Incapacity Determination

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Incapacity Determination - PEP Step II

Revised November 4, 2011

PEP Step II - Determining the severity of mental impairments

WAC 182-508-0050

PEP Step II--Determining the severity of mental impairments. (Emergency rule effective 11/1/11.)

WAC 182-508-0050

Effective November 1, 2011

WAC 182-508-0050 PEP Step II--Determining the severity of mental impairments. (Emergency rule effective 2/29/12.)

If the individual is diagnosed with a mental impairment by a professional described in WAC 388-508-0020, the agency or the agency's designee uses information from the provider to determine how the impairment limits work-related activities.

(1) The agency or the agency's designee reviews the following psychological evidence to determine the severity of the individual's 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 practitioner that show how the individual's impairment affects their ability to perform basic work-related activities.

(2) The agency or the agency's designee excludes diagnosis and related symptoms of alcohol or substance abuse or addiction when the only impairment supported by objective medical evidence is drug or alcohol addiction..

(3) If the individual is diagnosed with mental retardation, 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 the individual is diagnosed with a mental impairment with physical causes, the agency or the agency's designee assigns 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) The agency or the agency's designee bases the severity of an impairment diagnosed as a mood, thought, memory, or cognitive disorder on a clinical assessment of the intensity and frequency of symptoms that:

(a) Affect the individual's 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) The agency or the agency's designee bases the severity rating for a functional mental impairment on accumulated severity ratings for the symptoms in subsection (5)(a) of this section as follows:

Symptom Ratings or Condition	Severity Rating
(a) The individual is diagnosed with a functional disorder with psychotic features; (b) The individual has had two or more hospitalizations for psychiatric reasons in the past two years; (c) The individual has had more than six months of continuous psychiatric inpatient or residential treatment in the past two years; (d) The objective evidence and global assessment of functioning score are consistent with a significant limitation on performing work activities.	Moderate (3)
(e) The objective evidence and global assessment of functioning score are consistent with very significant limitations on ability to perform work activities.	Marked (4)
(f) The objective evidence and global assessment of functioning score are consistent with the absence of ability to perform work activities.	Severe (5)

(7) If the individual is diagnosed with any combination of mental retardation, mental impairment with physical causes, or functional mental impairment, the agency or the agency's designee assigns 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 severity (4).

Marked (4)

Severe (5)

(8) The agency or the agency's designee denies incapacity when the individual hasn't been diagnosed with a significant physical impairment and the individual's overall mental severity rating is one or two;

(9) The agency or the agency's designee approves incapacity when the individual has an overall mental severity rating of 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.

NOTE:

The DSHS 13-865 Psychological/Psychiatric Evaluation form, DOC 13-450 Behavioral Health Discharge Summary, or typed narrative evaluation may be used to assess mental health impairments.

CLARIFYING INFORMATION

The Short Clinical Scale is no longer used in the mental health community and has been removed from the psychological evaluation form. Any symptom that affects work function and is listed in the DSM IV may be listed by the mental health provider.
Only consider symptoms that have an impact on work function when determining incapacity.
See the learning disabilities and deficits chapter when a learning disorder is diagnosed. Most learning disorders, including ADHD, aren't incapacitating.
Don’t consider diagnosis and symptoms of alcohol or substance abuse, or dependence, when determining incapacity through the PEP.
Alcohol and substance use information is requested in order to differentiate between substance use and mental health symptoms, and to provide information for the development of a case plan.
A symptom that was not observed by the evaluator may be considered when determining incapacity accepted if consistent with others symptoms of a diagnosis the evaluator observed.
The Global Assessment of Functioning (GAF) is commonly used in the mental health community to provide an overall assessment of how well a person is functioning. Factors such housing and employment may be used by a mental health provider when assigning a GAF.

NOTE:

A low GAF score based primarily on homelessness or lack of employment must be adjusted to be consistent with the person’s mental health symptoms and the objective evidence contained in the psychological evaluation. Give clear and convincing reasons when changing any rating given by a health professional.

AXIS I	Clinical disorders, including major mental disorders, as well as developmental and learning disorders. Common Axis I disorders include depression, anxiety disorders, bipolar disorder, Autism, phobias, and schizophrenia.
AXIS II	Underlying pervasive or personality conditions, as well as mental retardation. Common Axis II disorders include personality disorders and mental retardation.
AXIS III	Acute medical conditions and physical disorders. Common Axis III disorders include brain injuries and other medical/physical disorders, which may aggravate existing diseases or present symptoms similar to other disorders.
AXIS IV	Psychosocial and environmental factors contributing to the disorder. Factors such as homelessness and employment status are reflected in Axis IV.
AXIS V	Global Assessment of Functioning. Used by mental health professionals and physicians to subjectively rate the social, occupational and psychological functioning of adults. See chart below.

8. The following chart lists the GAF score ranges with descriptions of functioning and the associated severity rating.

Severity Rating	GAF	Description of functioning.
1	81-100	Absent to minimal symptoms with good to superior functioning in all areas.
2	61-80	Some mild or transient symptoms that are expectable reactions to psychological stress.
3	51-60	Moderate symptoms or any moderate difficulty in social, occupational, or school functioning.
4	31-50	Serious symptoms or impairment in social functioning. May have some impairment in reality testing or communication.
5	1-30	Behavior is influenced by delusions or hallucinations, inability to function in all areas.

WORKER RESPONSIBILITIES

On the DSHS 13-865, Psychological/Psychiatric Evaluation form, DOC 13-450, or narrative psychological evaluation:

When a mental impairment with physical causes is identified as deteriorating, add one adjustment point to the severity rating.
For a functional mental disorder, use the Global Assessment of Functioning (GAF) as the severity rating If the GAF is consistent with the objective narrative information in the psychological evaluation.

NOTE:

Read the entire psychological evaluation before starting the PEP. The report must be internally consistent and severity ratings must be supported by narrative sections describing how the person is functioning.

EXAMPLE

Tom has a GAF rating of 51-60 (moderate), which is a "3" severity rating. However the psychologist has described Tom as having "marked" severity on two psychological symptoms and "severe" on another symptom. Tom is described as isolating himself and needs help with ADLS. Since the report as a whole supports a marked severity, assign marked, or “4” as the severity and document the symptoms and ADL problems listed by the provider.