Incapacity Determination - Assignment of Severity Ratings
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Incapacity Determination - Assignment of Severity Ratings


Revised December 30, 2013


How severity ratings are assigned for HEN Referral incapacity determinations


WAC 388-447-0020How does the department assign severity ratings to my impairments?
WAC 388-447-0040Progressive Evaluation Process Step II - How does the department determine the severity of mental impairments?
WAC 388-447-0050Progressive evaluation process step III — How does the department determine the severity of physical impairments?

<p>WAC 388-447-0020

WAC 388-447-0020

Effective January 1, 2014

WAC 388-447-0020 How does the department assign severity ratings to my impairments?

(1) "Severity rating" is a rating of the extent of your impairment and how it impacts your ability to perform the basic work activities detailed in WAC 388-447-0001. Severity ratings are as-signed in Steps II through IV of the progressive evaluation process (PEP). The following chart provides a description of levels of limitations on work activities and the severity ratings that would be assigned to each.

   Effect on Work Activities Degree of Impairment Numeric Value
 (a)  There is no effect on your performance of one or more basic work-related activites.  None  1
 (b)  There is no significant limit on your performance of one or more basic work-related activities.  Mild  2
 (c) There are significant limits on your performance of one or more basic work-related activity.  Moderate  3
 (d)  There are very significant limits on your performance of one or more basic work-related activities.  Marked  4
 (e)  You are unable to perform at least one basic work-related activity.  Severe  5

(2) We use the description of how your condition impairs your ability to perform work activities given by the medical evidence provider to establish severity ratings when the impairments are supported by, and consistent with, the objective medical evidence.

(3) A contracted doctor reviews your medical evidence and the ratings assigned to your impairment when:

(a) The medical evidence indicates functional limitations con-sistent with at least a moderate physical or mental impairment; and

(b) Your impairment has lasted, or is expected to last, nine months or more with available treatment.

(4) The contracted doctor reviews the medical evidence, severity ratings, and functional assessment to determine whether:

(a) The medical evidence is objective and sufficient to support the findings of the medical evidence provider;

(b) The description of impairments is supported by the medical evidence; and

(c) The severity rating, duration, and assessment of functional limitations assigned by DSHS are consistent with the medical evidence.

(5) If the medical evidence provider's description of your im-pairments is not consistent with the objective medical evidence, we will:

(a) Assign a severity rating, duration, and functional limita-tions consistent with the objective medical evidence;

(b) Clearly describe why we rejected the medical provider's opinion; and

(c) Identify the medical evidence used to make the determination.

 

This is a reprint of the official rule as published by the Office of the Code Reviser. If there are previous versions of this rule, they can be found using the Legislative Search page.

<p>WAC 388-447-0040

WAC 388-447-0040

Effective January 1, 2014

WAC 388-447-0040 Progressive Evaluation Process Step II - How does the department determine the severity of mental impairments?

If you are diagnosed with a mental impairment by a professional described in WAC 388-447-0005, we use information from the medical evidence provider to determine how the impairment limits work-related activities.

(1) We review the following psychological evidence to determine the severity of your mental impairment:

(a) Psychosocial and treatment history records;

(b) Clinical findings of specific abnormalities of behavior, mood, thought, orientation, or perception;

(c) Results of psychological tests; and

(d) Symptoms observed by the examining professional that show how your impairment affects your ability to perform basic work-related activities.

(2) We do not consider diagnoses or symptoms of alcohol or sub-stance use or dependency when the only impairment supported by objective medical evidence is drug or alcohol addiction.

(3) If you are diagnosed with an intellectual disability, the diagnosis must be based on the Wechsler adult intelligence scale (WAIS). The following test results determine the severity rating:

 Intelligence Quotient (IQ) Score

 Severity Rating

 85 or above

 1

 71 to 84

 3

 70 or lower

 5

 


(4) If you are diagnosed with a mental impairment with physical causes, we assign a severity rating based on the most severe of the following four areas of impairment:

(a) Short term memory impairment;

(b) Perceptual or thinking disturbances;

(c) Disorientation to time and place; or

(d) Labile, shallow, or coarse affect.

(5) We base the severity of an impairment diagnosed as a mood, anxiety, thought, memory, personality, or cognitive disorder on a clinical assessment of the intensity and frequency of symptoms that:

(a) Affect your ability to perform basic work-related activities; and

(b) Are consistent with a diagnosis of a mental impairment as listed in the most recent version of the Diagnostic and Statistical Manual of Mental Disorders(DSM).

(6) We base the severity rating for a functional mental impair-ment on accumulated severity ratings for the symptoms in subsection (5) of this section as follows:

 Condition

Severity Rating

(a) The clinical findings and objective evidence are consistent with a significant limitation on performing one or more basic work activities.

(b) You are diagnosed with a functional disorder with psychotic features; 

(c) You have had two or more hospitalizations for psychiatric reasons in the past two years;   

(d) You have had more than six months of continuous psychiatric inpatient or residential treatment in the past two years;   

(e) The clinical findings and objective evidence are consistent with very significant limitations on ability to perform one or more basic work activities.   

 Moderate (3)

(f) The clinical findings and objective evidence are consistent with an inability to perform one or more basic work activities.

 Severe (5)


(7) If you are diagnosed with any combination of mental retardation, mental impairment with physical causes, or functional mental impairment, we assign a severity rating as follows:

 Condition

 Severity Rating

(a) Two or more disorders with moderate severity (3) ratings; or 

(b) One or more disorders rated moderate severity (3), and one rated marked. 

    Marked (4)

(c) Two or more disorders rated marked severity (4).

Severe (5)

(8) We deny incapacity when you haven't been diagnosed with a significant physical impairment and the overall severity of your mental impairment is one or two;

(9) We approve incapacity when your overall mental severity rating is severe (5).

This is a reprint of the official rule as published by the Office of the Code Reviser. If there are previous versions of this rule, they can be found using the Legislative Search page.

<p>WAC 388-447-0050

WAC 388-447-0050

Effective January 1, 2014

WAC 388-447-0050 Progressive evaluation process step III — How does the department determine the severity of physical impairments?

"Severity of a physical impairment" means the degree that an impairment restricts you from performing the basic work-related activities in WAC 388-447-0001. Severity ratings range from one to five, with five being the most severe. We assign severity ratings based on the table in WAC 388-447-0020.

  1. We assign to each physical impairment a severity rating that is supported by medical evidence.
  2. If your physical impairment is rated two, and there is no mental impairment or a mental impairment that is rated one, we deny incapacity.
  3. If your physical impairment is rated five, we approve inca-pacity.

This is a reprint of the official rule as published by the Office of the Code Reviser. If there are previous versions of this rule, they can be found using the Legislative Search page.

CLARIFYING INFORMATION

1.  When the provider does not give a severity rating:

a.  Review the medical evidence. Use reference sources, facts present in the medical evidence, and your professional judgment to assign a severity rating that is consistent with the objective medical evidence and severity definitions in WAC 388-447-0020 and 388-447-0040; and/or

b.  Refer the case to a Medical Consultant  for assistance with interpreting the medical information.

3.  When the severity rating given by the provider is supported by the objective findings, accept the rating.

4.  You may adjust the provider's ratings if you have clear and convincing reasons why the rating should be adjusted (e.g. rating is not consistent with the objective medical evidence). If the adjusted rating results in the person having only one impairment with a severity rating less than three, deny incapacity at Step 1 (see WAC 388-447-0030).

 

Modification Date: December 30, 2013