a helpful way to communicate the effects of a psychological condition, or the effects of treatment for such a condition.
Doctors treating psychiatric conditions allowed on a claim are required to submit progress reports to the claim manager every sixty days (WAC 296-21-270). If temporary treatment has been authorized for an unrelated psychiatric condition, progress reports are required to be submitted to the claim manager every thirty days (WAC 296-20-055). (Refer to the original guideline document for information on billing codes.)
