Incapacity Determination - Required medical evidence

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Revised November 28, 2011

Purpose: This chapter describes when to request vendor services and how to make payments to vendors for incapacity determinations and expedited Medicaid evaluation services.

WAC 182-508-0030

Required medical evidence. (Emergency rule effective 11/1/2011.)

WAC 182-508-0030

Effective October 14, 2012

WAC 182-508-0030 Required medical evidence.

An individual must provide medical evidence of an impairment (s) and how the impairment (s) affects the ability to perform regular and continuous work activity. Medical evidence must be in writing and be clear, objective and complete.

(1) Objective evidence for physical impairments means:

(a) Laboratory test results;

(b) Pathology reports;

(c) Radiology findings including results of X rays and computer imaging scans;

(d) Clinical finding including, but not limited to, ranges of joint motion, blood pressure, temperature or pulse; and documentation of a physical examination; or

(e) Hospital history and physical reports and admission and discharge summaries; or

(f) Other medical history and physical reports related to the individual's current impairments.

(2) Objective evidence for mental impairments means:

(a) Clinical interview observations, including objective mental status exam results and interpretation.

(b) Explanation of how examination findings meet the clinical and diagnostic criteria of the most recent edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM).

(c) Hospital, outpatient and other treatment records related to the individual's current impairments.

(d) Testing results, if any, including:

(i) Description and interpretation of tests of memory, concentration, cognition or intelligence; or

(ii) Interpretation of medical tests to identify or exclude a connection between the mental impairment and physical illness.

(3) Medical evidence sufficient for an incapacity determination must be from a medical professional described in WAC 182-508-0020 and must include:

(a) A diagnosis for the impairment, or impairments, based on an examination performed within twelve months of application;

(b) A clear description of how the impairment relates to the individual's ability to perform the work-related activities listed in WAC 182-508-0015 (5); and

(c) Documentation of how the impairment, or impairments, is currently limiting the individual's ability to work based on an examination performed within the ninety days of the date of application or the forty-five days before the month of incapacity review; and

(4) When making an incapacity decision, the agency or the agency's designee considers documentation in addition to objective evidence to support the acceptable medical source or treating provider's opinion that the individual is unable to perform substantial gainful employment, such as proof of hospitalization.

(5) The agency or the agency's designee doesn't use symptoms related to substance abuse or a diagnosis of addiction or chemical dependency when determining incapacity when the only impairment supported by objective medical evidence is drug or alcohol addiction.

(6) The agency or the agency's designee considers diagnoses that are independent of addiction or chemical dependency when determining incapacity.

(7) The agency or the agency's designee determines the individual has a diagnosis that is independent of addiction or chemical dependency if the impairment will persist at least sixty days after the individual stops using drugs or alcohol.

(8) If the individual can't obtain medical evidence sufficient for the agency or its designee to determine if the individual is likely to be disabled without cost to the individual, and the individual meets other eligibility conditions in WAC182-508-0005, the agency pays the costs to obtain objective evidence based on the agency's published payment limits and fee schedules.

(9) The agency or the agency's designee can't use a statement from a medical professional to determine that the individual is incapacitated unless the statement is supported by objective medical evidence.

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

WAC 182-508-0030(4) - if you cannot obtain medical evidence without cost to you and you meet the eligibility conditions other than incapacity in WAC 182-508-0005, we pay the costs to obtain objective evidence based on our published payment limits and designated fee schedules.

Medical evidence reimbursements described in this chapter are solely to pay the fees to obtain objective medical evidence of an impairment that limits work activity. The medical evidence obtained may indicate there is no incapacity, or may be used to support SSI facilitation, but we do not pay for medical evidence to rule out medical conditions that are not incapacitating.

Clients must appear to be financially eligible for MCS before we authorize payment.
These payments do not apply to services authorized by DDDS (Division of Disability Determination Services) or to medical examinations or reports requested in relation to placement in treatment or court orders.
Request existing medical records before obtaining new evaluations or services.
Use DSHS 14-150, Medical Evidence Request (Physical) and DSHS 14-150(A) Medical Evidence Request (Psychological) to communicate to the provider that we need objective medical evidence and we reimburse for services necessary to evaluate incapacitating conditions.
When requesting examinations or other diagnostic services attach a copy of the Statement of Health, Education and Employment (DSHS 14-050).

How to decide what medical evidence is needed

1. Initial decision: Current medical evidence for an initial decision is a report containing objective findings based on an examination within 90 days of the date of application. Only request new medical evidence when available evidence is either older than 90 days or insufficient for a determination of disability.

a. Document your reason for obtaining new medical evidence.

b. Medical evidence more than 90 days old is acceptable when it is:

1. Intelligence testing scores from a Weschler Adult Intelligence Scale (WAIS - III or IV editions) administered after age 18;

2. Medical evidence used by DDDS to approve a NGMA (non-grant medical assistance decision that is still in effect, where the medical information was obtained no longer than 12 months ago; or

3. For a client more than 50 years old, objective findings of a chronic, deteriorating condition based on an exam within the last 12 months;

4. A radiology report such as an X-ray or MRI when referenced in an examination performed within 90 days of application.

2. Review decision: Current medical evidence for review decisions is a report containing objective findings obtained within the past 45 days.

a. If the client has seen his medical provider within the past 45 days, do not authorize a new evaluation. Obtain a report from records and authorize payment using the "report from records" service.

b. Explain reasons for obtaining any new testing or evaluations at review in the ICMS (Inclusive Case Management System) case notes.

Medical Evaluations/Procedures

General physical evaluation: A general physical evaluation should contain all of the following information:

a. Chief complaint or reason for the visit.

b. Medical history including date the condition began, response to treatment, and any hospitalizations.

c. Physical examination findings including vital signs, description and explanation of abnormal findings, and range of motion (if done).

d. Results of diagnostic testing (lab work, x-rays, etc.).

e. Diagnosis with ICD-9 codes for any impairment that affects work activity and is supported by objective findings.

f. History of drug and/or alcohol use.

g. Description of how the medical condition affects the client’s overall ability to perform basic work-related activities.

h. Prognosis and estimate of how long the person will be limited to the listed severity and functional rating.

i. Medications, equipment, and/or supplies prescribed or provided.

j. Recommendations for additional testing or consultation.

k. Recommended treatment.

l. Name, title and signature of the person performing the service.

m. Date of service.

n. Copies of chart notes from the last six months, hospital summaries, medical records or lab results attached to DSHS 14-150, Physical Evaluation form or a narrative report.

Comprehensive physical evaluation (e.g. orthopedic or neurological): A comprehensive physical evaluation contains all of the information listed under the general physical evaluation section above, in addition to:

a. Progression of symptoms such as motor loss, sensory loss or mental restrictions;

b. Description of any restrictions on personal care or daily activities caused by the condition; and

c. Copies of clinic records.

Mental health evaluation completed by an MHP (mental health professional):

The written report must include an MSE (mental status exam) and copies of the client's records. The evaluator must include information indicating they are a qualified MHP. If the evaluator does not indicate this, contact the evaluator to verify their status. If the person is not an MHP, do not authorize payment for the service.

4. Psychological and psychiatric evaluation:

The Psychological evaluation is a diagnostic interview, including an MSE (mental status exam) and an assessment of daily living skills, conducted by a licensed psychologist.
The Psychiatric evaluation is a diagnostic interview, including an MSE (mental status exam) and an assessment of daily living skills, conducted by a licensed psychiatrist..
Both evaluation types result in a written report that must include:

	Chief complaint;	Diagnosis
	History of past & present illness	Prognosis
	MSE (mental status exam)	Capability to manage funds
	Functional information	Medical source statement, indicating what the client can do despite the impairment

5. Psychological diagnostic testing is only reimbursed when necessary to establish a diagnosis or the severity of a mental health condition and is limited to the following:

a. For a general claim of mental disorder:

· MMPI-II: Minnesota Multiphasic Personality Inventory or

· PAI-II: Personality Assessment Inventory.

b. For a claim of cognitive disorder:

· WAIS-III or WAIS-IV: Weschler Adult Intelligence Scale

· WMS-III: Weschler Memory

· TOMM Test of Memory Malingering

· Rey: This is a 15-item visual memory test, often used to determine malingering

· Trailmaking: Used to determine cognitive damage

Request subtest scores, statistical scores, and the narrative summary of all tests that you request. The narrative summary of the testing may help prevent the purchase of another exam/testing when the person applies for SSI. Division of Disability Determination Services (DDDS) calls this the “analysis of the information”.

NOTE:

The examining psychologist determines which tests are appropriate and documents why each test performed is necessary. Diagnostic testing is not usually necessary at review.

Payment for Medical Evidence

You must have an itemized bill with the provider's usual and customary fees before authorizing payment. The bill must be kept in the client's case file for audit purposes.
Physician Services for Diagnostic procedures: Diagnostic procedures include laboratory work (examples include urinalysis, blood chemistry tests etc), radiology, spirometry, strength testing and other procedures. For diagnostic procedures, pay the provider's usual and customary fee or the allowable maximum, whichever is less. The allowable maximums are found in the "Physician Related Services Billing Instructions" issued by the Health Care Authority (HCA).
1. Pay no more than $250 total for all diagnostic procedures, per client per initial physical evaluation, if an MRI was not obtained.
2. Pay no more than $550 total for all diagnostic procedures per client per initial physical evaluation, if an MRI was obtained.
3. If more than one MRI is needed, request an expenditure approval from headquarters.
Hospital Services for Diagnostic Procedures: For outpatient diagnostic procedures performed in a hospital setting, pay the usual and customary fee or the allowable maximum for the relevant CPT code, whichever is less.
1. For most hospitals, use the Outpatient Hospital Fee Schedule.
2. When a facility is a Critical Access Hospital, use the Outpatient Percentage as the allowable maximum.
Medical evidence other than diagnostic procedures: Payments for these services are made according to the Medical Evidence Fee Schedule (shown below). Pay the providers' usual and customary fee or the amount shown in the fee schedule, whichever is less.
When you decide a client is eligible for MCS complete the DSHS 14-332 (Disability Assessment) before paying for medical evidence. If an ABD/SSIF referral is appropriate per the 14-332, use service code 6220 to pay for the medical evidence. If a referral is not appropriate, use code 6020.

SSPS Codes

Pay either the provider's usual and customary fee or the maximum payment, whichever is less. Refer to the Medical Evidence Fee Schedule below for maximum payment amounts. If you obtain approval to exceed the allowable maximum, you must document the approval, by the appropriate authority, to do so in the case record. To exceed the allowable maximum enter a 9 in front of the SSPS code.

SSPS Code	Use For	Exceed Maximum When
6020	Medical evidence when a referral to the SSIF is not appropriate per the DSHS 14-332 (Disability Assessment).	Approved by state office; or Directed by an ALJ (Administrative Law Judge) as the result of an Administrative Hearing and approved by HQ.
6220	Medical evidence when a referral to the SSIF is appropriate per the DSHS 14-332 (Disability Assessment).	Approved by state office; or Directed by an ALJ as the result of an Administrative Hearing and approved by HQ.
6222	Additional medical evidence to determine eligibility for ABD when requested by the contracted physician.	Requested by the ABD contractor; and Approved by state office.
6224	Obtaining records to support an SSI claim at the SSI initial claim, reconsideration, or administrative hearing level, when DDDS will not pay per their policy.	Approved by state office.

Medical Evidence Fee Schedule

Pay either the provider's usual and customary fee or the maximum payment in this fee schedule, whichever is less.

NOTE:

The maximum payment for all services in the fee schedule include the cost of copies of chart notes.

Reason Code	Service Description	Maximum Payment
A	Medical records (copies) Note: Only pay additional charges, e.g., sales tax, when itemized on the bill. *Only pay when we could not provide the vendor with a postage-paid business reply envelope.	$ .30 per page, with a maximum of 150 pages. Additional charges allowed: $20 for handling or clerical fee Actual cost of sales tax Actual cost of postage*
B	Report from records	$31.00
C	General physical evaluation	$130.00
D	Comprehensive physical evaluation	$150.00
E	Comprehensive eye exam	$78.00
F	Goldman perimeter testing (visual field exam)	$59.00
G	Mental Health Professional (MHP) evaluation, including MSE and copies of client records	$60.00
H	Psychological evaluation, including MSE, and assessment of daily living skills. Clinical interview and correlation of any testing must be performed by a licensed psychologist. *Only pay when the provider provides a receipt from a transcription service agency.	$130.00 Actual cost of transcription services. Not to exceed $60.00*
I	Psychological diagnostic testing. Correlation of test results must be completed by the psychologist or psychiatrist who conducted the clinical interview.
I	MMPI-II PAI-II WAIS-III or IV WMS-III TOMM Rey Trailmaking	$50.00 $50.00 $120.00 $120.00 $30.00 $10.00 $10.00
J	Psychiatric evaluation, including MSE, and assessment of daily living skills. *Only pay when the provider provides a receipt from a transcription service agency.	$150.00 Actual cost of transcription services. Not to exceed $60.00*
L	Missed appointment or cancellation without 24-hour notice:
L	Physical Psychological Do not pay more than $40.00 total for a missed appointment. An evaluation and testing by the same provider is considered to be one appointment even is scheduled over multiple days.	$30.00 $40.00
M	Special report for SSI administrative hearing purposes, when approved by headquarters.	$60.00 / hour $15.00 per 15 minute increment Limited to 3 hours maximum
N	SSI consultative narrative examinations, when approved by headquarters: Narrative Psychological Evaluation Narrative Psychiatric Evaluation Comprehensive review of psychiatric history Unduplicated, necessary psychological testing, paid per medical evidence fee schedule section (I).	· $180.00 · $218.67 · $60.00

NOTE:

Mental health providers may choose to use DSHS form 13-865 or provide a narrative report. The psychological evaluation form 13-865 must be typed in order to be eligible for payment. This requirement is clearly stated at the top of the form.

Modification Date: November 28, 2011