Treatment Must Focus on Return to Work

Under workers’ compensation insurance, mental health treatment must focus on helping occupationally injured and ill workers heal and return to work.

For detailed information, see Authorization and Reporting Requirements for Mental Health Specialists.

When treatment is covered

• Mental health conditions are caused or aggravated by a work-related injury or illness.
• A pre-existing or unrelated condition is delaying recovery from work-related injury or illness.
• When documentation shows clinically meaningful improvement.
• Authorization is required for the initial evaluation and ongoing treatment (up to 90 days at a time).

Treatment that is NOT covered

• Palliative care (when treatment is not curative and rehabilitative).
• Treatment has reached maximum medical improvement.
• Temporary treatment does not improve physical function of the industrial injury or occupational disease.

Use of DSM-5 criteria is required

L&I or the self-insured employer uses your information to determine the relationship between industrial injuries and mental health conditions.

During evaluation and ongoing reports, you must clearly indicate your opinion about the possible relationship between a mental health condition and an industrial injury — and the basis for your opinion using the criteria of the American Psychiatric Association’s Fifth Edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5).

Authorization Requirements

All mental health care requires prior authorization. Ongoing treatment may be approved for up to 90 days at a time.

How to request prior authorization for mental health services

Schedule for chart notes and reports

Reporting requirements summary

Under workers’ compensation insurance, mental health treatment must focus on helping occupationally injured and ill workers heal and return to work. We require documentation that gives claim managers the information they need to make timely and fair decisions. These requirements apply to treatment for workers covered by L&I as well as by self-insured employers.

"All reports must be legible, preferably electronic, and in a style that can be understood by non- medical personnel. Each report must contain at least:

1. Diagnosis, explicitly using DSM-5 criteria and the appropriate specifier (e., severe vs. mild, partial remission vs. in remission),
2. Relationship of the diagnosis, if any, to the industrial injury or occupational disease,
3. Summary of subjective complaints,
4. Objective findings,
5. Time limited, intensive treatment plan focusing on functional improvement,
6. Medications prescribed,
7. Assessment of functional status using a validated functional status instrument as recommended by the department at baseline and every 30 days. The approved functional status instruments are:

• World Health Organization Disability Assessment Schedule 2.0 (WHODAS 2.0), 36 or 12 item version
• Patient-Reported Outcomes Measurement Information System (PROMIS) Global-10 or CAT method.
• Short-Form Survey 36- or 12-item (SF-36 or SF-12). 

8. Assessment of targeted symptoms using standardized instruments to measure symptom severity, when indicated (for example, PHQ-9, or BDI for depression or GAD-7 or BAI for anxiety). 
9. Worker’s ability to work as it relates to the mental health condition, including specific targeted symptoms that are barriers to work. Include the treatment plan related to those barriers. Recommend work modifications when appropriate."

Detailed information about how to write reports and treatment plans

• Authorization and Reporting Requirements for Mental Health Specialists

Billing Note:

Reimbursement requirements

Additional documentation may be required for reimbursement. For complete information, see the Billing and Payment tab on this page.

Assessment of Functional Status During Treatment

The worker's functional status must be measured by using a validated functional status instrument recommended by L&I. These instruments are standardized and validated for assessing disability both physically and mentally. The degree of improvement documented by the instruments should be clinically meaningful and consistent with L&I's definition of “proper and necessary” in WAC 296-20-01002. The recommended instruments are:

• World Health Organization Disability Assessment Schedule 2.0 (WHODAS 2.0), 36- or 12-item version.
• Patient-Reported Outcomes Measurement Information System (PROMIS) Global-10 or CAT method.
• Short-Form Survey 36- or 12-item (SF-36 or SF-12).

These instruments can be completed as a self-administered scale (such as by a patient in the waiting room). They are easy to score and available in many languages. Some of the items in each of these tools deal with physical capacities and mental functioning. The goal of using functional status measures is to determine the degree of change in the process of rehabilitation. A lack of improvement suggests a failure to accomplish goals of treatment.

For additional details on assessing workers, see Authorization and Reporting Requirements for Mental Health Specialists.

Billing and Payment

Billing codes and payment policies

• Fee Schedules and Payment Policies (MARFS)
• Chapter 17: Mental Health Services
• Chapter 10: Evaluation and Management (E/M) Services
• Mental Health Services Fee Schedule (Quick Reference Card)

Pre-authorization is key

1. Use the preauthorization form to request authorization to provide services.
2. When you receive your authorization, check the authorized dates of service. If they are different from what you expected, contact the claim manager immediately. Do not provide services beyond the authorized dates.
3. Request an extension 2 weeks before the end of the currently authorized period to reduce the possibility of a disruption in care.
4. Additional treatment is more likely to be authorized if your notes/reports clearly show the injured worker is improving as a result of the therapy.

Other billing information

1. It’s important to know who and where to bill:
   • Washington State workers’ compensation State Fund claims begin with 2 alpha characters followed by 5 numeric characters (for example, BB12345, ZB12345): Billing L&I
   • Self-Insured Employer claims begin with S, T, or W (for example, SZ12345): Billing Self-Insured Employers
2. Bill L&I electronically using our free online Provider Express Billing system to bill for State Fund claims. Electronic bills process faster.
3. When submitting bills, remember to:
   • Use dates of service only within the authorized date span.
   • Use ICD-10 diagnosis codes. If you are making a new diagnosis, or adding one, then discuss the new diagnosis with the claim manager.
   • Bill for the work you do, including phone calls (see Chapter 10 above), electronic communications (Claim & Account Center), return to work offers, and 60-day reports. See our Quick Reference Fee Card for Providers.
4. Include the diagnosis you made during your assessment. A mental health condition may not have been be allowed on your patient’s claim yet. The claim manager will review your report to determine if it should be accepted on that claim.
5. Mental Health providers may request temporary access to the Claim & Account Center to access the patient’s claim file.

• • Consulting or concurrent care providers may call the claim manager to request 90-day access.
  • Need assistance signing up? Call Web Customer Support at 360-902-5999.

Resources

Providers must use the criteria in the DSM-5 to diagnose mental health conditions.

See Authorization and Reporting Requirements for Mental Health Specialists to track and document functional status.

See RCW 51.08.142 for conditions related to stress and trauma.