1. Update: Draft DSM-5 Rules IIMAC – April 23, 2015 Diane Reus, Clinical Nurse Specialist

2. DSM-IV to DSM-5 Scope of Rule Changes Rule changes are limited to what is needed to implement DSM-5. They do not address all policy issues related to mental health services. Scope includes:  Edition Citation Change  Post-traumatic Stress Disorder  Somatic Symptom Disorders  Functional Assessment Tool 2

3. Rulemaking Timeline Statement of Inquiry Filing:August 5, 2014 Webinar:April 7, 2015 Finalize Language with IIMAC:April 23, 2015 Proposed Language Filing:June 2, 2015 Proposed Hearing Date:July 13, 2015 Proposed Adoption Date:September 1, 2015 Proposed Effective Date: October 1, 2015 3

4. Industrial Insurance Medical Advisory Committee (IIMAC) activities January 23, 2014 IIMAC Meeting  Committee recommended L&I adopt DSM-5 within a realistic timeframe July 24, 2014 IIMAC Meeting  Discussion of major policy issues: Post Traumatic Stress Disorder (PTSD), Somatic Symptom Disorders and Functional Measurement Tools September 2, 2014 Conference Call  Review of draft rule language by IIMAC subgroup October 23, 2014 IIMAC Meeting  Committee voted to approve draft rule changes April 23, 2015 IIMAC Meeting  Review comments from April 7 th webinar and finalize draft language 4

5. Purpose of April 7, 2015 Webinar  Share information about DSM-5 and the impacts on L&I  Provide an overview of L&I’s engagement with statutory Industrial Insurance Medical Advisory Committee (IIMAC)  Present draft rule changes before formal public comment period  Collect written comments and questions during and following the webinar for review by IIMAC 5

6. Webinar Summary  18 people registered for the webinar (6 external and 12 department staff)  Eleven people attended (5 external and 6 internal department staff)  Received one comment during registration  Received two emails prior to the webinar with feedback.  No feedback or questions received during the webinar. 6

7. Comment Overview  ICD-10 Overlap –Two commenters pointed out that ICD-10 is required October 2015, and L&I should adopt it  L&I response: L&I agrees. – The department is adopting ICD-10 for billing. – DSM-5 is fully compatible with ICD-10 and is a complementary code set for mental health diagnosis and services. 7

8. Comment Overview  Rulemaking Authority and Philosophical Disagreement –One commenter indicated (1) L&I lacks rulemaking authority and (2) that the L&I rule will set L&I policy back prior to a time when the severity and pervasiveness of mental illness was not recognized and it will treat mental conditions different than physical conditions.  L&I Response: L&I disagrees. –The changes update currently existing rules relating to mental health that reference or implement DSM-IV. –The implementation of changes to adopt DSM-5 acknowledges and updates L&I policy and rule to be consistent with the latest clinical guidance. 8

9. IIMAC Discussion  Recommendation: L&I is not recommending changes to the rule language that IIMAC and the sub-committee developed and previously approved based on comments received. Discussion 9

10. Reference Slides 10

11. WAC 296-20-330 Impairments of mental health Draft Rule Language for Edition Citation Change: (5) All reports of mental health evaluations shall use the diagnostic terminology listed in the edition of the Diagnostic and Statistical Manual of Mental Disorders ((of the American Psychiatric Association)) (DSM) designated by the department. Note: Until formal adoption of the DSM-5 rule changes, the department currently allows providers to use either DSM-IV or DSM-5 for disease identification. 11

12. WAC 296-20-330 Impairments of mental health Draft Rule Language for Edition Citation Change: (7) The physician shall identify the ((schizoid, antisocial, inadequate, sociopathic, passive, hysterical, paranoid, or dependent personality types)) personality disorders as defined in the edition of the DSM designated by the department. 12

13. WAC 296-21-270 Psychiatric services Draft Rule Language for Edition Citation Change: (b) Providers must use the ((current)) edition of the Diagnostic and Statistical Manual of Mental Disorders of the American Psychiatric Association ((axis format)) designated by the department in the initial evaluation, follow-up evaluations and sixty-day narrative reports((, and explanation of the numerical scales are required)). 13

14. Post-traumatic Stress Disorder (PTSD) 14

15. WAC 296-14-300 Mental condition/mental disabilities Draft Rule Language for Post-traumatic Stress Disorder: (2)(a) Stress resulting from extreme exposure to a single traumatic event will be adjudicated ((with reference to)) as an industrial injury. See RCW 51.08.100. (b) Examples of extreme single traumatic events include: Actual or threatened death, actual or threatened physical assault, actual or threatened sexual assault, and life-threatening traumatic injury. (c) These exposures must occur in one of the following ways: (i) Directly experiencing the traumatic event; or (ii) Witnessing, in person, the event as it occurred to others. (d) Repeated exposure to aversive details of traumatic events, none of which rises to the level of extreme exposure, is not an industrial injury (see RCW 51.08.100) or an occupational disease (see RCW 51.08.140 and 51.08.142). 15

16. Somatic Symptom and Related Disorders 16

17. WAC 296-14-300 Mental condition/mental disabilities Proposed Rule Language for Somatic Symptom Disorders: (3) Claims based on mental conditions or mental disabilities that specify pain primarily as a psychiatric condition (e.g., somatic symptom disorder, with predominant pain), or that are characterized by excessive or abnormal thoughts, feelings, behaviors or neurological symptoms (e.g., conversion disorder, factitious disorder) are not industrial injuries (see RCW 51.08.100) or occupational diseases (see RCW 51.08.140 and 51.08.142). 17

18. Functional Assessment 18

19. WAC 296-21-270 Psychiatric services Draft Rule Language for Functional Assessment Tool: (7) When providing mental health services, providers must track and document the worker's functional status using validated instruments such as the World Health Organization Disability Assessment Schedule (WHODAS) or other substantially equivalent validated instruments recommended by the department. A copy of the completed functional assessment instrument must be sent to the attending provider and the department or self-insurer, as required by department policy or treatment guideline. 19

20. Additional Written Comments & Questions Contact: Jami Lifka, Office of the Medical Director Email:jami.lifka@Lni.wa.gov 20

21. RCW 51.08.100 "Injury."  "Injury" means a sudden and tangible happening, of a traumatic nature, producing an immediate or prompt result, and occurring from without, and such physical conditions as result therefrom. Appendix A

22. RCW 51.08.140 "Occupational disease." "Occupational disease" means such disease or infection as arises naturally and proximately out of employment under the mandatory or elective adoption provisions of this title. Appendix B

23. RCW 51.08.142 "Occupational disease" — Exclusion of mental conditions caused by stress. The department shall adopt a rule pursuant to chapter 34.05 RCW that claims based on mental conditions or mental disabilities caused by stress do not fall within the definition of occupational disease in RCW 51.08.140.34.0551.08.140 Appendix C