Medical Evidence Requirements and Reimbursements

Revised on: March 26, 2018

Clarifying Information

Reimbursements described in this section are solely to pay the fees necessary to obtain objective medical evidence of an impairment that limits work activity. We do not pay for medical evidence to evaluate medical conditions that are not claimed or unlikely to impair work functions.

If a person meets all of the non-disability/incapacity eligibility requirements listed in WAC 388-400-0060 or WAC 388-400-0070, we reimburse for the costs of obtaining the objective evidence necessary to determine disability/incapacity based on our published fee schedules.

  1. Clients must be determined financially eligible before we authorize an evaluation or payment.
  2. Request medical records if available before authorizing new evaluations or services.
  3. Payments do not apply to services authorized by the Division of Disability Determination Services (DDDS) or medical examinations or reports required by court order or treatment placement.
  4. Payments for medical evidence related to TANF cases are authorized in eJAS as Support Services (WorkFirst Handbook 2.2).
  5. See WorkFirst Handbook 3.7.1.6 for information regarding reimbursement for medical evidence associated with TANF/SFA ineligible parent time limit extensions.

What is "Current" Medical Evidence?

  1. Initial decision: Current medical evidence for an initial decision must be based on an examination or findings from within 90 days of the date of application. Only request new medical evidence when available evidence is either older than 90 days or insufficient to determine disability.
    1. Document your reason for obtaining new medical evidence.
    2. For the purposes of establishing a diagnosis, medical evidence greater than 90 days old from the date of application is acceptable when it is:
      • A report within the past 5 years that includes a diagnosis of a medically determinable impairment based on an examination by an “acceptable medical source,” defined in WAC 388-449-0010 and WAC 388-447-0005;
      • Intelligence testing scores from a Wechsler Adult Intelligence Scale (WAIS - III or IV editions) administered after age 18; or
      • A diagnostic imaging 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 a review decision must be based on an examination or findings from within the past 45 days for the ABD Program or 90 days for the HEN Referral Program.
    1. If the client has seen a medical provider within the past 45 days, request a report from records rather than authorizing a new evaluation whenever possible.
    2. If existing available medical records are not sufficient to determine disability, clearly document the reason for obtaining any new testing or evaluations at review.
NOTE:  Under the Concurrent Determination process, first attempt to obtain medical evidence (identified in WAC 388-449-0015) necessary to determine eligibility for the ABD program.

Medical Evaluations and Testing

  1. General physical evaluation: A general physical evaluation should contain all of the following information:
    1. The Chief complaint and symptoms reported by the client;
    2. Medical history including onset date and treatment history;
    3. Physical examination findings including but not limited to: vital signs, observations, a description of any abnormal findings, and range of motion (when appropriate);
    4. Results of diagnostic testing and imaging (e.g. labs, X-rays, pulmonary function tests, etc.);
    5. A diagnosis and International Classification of Diseases (ICD) code for any impairment that affects work activity and is supported by objective findings;
    6. A description of how the medical condition impacts the client's overall ability to perform basic work-related activities;
    7. A description of any non-exertional limitations which may include workplace restrictions;
    8. A prognosis including an estimate of how long the functional impairment will persist at the current level of severity;
    9. Current or past drug or alcohol use;
    10. An opinion whether current impairments which limit work activity are primarily the result of alcohol or drug use within the past 60 days;
    11. Recommendations for additional testing or consultation;
    12. Treatment recommendations;
    13. The name, title and signature of the person performing the evaluation;
    14. The date of service; and
    15. Copies of all available chart notes, hospital discharge summaries, diagnostic reports, and other medical records from the past six months.
  2. Comprehensive physical evaluation (e.g. orthopedic, neurological): A comprehensive physical evaluation contains all of the information listed under the general physical evaluation section above, in addition to:
    1. Progression of symptoms such as motor loss, sensory loss, or mental restrictions;
    2. Description of any restrictions on personal care or daily activities caused by the condition; and
    3. Copies of clinic records.
  3. Psychological and psychiatric evaluation:
    1. Psychological evaluation is a diagnostic interview, including an MSE (mental status exam) and an assessment of daily living skills conducted by an “acceptable medical source” defined in WAC 388-449-0010.
    2. Psychiatric evaluation is a diagnostic interview, including an MSE (mental status exam) and an assessment of daily living skills conducted by a licensed psychiatrist (MD, DO).
    3. Both evaluation types result in a written report that must include:
      1. The chief complaint or the impairment/symptoms claimed by the client;
      2. Psychosocial history including onset date and treatment history;
      3. Educational and work history;
      4. Any past or present drug or alcohol use, including treatment history;
      5. A description of the client's activities of daily living;
      6. A list of all mental health symptoms that impact the client's ability to work, including a description of the severity and frequency of those symptoms;
      7. A diagnosis; from the current Diagnostic and Statistical Manual of Mental Disorders (DSM), or lack thereof, of any impairment that impacts work activity and is supported by objective findings;
      8. A description of how the medical condition impacts the client's overall ability to perform basic work-related activities;
      9. An opinion whether any current limitations on work activity are primarily the result of a substance use disorder;
      10. A prognosis including an estimate of how long any functional impairment will persist at the current level of severity;
      11. An opinion of the client's capacity to manage funds;
      12. Treatment recommendations;
      13. The name, title, and signature of the person performing the evaluation; and
      14. The date of service.
  4. Psychological diagnostic testing is only reimbursed when necessary to establish a diagnosis or the severity of a mental health impairment. Psychological diagnostic testing is limited to the following:
    1. Evaluation of personality disorders:
      1. MMPI-II: Minnesota Multiphasic Personality Inventory
      2. PAI-II: Personality Assessment Inventory
    2. Evaluation of depression:
      1. BDI-II: Beck Depression Inventory
      2. HAM-D: Hamilton Rating Scale for Depression
    3. Evaluation of anxiety:
      1. BAI: Beck Anxiety Inventory
      2. HAM-A: Hamilton Rating Scale for Anxiety
    4. Evaluation of a potential cognitive disorder:
      1. WAIS-III or WAIS IV: Wechsler Adult Intelligence Scale
      2. WMS-III: Wechsler Memory Scale
      3. TONI-4: Test of Nonverbal Intelligence, Fourth Edition
      4. Trails: Trail Making Test Parts A and B
    5. Evaluation of potential memory malingering:
      1. REY 15-Item Memory Test
      2. TOMM: Test of Memory Malingering
    6. Evaluation of potential psychiatric illness malingering
      1. M-FAST: Miller Forensic Assessment of Symptoms Test
      2. SIRS: Structured Interview of Reported Symptoms

Sub-test scores, statistical scores, and a narrative summary of all tests must be included. Please see Mental Incapacity Evaluation Services: Fee Schedule, for limitations on testing reimbursements and additional details.

NOTE:  The examining "acceptable medical source" determines which of the listed tests are clinically appropriate and must clearly document in the evaluation report why each test is performed.

Psychological Evaluations from Providers who are not an ABD “Acceptable Medical Source”

  1. Psychological evaluations or reports from the following sources may only be used for purposes of determining incapacity for the HEN Referral program per WAC 388-447-0005:
    1. Clinical social worker;
    2. Mental health professional (MHP); or
    3. Physician treating the individual for a mental impairment
  2. No reimbursement, other than copy fees, shall be authorized for psychological evaluations or reports authored by the sources listed above.
NOTE:  Under the Concurrent Determination process, first attempt to obtain medical evidence (identified in WAC 388-449-0015) necessary to determine eligibility for the ABD program.

ProviderOne and the Social Service Payment System (SSPS)

  1. Providers must be enrolled with ProviderOne to claim and receive payment for Incapacity Evaluation services. 
  2. Continue to use SSPS to reimburse for Medical Records (copies), SSI Medical Evidence Transportation costs, and Medical Evidence to Support SSI Applications (approved through the Barcode ETR process). Most services are paid using SSPS Service Code 6220. Refer to SSPS Manual Appendix H for details regarding available Service Codes and how to use them.
  3. Pay either the provider's usual and customary fee or the maximum payment, whichever is less. Refer to the Medical Evidence Fee Schedules section for maximum payment amounts.

ABD/HEN Referral Payment Review Request

The Payment Review Request (PRR) tool in ICMS can be used to identify and report psychological and physical functional evaluations that lack elements required by ABD/HEN Referral program rules, and are in need of further review. Please visit the ABD/HEN Referral Payment Review Request section of the CSD Procedure Handbook for additional information.  

NOTE: Social Service staff must first attempt to obtain missing information by contacting the medical provider by phone, FAX, or by mail before initiating the PRR tool.  Be sure to document the attempt in ICMS case notes.

 

Medical Evaluations and Diagnostic Procedures

Created on: 
Aug 05 2015

Medical Evidence Fee Schedule

Medical Evaluations and Diagnostic Procedures

You must be enrolled in ProviderOne to claim reimbursement for these services.  Please visit the Health Care Authority’s New Providers page for information about ProviderOne enrollment.

 

NOTE: We only pay for non-invasive diagnostic services and exams necessary to establish a diagnosis or the severity of an impairment that limits work activity.  We reimburse for the costs of obtaining the objective evidence necessary to determine disability based on our published fee schedule and established Medicaid rates.
For services not included on this fee schedule, you may need to submit a separate claim to ProviderOne using established CPT codes.
The maximum payment for all evaluation and report services includes the cost of providing chart notes and medical records.
Reimbursement Fee Table

Service Type

Reimbursement Fee

ProviderOne Service Code

General physical evaluation

$150.00

99455

Comprehensive physical evaluation

$170.00

99456

Report from records

$31.00

99080

Missed appointment

$30.00

99199

Non-Invasive Diagnostic Testing

Established Medicaid Rates

Established CPT Codes

⃰  This section details Aged, Blind, or Disabled (ABD) program medical evidence reimbursement rates.  For a detailed service descriptions visit the Medical Evidence Reimbursements section of the ESA Social Services Manual.

Mental Incapacity Evaluation Services

Medical Evidence Fee Schedule

Mental Incapacity Evaluation Services

Reimbursement for psychological evaluations and testing is limited to the terms and conditions outlined in the Community Services Division (CSD) Mental Incapacity Evaluation contract. 

For information about contracting with DSHS please visit the CSD Mental Incapacity Evaluations contracts page.

CSD Contractors must be enrolled in ProviderOne to claim reimbursement for these services.  Please visit the Health Care Authority’s New Providers page for information about ProviderOne enrollment.

 

NOTE:  The maximum payment for all evaluation and report services includes the cost of providing chart notes and medical records.  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.

Service Type

Service Description

Reimbursement Fee

ProviderOne Service Code

Additional Conditions

Clinical Evaluation

When performed by a licensed/contracted psychologist (Taxonomy:  103T00000X)

$150.00

96150

Modifier 25

Must be an acceptable written report as described in Exhibit B, Statement of Work.

Clinical Evaluation

When performed by a licensed/contracted psychiatrist (Taxonomy:  2084P0800X)

$170.00

90791

Must be an acceptable written report as described in Exhibit B, Statement of Work.

Evaluation of general mental disorders

  • MMPI-2:  Minnesota Multiphasic Personality Inventory*

 

  • PAI-II:  Personality Assessment Inventory

 

 

 

$50.00

 

 

 

$50.00

 

 

 

96101

Modifier U6

 

 

96101

Modifier U1

No more than one (1) test from this category per evaluation

 

*May substitute the MMPI-2: Restructured Form provided the report documents why the substitution is necessary.

Evaluation of depression

 

  • BDI-II:  Beck Depression Inventory

 

  • HAM-D:  Hamilton Rating Scale for Depression

 

$10.00

 

 

$10.00

 

96101

Modifier U7

 

96101

Modifier U8

No more than one (1) test from this category per evaluation.

Evaluation of anxiety

  • BAI:  Beck Anxiety Inventory

 

  • HAM-A:  Hamilton Rating Scale for Anxiety

 

$10.00

 

 

$10.00

 

96101

Modifier UB

 

96101

Modifier UC

No more than one (1) test from this category per evaluation.

Evaluation of cognitive disorders

  • WAIS-III or WAIS-IV:  Wechsler Adult Intelligence Scale

 

  • WMS-III:  Wechsler Memory Scale

 

  • Test of Nonverbal Intelligence, Fourth Edition (TONI-4)

 

  • Trails:  Trail Making Test Parts A & B

$120.00

 

 

 

$120.00

 

 

$30.00

 

 

$10.00

96101

Modifier U3

 

 

96118

Modifier U4

 

96101

Modifier U4

 

96118

Modifier U5

The TONI is used to evaluate individuals with limited language ability.  It is reimbursed instead of and not in addition to the WAIS and WMS.

Evaluation of potential memory malingering

  • Rey Fifteen-Item Memory Test

 

  • TOMM:  Test of Memory Malingering

$10.00

 

 

$30.00

96101

Modifier U9

 

96101

Modifier U2

No more than one (1) test from this category per evaluation.

Evaluation of potential psychiatric illness malingering

  • M-Fast:  Miller Forensic Assessment of Symptoms Test

 

  • SIRS:  Structured Interview of Reported Symptoms

$20.00

 

 

$10.00

96101

Modifier UA

 

96101

Modifier U5

No more than one (1) test from this category per evaluation.

Missed appointment

  • DSHS Client fails to appear at scheduled date and time and the DSHS Client or referring CSO did not request cancellation within twenty-four (24) hours prior to the appointment, unless the conditions in the Additional Limitations column apply.

 

  • The DSHS Client arrives more than ten (10) minutes after the scheduled start time unless the conditions in the Additional Limitations column apply.

 

  • The Contractor observes the DSHS Client to be intoxicated.

$30.00

99199

This is not paid when the Contractor is providing services at a CSO and another DSHS Client is available.

 

This fee is only paid once per referral.

This section details Aged, Blind, or Disabled (ABD) program medical evidence reimbursement rates.  For a detailed service descriptions visit the Medical Evidence Reimbursements section of the ESA Social Services Manual.

 

Medical Records-Medical Evidence Fee Schedule

Created on: 
Aug 05 2015

Medical Evidence Fee Schedule

Medical Records

We use the Social Service Payment System (SSPS) to reimburse for medical records.  Please submit claims to the requesting DSHS Community Services Office for processing.

 

Service Type

Reimbursement Fee

SSPS Reason Code

Medical Records (copies)

$0.30 per page – maximum of 150 pages

Additional charges allowed:

$20 for handling or clerical fee**

Actual cost of sales tax**

Actual cost of postage***

 

A

⃰  This section details Aged, Blind, or Disabled (ABD) program medical evidence reimbursement rates.  For a detailed service descriptions visit the Medical Evidence Reimbursements section of the ESA Social Services Manual.

** Additional charges must be itemized on the bill to be eligible for reimbursement.

*** The cost of postage is eligible for reimbursement only if the Department was unable to provide the vendor with a postage-paid business reply envelope.