ADOPTED 
 RULES 
 
 An agency may take final action on a section 30 days after a proposal has been 
published in the  Texas Register. The section becomes effective 20 days after 
the agency files the correct document with the  Texas Register, unless a later 
date is specified or unless a federal statute or regulation requires 
implementation of the action on shorter notice. 
 If an agency adopts the section without any changes to the proposed text, only 
the preamble of the notice and statement of legal authority will be published. 
If an agency adopts the section with changes to the proposed text, the proposal 
will be republished with the changes. 
 
   
  TITLE 10. COMMUNITY DEVELOPMENT 
 Part IV. Texas Department of Housing and Community Affairs 
  Chapter 1. Administration 
  
  Subchapter D. Public Records 
 
  10 TAC sec.sec.1.51-1.56 
 
  The Texas Department of Housing and Community Affairs adopts new sec.sec.1. 
51-1.56, without changes to the proposed text as published in the July 19, 1994, 
issue of the Texas Register (19 TexReg 5569) describing the charges that the 
agency will make for copies of public records. This section is proposed to 
comply with Chapter 428, Acts of the 73rd Legislative Regular Session (1993), 
which requires state agencies to adopt rules setting forth the charges the 
agency will make for copies of public records. The Texas Department of Housing 
and Community Affairs follows the guidelines adopted by the Texas General 
Services Commission. 
 No comments were received regarding adoption of the new sections. 
 The new sections are adopted pursuant to the authority of the Texas Government 
Code, Chapter 2306; Acts of the 73rd Legislative Regular Session, Chapter 141, 
page 292, SB 45, effective May 16, 1993; and Acts of the 73rd Legislative 
Regular Session, Chapter 725, page 2838, SB 1356, effective September 1, 1993, 
which provides the Texas Department of Housing and Community Affairs the 
authority to adopt rules governing the administration of the agency and its 
programs and Chapter 428, Acts of the 73rd Legislative Regular Session (1993), 
which requires the adoption of rules on open records charges. 
 
  This agency hereby certifies that the rule as adopted has been reviewed by 
legal counsel and found to be a valid exercise of the agency's legal authority. 
 Issued in Austin, Texas, on December 29, 1994. 
 TRD-9452952 
  Henry Flores 
 Executive Director 
 Texas Department of Housing and Community Affairs 
    Effective date: January 19, 1995 
 Proposal publication date: July 19, 1994 
 For further information, please call: (512) 475-3978 
         
               
  TITLE 28. INSURANCE 
 Part I. Texas Department of Insurance 
  Chapter 7. Corporate and Financial 
  
  Subchapter T. Permissible Payments to Insurers, Agents, and Sponsoring 
Organizations 
 
  28 TAC sec.7.2001 
 
  The Commissioner of Insurance of the Texas Department of Insurance adopts new 
sec.7.2001, concerning sponsoring organizations soliciting voluntary 
contributions pursuant to the Insurance Code, Article 21.35B, without changes to 
the proposed text as published in the November 8, 1994, issue of the Texas 
Register (19 TexReg 8842). 
 Section 7.2001 permits a sponsoring organization to solicit a voluntary 
contribution from an insured. A solicitation of a voluntary contribution can be 
made in connection with the sponsoring organization's membership renewal 
solicitation but the contribution solicitation must be entirely separate from 
any type of insurance billing. The new section is necessary because the 73rd 
Texas Legislature amended Article 21.35B to require the Commissioner to 
promulgate a rule permitting sponsoring organizations to solicit voluntary 
contributions under certain prescribed circumstances. 
 The effect of the new section will be to permit the sponsoring organization's 
practice of soliciting voluntary contributions at the same time they solicit 
membership renewals but protect members of the sponsoring organization from the 
solicitation of contributions as part of an insurance billing. 
 No comments were received regarding adoption of the new section. 
 The new section is adopted pursuant to the Insurance Code, Articles 21.35B, 
1.03A, and 1.04C; and the Government Code,  sec.sec.2001.004 et seq. The 
Insurance Code, Article 21.35B requires the Commissioner to adopt a rule 
permitting sponsoring organizations to solicit voluntary contributions with 
membership renewals, but explicitly prohibiting solicitation of contributions 
with an insurance billing. Article 1.03A provides that the Commissioner of 
Insurance may adopt rules and regulations, which must be for general and uniform 
application, for the conduct and execution of the duties and functions of the 
Texas Department of Insurance only as authorized by statute. Article 1.04C of 
the Insurance Code requires the Commissioner to develop and implement policies 
that provide the public with a reasonable opportunity to appear before the 
Commissioner and to speak on any issue under the Commissioner's jurisdiction. 
The Government Code, sec.sec.2001.004 et seq (Administrative Procedures Act) 
authorizes and requires each state agency to adopt rules of practice setting 
forth the nature and requirement of available procedures and to prescribe the 
procedures for adoption of rules by a state administrative agency. 
 
  This agency hereby certifies that the rule as adopted has been reviewed by 
legal counsel and found to be a valid exercise of the agency's legal authority. 
 Issued in Austin, Texas, on January 2, 1995. 
 TRD-9500001 
  D. J. Powers 
 Chief Clerk and General Counsel 
 Texas Department of Insurance 
    Effective date: January 23, 1995 
 Proposal publication date: November 8, 1994 
 For further information, please call: (512) 463-6327 
         
               
  Part II. Texas Workers' Compensation Commission 
  Chapter 134. Guidelines for Medical Services, Charges, and Payments 
  
  Chapter K. Treatment Guidelines 
 
  28 TAC sec.134.1000 
 
  The Texas Workers' Compensation Commission (the commission) adopts new 
sec.134.1000, concerning mental health treatment guidelines, with changes to the 
proposed text published in the June 24, 1994, issue of the Texas Register  (19 
TexReg 4869). Revisions to the proposed rule that were made in response to 
public comment received are referred to in the summary of comments and responses 
portion of this preamble. Other revisions made to the proposed rule consist of 
the correction of typographical errors and rewording for clarification purposes. 
As required by the Government Code, sec.2001.033(1), the commission's reasoned 
justification is set out in the following paragraphs of this preamble which 
discuss the reasons why the rule is necessary, the factual, policy, and legal 
bases for the rule, a summary of comments received, names of interested groups 
or associations that commented and whether they are for or against adoption of 
the rule; and the reasons why the agency disagrees with the comments, 
submissions, and proposals. 
 The Medical Review Division, in conjunction with the Medical Advisory Committee 
(MAC), a work group, and a broad representation from the medical community have 
worked together to develop the Mental Health Treatment Guideline. By statute, 
the MAC is to advise the division in developing and administering the medical 
policies, fee guidelines, and utilization guidelines established under the Texas 
Labor Code, sec.413.011. The MAC advises the commission or professional 
organization in the review and revision of medical policies and fee guidelines 
required under the Texas Labor Code, sec.413.012. The MAC is composed of members 
from the following fields, appointed by the commission: public health care 
facility, private health care facility, a doctor of medicine, doctor of 
osteopathic medicine, a chiropractor, a dentist, a physical therapist, a 
pharmacist, a podiatrist, an occupational therapist, a medical equipment 
supplier, a registered nurse, a representative of employers, a representative of 
employees, and two representatives of the general public. A work group was 
developed because the MAC does not have a representative from the mental health 
profession at this time. Recommendations for work group members were obtained 
from selected MAC members and professional organizations. The work group was 
composed of two psychologists, a psychiatrist, and commission staff (some with 
medical backgrounds). Members of the work group, along with Medical Review 
staff, met on a routine basis to develop the ground rules and clinical courses 
of treatment. A representative from the work group as well as the Medical Review 
Division Director provided updates to the MAC at their monthly meetings. The 
decision as to which treatments would go into the guideline, and the frequency 
and duration of those treatments was based on consideration of all statutory 
factors (discussed in the following paragraphs of this preamble), the input of 
the participants regarding treatments that are commonly used and medically 
accepted, recognized research studies, and consideration of all comments on the 
proposed rule. The research studies used as a reference and factual basis by the 
work group are reflected in the bibliography contained in the guideline. The 
knowledge, clinical expertise and qualifications of the work group members and 
the agency board and staff also served as the basis for the development and 
drafting of the guideline. The expertise was used to establish typical courses 
of intervention and to set documentation standards. 
 This guideline is proposed in order to comply with a statutory mandate that the 
commission effect cost containment, as well as to fulfill the directives in the 
Texas Labor Code, sec.413.011 and sec.413.013 that the commission establish 
guidelines for medical policies relating to necessary treatments for injuries 
that ensure the quality of medical care and achieve effective medical cost 
control (sec.413.011); and programs for prospective, concurrent, and 
retrospective review of the necessity of treatments administered sec.(413.013). 
 This rule provides guidelines to address the issue of mental health treatment. 
Injured workers' emotional health is affected by the socioeconomic stressors of 
dealing with a work-related injury, hence the importance of this guideline. In 
addition, because of the subjectivity of mental health and mental health 
treatments and services, this is an area perceived as one of potential abuse. 
The potential for abuse is perceived by both employers and insurance carriers. 
This is due to the fact that the tests and treatments provided by the mental 
health profession are open to interpretation and a direct relation between 
testing, treatment and resulting changes in conditions cannot be consistently 
proven. For these reasons, and as directed by statute, the commission has 
adopted treatment guidelines for the area of mental health treatment. This 
guideline, through established criteria, documentation requirements, and 
timeframes provides a basis for review of these treatments and services as 
required by statute to ensure quality medical care, cost control, and review of 
necessity of treatments. This guideline should help reduce negative perceptions 
regarding potential abuse due to the subjectivity of mental health treatments 
and services, because it sets forth some standard courses of treatment and 
documentation which are agreed upon by the experts as being appropriate, 
reasonable and necessary for specific mental disorders. It also requires 
additional documentation/justification for treatment outside the guideline 
parameters. 
 This guideline is to be used by health care providers as a tool to establish 
the required elements for all providers to initiate treatment. The insurance 
carrier should use this guideline to compare treatment prospectively, 
concurrently, and retrospectively with the predetermined elements contained in 
this guideline. The commission's primary mission in initiating and developing 
this guideline is to ensure appropriate parameters relating to necessary 
treatments for compensable injuries; to provide a tool for monitoring of the 
necessity of treatments administered; and to provide a tool to review typical 
healthcare treatment. 
 The guideline provides for a mental health evaluation without referral from a 
treating doctor only in emergency situations. It also sets out the documentation 
required for treatment beyond the initial emergency mental health evaluation. 
Preauthorization of a mental health evaluation and mental health treatment will 
be as required in the commission's rule on preauthorization, which was recently 
published in the November 1, 1994, issue of the Texas Register (19 TexReg 8665), 
as a proposed new rule for public comment. 
 This guideline is not to be viewed as being prescriptive or prohibitive in 
nature, or to be used as the sole basis for denial of services. It reflects 
typical courses of intervention. Treatment falling outside these parameters is 
allowed, but will be subject to more careful scrutiny and require additional 
documentation of the special circumstances to justify the need for treatment. 
 The guideline has been designed to achieve the following statutory and policy 
objectives: 
 (1) to ensure quality health care to the injured workers of Texas; 
 (2) to achieve effective medical cost control; and 
 (3) to establish a program for prospective, concurrent, and retrospective 
review of the necessity of treatments. 
 The guideline achieves these objectives by: 
 (1) assisting all parties with regard to the appropriate treatment and 
management of mental disorders in workers' compensation healthcare; 
 (2) identifying clinically acceptable courses of treatment for specific mental 
disorders; 
 (3) establishing documentation standards which support the appropriateness of 
the level of service for assessment/evaluation and on-going treatment; 
 (4) establishing treatment parameters based on a diagnostic grading system 
which allows for categorization of the manifestation of distress during the 
current phase of injury; 
 (5) establishing parameters for eligibility for and termination of treatment; 
and 
 (6) providing a mechanism for a prospective, concurrent, and retrospective 
review to ensure efficient and effective utilization of healthcare services. 
 Quality of medical care is ensured by reliance upon input from experts and 
recognized studies in the field of mental health treatment, and establishment of 
acceptable courses of treatment and treatment parameters for specific mental 
health disorders. The guideline ensures access to health care and that quality 
care will be available in each individual case by its ground rules that allow 
for treatment outside the stated parameters. 
 Effective medical cost control is achieved by establishing parameters for 
eligibility and termination of treatment, by setting documentation standards 
which support the appropriateness of the treatment; by requiring additional 
documentation for treatment falling outside the guideline's parameter; and by 
providing that mental health evaluations and treatments are subject to the 
commission's separate rule requiring carrier preauthorization for certain 
treatments as a prerequisite to payment for the services. 
 The guideline allow for prospective, concurrent, and retrospective treatment 
by: setting standards for eligibility and treatment and setting documentation 
standards. These standards are to be used by mental health care providers as a 
basis for prospective review of possible treatment. The guideline and the 
documentation requirements should also provide the mental health care provider 
with a means to justify treatments when questioned concurrently or 
retrospectively by an insurance carrier. 
 The guideline and documentation also provide a starting point for carriers in 
conducting prospective, concurrent, or retrospective review of treatment. 
Finally, the Medical Review Division and the Compliance and Practices Division 
will also use the guideline and documentation as a tool for prospective, 
concurrent, and retrospective review of treatment, including use in conducting 
on-site audits of health care providers and insurance carriers. 
 The commission carefully and fully analyzed all the facts presented and the 
statutory objectives in formulating this guideline. In accordance with these 
statutory objectives and commission policy, the guideline balances the need for 
cost control and review with the need for access to quality medical care by 
establishing typical courses of treatment, but allowing treatment outside the 
set parameters with additional documentation of the need for the treatment. As a 
result, mental health treatment will be scrutinized and reviewed, but all 
reasonable and necessary mental health treatment will be provided. This is in 
accord with statutory objectives as well as commission policy and the facts 
before the commission. 
 Comments on the proposed new rule were received from The Texas Workers' 
Compensation Insurance Fund, the Texas Back Institute Research Foundation, EBI 
Companies, Williams Insulation Co., The University of North Texas Health Science 
Center at Fort Worth, the Texas Osteopathic Medical Association, Life Care 
Consultants, Advanced Pain Management, Smith & Associates, the American 
Insurance Association, the Texas Association of Business, the Texas Chiropractic 
Association, Hammerman and Gainer, Kyle Babick, Ph.D., Steven Callahan, Ph.D., 
and Dr. Robert Peinert. 
 The following groups submitted comments which expressed general opposition to 
the proposed rule: EBI Companies, the Texas Association of Business, the 
American Insurance Association, Hammerman & Gainer, Advanced Pain Management, 
Williams Insulation Co. of Austin, and the Texas Workers' Compensation Insurance 
Fund. 
 The following groups submitted comments which expressed general support of the 
proposed rule: the Texas Back Institute Research Foundation, the University of 
North Texas Health Science Center at Fort Worth, Smith & Associates, the Texas 
Physical Therapy Association, Life Care Consultants, Kyle Babick, Ph.D., and 
Steven Callahan, Ph.D. 
 The following groups and/or individuals submitted comments which suggested 
changes to the rule as proposed, but did not specifically state whether they 
were in overall support or opposition to the rule: The Texas Osteopathic Medical 
Association and Dr. Robert Peinert. 
 Full and objective analysis and consideration was given to all comments 
received, as evidenced by the revisions made from the rule as proposed, and the 
responses to comments in the following paragraphs of this preamble. The factual, 
statutory, and policy bases for parts of the rule which received comments, are 
described in these responses. 
 A summary of the comments received and the commission responses are as follows. 
 The following comments were received regarding review of records: 
 COMMENT: In subsection (e)(1)(A), the term "health care professional" is used. 
This term should be changed to either "health care practitioner" or "health care 
provider", terms used in the Texas Workers' Compensation Act. 
 RESPONSE: The commission agrees. To be consistent with the other proposed 
guidelines, the defined term "health care provider" has been used in the revised 
guideline instead of the undefined term "health care professional". 
 COMMENT: In subsection (e)(2)(D), the release of "raw" (uninterpreted) data to 
an unknown peer reviewer appears to be permitted. Under Rule 465.2 of the Texas 
State Board of Examiners of Psychologists, release of this data may only be done 
to another qualified and licensed psychologist. Therefore, the last sentence of 
this paragraph which currently reads "Providers who are unable to obtain the 
name of the reviewer, but who have inquired and been told the reviewer is a 
licensed psychologist are considered to have satisfied their obligation 
regarding appropriate disclosure." needs to be altered to read: "Psychologists 
who are asked to submit such documents must be given the name of the licensed 
psychologist conducting the review, in order to verify qualification and 
licensure, consistent with Rule 465.2 of the Texas State Board of Examiners of 
Psychologists." An alternate suggestion was to delete this section. 
 RESPONSE: The commission agrees that the sentence should be revised, but not 
that it should be deleted. The commission acknowledges the concern expressed by 
the commenters regarding this paragraph. This paragraph [now (d) (2)(D)] has 
been revised to read as follows: "Qualified mental health providers who are 
asked to submit such documents must be given the name of the qualified mental 
health provider conducting the review in order to verify qualification and 
licensure, consistent with the requirements of the governing board for that 
profession." 
 COMMENT: There are several problems with subsection (e) relating to 
confidentiality. This draft does not appear to recognize the existence of some 
significant federal statutes and regulations affecting confidentiality of mental 
health and substance abuse records. 
 RESPONSE: The commission agrees, and acknowledges concerns expressed by the 
commenter regarding the need to preserve the confidentiality of mental health 
and substance abuse records. It is acknowledged that there are some federal 
statutes which should be taken into consideration regarding the confidentiality 
of these records. These statutes apply to providers or facilities receiving 
federal funding, including Medicare and Medicaid funding. These statutes may 
also apply to federally tax exempt, nonprofit organizations. An additional 
paragraph, addressing this concern, has been added to the guideline. This 
paragraph [now (d)(2)(G)] reads as follows: "TWCC will address situations where 
federal statutes supersede state statutes regarding confidentiality on a case-
by-case basis." 
 COMMENT: In subsection (e)(2)(B) and (C) and in subsection (e)(3), it appears 
that access by the insurance carrier to routine session notes would be limited. 
This would make it difficult for the insurance carrier to determine the causal 
relation between the treatment provided and the compensable injury. According to 
the commenter, the Health and Safety Code authorizes the release of these notes 
to a carrier, and the proposed language exceeds TWCC's statutory authority. A 
recommendation was made to either delete or edit this section. 
 RESPONSE: The commission disagrees. In writing this these paragraphs and 
subparagraphs [now (d)(2)(B) and (C) and (d)(3)], an attempt was made to strike 
a balance between the carrier's need to have detailed information about the 
injured worker's treatment, and the injured worker's need to have a reasonable 
expectation of confidentiality when working with the mental health provider. It 
is not uncommon for the injured worker to share personal information with the 
mental health provider which must be documented for professional and liability 
reasons. If it is known that this personal information may be regularly 
disseminated to a variety of parties, it is unlikely that the injured worker 
will share this information, and his/her treatment may be limited by this self-
censorship. It is also acknowledged that the insurance carrier needs sufficient 
information to determine the causal relation between the treatment provided and 
the compensable injury, and to determine the effectiveness of this treatment. In 
order to provide a balance between these two needs, a specific documentation 
format was provided for evaluations and ongoing treatment, providing necessary 
information to the carriers while limiting access to individual session notes 
except under specific circumstances. Documentation requirements are located in 
subsection (g)(4) and subsection (h)(6) of this guideline. In addition, the 
Health and Safety Code governing authorized disclosure of confidential 
information does not require disclosure but provides limitations regarding to 
whom some information may be disclosed. 
 COMMENT: In subsection (g)(5)(A)(iv) and subsection (h)(3)(B)(iii), CPT codes 
are provided not only for consultations but also for the review of records. The 
E/M codes for consultation incorporate the review of records under the medical 
decision-making component. The recommendation, as stated in these sections, 
appears to endorse an "unbundling" of these E/M codes. 
 RESPONSE: The commission disagrees. The commission acknowledges the concerns 
expressed that these sections [now (f)(5)(A)(iv) and (f)(3)(B)(iii)] appear to 
recommend an "unbundling" of the E/M codes for evaluation of the injured worker. 
It is incumbent on the provider to use the most appropriate code in billing for 
his/her services. If the code selected includes the preparation of a report, 
then a separate code for that service should not be included on the bill. If the 
provider only performs a review of the medical records, then the code for that 
service should be used. It is the responsibility of both the provider and the 
carrier to ensure that appropriate coding is utilized for the services rendered. 
 COMMENT: Concern was expressed that the ground rules state that the guideline 
is not to be used as a basis for denial; however, it appears that the guideline 
opens up areas of potential abuse which can then only be refuted through peer 
review. 
 RESPONSE: The commission agrees. The statement referred to in subsection (e) 
(2)(A) has been revised to read as follows: "This guideline and its threshold 
levels or parameters is only a guideline and is not to be used as the sole  
reason for denial of treatments and services." 
 The following comments were received regarding stress related claims. 
 COMMENT: In subsection (g)(3)(C), the definition of post traumatic stress 
disorder is not specific. It is recommended that the definition be expanded to 
include the wording "experiencing an event that is outside the range of usual 
human experience and that would be markedly distressing to almost anyone." This 
addition to the definition would decrease the likelihood that there would be an 
increase in the number of "stress" type claims that are not truly post traumatic 
stress disorder. 
 RESPONSE: The commission agrees. The wording, as present in the published 
guideline, was vague and did not clearly define when the diagnosis of post 
traumatic stress disorder could be utilized. The guideline has been revised and 
subsection (f)(3)(C) now reads as follows: "Post traumatic stress disorder, or 
other mental disorders not accompanying a physical injury, are eligible for 
intervention provided the disorder has resulted from or was exacerbated by a 
compensable injury, including a mental trauma injury caused by a sudden and 
ascertainable traumatic event(s) that is traceable to a definite time, place, 
and cause on the job." 
 COMMENT: In subsection (g)(1)(A), the rule, as stated, does not appear to 
reflect current case law. The wording [now (f)(1)(A)] should be as follows: "An 
employee may receive psychological services prescribed by a doctor for a 
compensable mental disorder that has resulted from or was exacerbated by a 
compensable injury or an undesigned, untoward, accidental single event that is 
traceable to a definite time, place, and cause." An alternative wording 
suggested by another commenter is "In order for mental disorders to qualify for 
medical benefits under the Texas Workers' Compensation Act, documentation of the 
mental disorder must demonstrate that it has naturally resulted from ..." 
 RESPONSE: The commission agrees. In order to clarify the rule and bring it into 
compliance with current case law, this subparagraph has been re-worded. The 
subparagraph now reads as follows: "An employee may receive a mental health 
evaluation for a compensable mental disorder that has resulted from, or was 
exacerbated by, a compensable injury, including a mental trauma injury caused by 
a sudden and ascertainable traumatic event(s) that is traceable to a definite 
time, place, and cause on the job. The employee is entitled to this evaluation 
without referral, if the evaluation constitutes an emergency treatment. 
 COMMENT: It was not the intent of the work group to expand or restrict the 
scope of compensability as presently defined under the Act. If the commission 
does not want to expand the scope of mental claims, it should add clarifying 
terms such as "sudden and unexpected" or "outside the scope of normal employment 
experiences" to the guideline. 
 RESPONSE: The commission agrees. Revisions have been made to the guideline to 
more accurately reflect case law and to clarify the definition of post-traumatic 
stress disorder to reflect current limitations. Please refer to the first two 
questions of this category for the proposed revisions. 
 COMMENT: In subsection (g)(1)(B), the language, as written, is not clear. It is 
recommended that this subparagraph be reworded to state "must contact the 
referring doctor or prescribing doctor to clarify the indications for the mental 
health referral." 
 RESPONSE: The commission agrees. The commission acknowledges the concerns 
expressed regarding intent of this subparagraph [now (f)(1)(B)], as stated. 
However, the addition of the phrase recommended by the commenters does not 
appear to be necessary. The referral for mental health evaluation and treatment 
should originate from the treating doctor. "Treating doctor" is defined in the 
law and does not need to be further clarified in this subparagraph or modified 
to read "referring" or "prescribing". To clarify the intent of this paragraph, 
this section has been re-written and now reads as follows: "If the referral by 
the treating doctor does not clearly state the indications for 
assessment/evaluation as described in subsection (g)(2) or ongoing treatment as 
described in subsection (h)(2), the health care provider must contact the 
referral source to clarify the reason for the mental health intervention." 
 COMMENT: In subsection (g)(3)(A), the first sentence should be modified to read 
as follows: "personality disorders are eligible for intervention only if the 
personality disorder interferes with the ability to cooperate with medical 
treatment regimens for the compensable injury ." This change would exclude those 
situations where an injured worker is receiving treatment services for 
conditions not related to the compensable injury. 
 RESPONSE: The commission agrees. The language [now in (f)(3)(A)] has been 
revised and now reads as follows: "Personality disorders are eligible for 
intervention only if the personality disorder interferes with the ability to 
cooperate with medical treatment regimens for the compensable injury." 
 COMMENT: In subsection (g)(1)(A), a commenter suggested that the original 
language, as agreed upon by the work group, be restored as an additional 
requirement. This restored subparagraph should read as follows: "Additionally, 
documentation of the mental disorder must demonstrate that either (1) it 
presently interferes with, or is expected to interfere with recovery, compliance 
with treatment, or ability to benefit from treatment or, (2) presently limits, 
or is expected to limit, the injured worker's ability to return to and/or retain 
employment." 
 RESPONSE: The commission agrees. This original language of this subparagraph 
was inadvertently deleted in the editing process. The two statements are 
important, in that they directly link intervention for mental disorders with 
those health care services covered under the Act. The two statements have been 
reinserted [now in (f)(1)(A)]. 
 The following comments were received regarding the peri-operative algorithm and 
the peri-operative mental health evaluation. 
 COMMENT: The peri-operative algorithm appears to imply that vocational 
rehabilitation is covered under the auspices of the Mental Health Treatment 
Guideline. 
 RESPONSE: The commission disagrees. The commission acknowledges the concern 
expressed that the algorithm is confusing. However, within the context of the 
algorithm, vocational rehabilitation is not a recommended treatment. According 
to the algorithm, vocational rehabilitation referral is one of several factors 
which may need to be considered when determining whether an injured worker needs 
referral for mental health evaluation and/or treatment. Vocational 
rehabilitation is not a treatment which is covered under the Act. 
 COMMENT: Subsection (h)(2)(C), and the algorithm on peri-operative care, 
although initially appearing to increase the cost of care to the insurance 
carriers, may actually lower the cost of care to the surgical patient. By 
evaluating patients preoperatively, and eliminating those patients who are poor 
surgical candidates, it is insured that those patients who do undergo surgery 
are those who have the highest likelihood of successful postoperative recovery. 
Support was expressed for this section. 
 RESPONSE: The commission agrees. 
 COMMENT: It appears that the peri-operative algorithm was omitted from the 
Texas Register rule format. This algorithm was present in the original format. 
 RESPONSE: The commission disagrees. The peri-operative algorithm was published 
in the May 27, 1994 issue, of the Texas Register (page 4103), and in the 
reproposal published in the June 24, 1994, issue (page 4886). 
 COMMENT: In subsection (h)(2)(C)(vi), cigarette smoking appears to be a basis 
for peri-operative mental health evaluation. The inclusion of this factor in the 
list of conditions triggering a preoperative mental health evaluation is 
questioned. 
 RESPONSE: The commission agrees. Reference to cigarette smoking as a factor for 
consideration for referral for mental health treatment has been eliminated from 
the revised guideline [now (g)(2)(C)(iv)]. Although cigarette smoking has been 
demonstrated (in accordance with the research provided by the work group 
representing the medical community) to increase the risk of failure of bone 
growth in spinal fusions, the use of mental health treatment to address this 
issue is not necessary. It is necessary for the treating doctor and/or proposed 
surgeon to consider this factor when determining both the need for surgery and 
the chances for a successful outcome of this surgery when evaluating the injured 
worker, and to recommend, when appropriate, a program to enable the injured 
worker to stop smoking for a period of time perioperatively to increase the 
likelihood of a successful outcome for surgery. 
 COMMENT: In subsection (h)(2)(C)(vii), the list of those stressors as a basis 
for initiating a preoperative mental health evaluation is questioned. This could 
possibly provide a "back door" for treatment of conditions that are not related 
to the compensable injury. 
 RESPONSE: The commission disagrees. The factors included in this subsection 
[now (g)(2)(C)(vii)] have been demonstrated, as presented by the work group, to 
have a potential to interfere with the injured worker's appropriate activation 
or rehabilitation following surgery, thereby increasing the cost of 
postoperative care if these factors are not identified and appropriately 
treated. This subsection lists criteria which are considered appropriate for 
evaluation only; it does not guarantee that intervention for these factors or 
stressors will be eligible for treatment under the workers' compensation system. 
 COMMENT: In subsection (h)(2)(C), it appears that a mental health evaluation is 
deemed appropriate whenever "there is a desire" to determine psychological 
suitability. The subsection does not clarify who makes the "desire" effective; 
in addition, it establishes the preoperative mental health evaluation as a 
normative practice. This practice appears to increase the cost to the insurance 
carriers and employers. 
 RESPONSE: The commission agrees. This subsection does need to be clarified to 
indicate that the determination of the need for a peri-operative psychological 
evaluation is made by the treating doctor and/or surgeon. The guideline [now 
(g)(2)(C)] has been revised to read as follows: "In addition to the indications 
noted in subparagraphs(A) and (B) of subsection (g)(2), mental health 
assessment/evaluation is appropriate when a patient is a candidate for surgical 
intervention and the treating doctor and/or surgeon has determined there is a 
need to assess the patient's psychological suitability for surgery and risk of 
poor outcome." However, this rule does not establish preoperative mental health 
evaluation as a normative practice. Preoperative mental health evaluation would 
be considered only in specific situations listed in this subsection where there 
is risk of failure or mental/behavioral issues interfering with recovery and 
increasing costs. Identifying the injured worker with a high risk of failure, 
particularly in situations where surgery is marginally indicated, should produce 
cost savings. This also gives carriers protection against the cost of surgery in 
cases where the physical indications for surgery are equivocal and mental 
factors clearly tip the scales against proceeding with surgery. 
 The following comments were received regarding biofeedback. 
 COMMENT: It appears that the number of treatments for biofeedback offered by 
the guideline exceeds the average number of treatments necessary, according to 
the commenter's experience. The commenter suggests that a total number of 12 
treatments would more closely approximate what is currently considered 
appropriate. A second commenter stated that treatment in excess of eight to ten 
sessions, if unsuccessful, may be of no further benefit. 
 RESPONSE: The commission disagrees. Based on clinical standards of treatment 
presented to the commission by the work group, which consisted of qualified 
mental health providers, 24 sessions is the proper number to cover the majority 
of situations. If a patient has achieved full benefits prior to this, treatment 
should be discontinued. However, if a patient is showing definite progress but 
requires more than 24 sessions, more treatment can be requested with adequate 
documentation of need and progress. 
 COMMENT: The commenter is pleased to see the role of biofeedback defined, 
especially the inclusion of conditions other than psychological conditions in 
the list of those diagnoses for which biofeedback is considered appropriate. 
However, the frequency schedule appears to be minimal for adequate training in 
the experience of this commenter. 
 RESPONSE: The commission disagrees. Based on clinical standards of treatment, 
presented by the work group which consisted of qualified mental health 
providers, 24 sessions should be adequate to cover the majority of situations. 
If a patient has achieved full benefits prior to this, treatment should be 
discontinued. However, if a patient is showing definite progress but requires 
more than 24 sessions, more treatment can be requested with adequate 
documentation of need and progress. 
 COMMENT: Subsection (g)(6) on biofeedback, as written, appears to threaten the 
jobs of those currently providing biofeedback training who are not Qualified 
Mental Health Professionals. The commenter is a certified biofeedback therapist 
but is not a qualified mental health professional. 
 RESPONSE: The commission disagrees. The intent of the guideline is not to 
restrict or threaten jobs of some providers. The guideline has been revised to 
better clarify the statutory limitations. Subsection (e)(1)(A) now reads, " A 
Qualified Mental Health Provider (QMHP) is defined as someone who is 
independently licensed to provide mental health services, within the scope of 
practice defined by their applicable practice Act. A nonlicensed individual is 
not a QMHP but may provide services defined in this guideline under the 
direction or supervision of a QMHP." According to the Texas Labor Code, sec.401. 
011(21)(a) and (b), "Health care practitioner means: (a) an individual who is 
licensed to provide or render and provides or renders health care; or (b) a 
nonlicensed individual who provides or renders health care under the direction 
or supervision of a doctor." 
 COMMENT: The list of nonmental health related medical conditions (subsection 
(g)(6)(D)) which are considered appropriate for biofeedback treatment is vague 
and needs clarification. 
 RESPONSE: The commission disagrees. The list of nonmental health related 
medical conditions, as listed [now(f)(6)(D)], is specific to either symptoms or 
diagnoses which are appropriate for biofeedback. This list of nonmental health 
related medical conditions is based on information presented to the staff, by 
the work group members, who are qualified health care providers. 
 COMMENT: In subsection (h)(3)(B)(v), there is a requirement that a mental 
health assessment evaluation be obtained prior to doing a psychophysiological 
assessment for biofeedback. This requirement may not be necessary for 
individuals referred for biofeedback for nonmental health purposes. When the 
target is to treat a specific neuromuscular habit problem not accompanied by any 
other indication of mental problems, the decision to provide a comprehensive 
mental health evaluation before initiating biofeedback should be left to the 
discretion of the qualified mental health provider. 
 RESPONSE: The commission disagrees. A major concern in referring the injured 
worker for biofeedback is the presence of an underlying mental or emotional 
disorder that has not been identified or addressed. This subsection [now 
(g)(3)(B)(vi)] was written in an effort to address this problem. While it is 
true that a "specific neuromuscular habit problem" may not be accompanied by a 
mental disorder, this can only be ruled out with some type of evaluation. Such 
an evaluation need not be elaborate, but should be conducted by a qualified 
mental health provider. 
 The following comments were received regarding consideration of injury 
related/non-injury related factors. 
 COMMENT: In subsection (g)(8)(A), (B), and (C), factors are outlined regarding 
liability for payment of mental health care treatments and services. This area 
is extremely contentious between the insurance carriers and the qualified mental 
health providers. It appears that the carrier is being asked to pay for services 
not directly related to the compensable injury. Clarification needs to be 
provided regarding where the burden of proof lies in proving causal relation 
between the compensable injury and mental health treatment. 
 RESPONSE: The commission disagrees. As is clearly stated in this subsection 
[now (f)(8)], "Any factor which does not arise from the compensable injury will 
not be considered as a rationale for the reasonableness or necessity of care 
under the Act." In other sections of the document, it is clearly outlined that 
the provider is required to assess the injured worker for the presence of a 
history of mental disorders, substance abuse, and other factors to determine 
whether the current symptoms are causally related to the compensable injury or 
to a pre-existent or non-related disorder and to document this determination. 
 The following comments were received regarding indications and parameters for 
assessment/evaluation and ongoing treatment. 
 COMMENT: Subsection (h)(2) and (3) are confusing as to the number of hours to 
be reimbursed for the interview. The paragraphs do not clarify what requires 
preauthorization. 
 RESPONSE: The commission agrees. Subsection (g)(2)(A) is confusing as written. 
This section has been re-written and now reads as follows: "An employee may 
receive both a mental health evaluation and treatment in the event of an 
emergency situation. In other instances, preauthorization for a mental health 
evaluation and any subsequent treatment will be as required in the commission's 
rule on preauthorization. 
 COMMENT: Support was expressed for the proposal allowing a limited 
psychological evaluation without preauthorization. This allows rapid 
psychological intervention in the wake of trauma or in the case where a 
determination is needed regarding treatment for a mental health disorder. By 
limiting this evaluation to three hours, the guideline has assured that there 
will be no overutilization. Support was also expressed for the assessment 
evaluation guidelines. It was felt that those guidelines provided a reasonable 
amount of time for initial evaluation and that the format for presenting 
findings should ease the concerns which the providers may have regarding the 
quality of services provided. 
 RESPONSE: The commission agrees with the statement that preauthorization is not 
required for mental health evaluation and treatment in the event of an emergency 
situation. However, except in an emergency situation, all mental health 
evaluation and treatment will still require a referral from a treating doctor, 
and preauthorization where required by the commission's preauthorization rule. 
 COMMENT: Disagreement was expressed regarding allowing a three hour mental 
health examination without the need for preauthorization. It was felt that this 
action would open the door for uncontrolled front-end costs, encouraging abuse. 
In addition, doctor referral, even in an emergency, was felt to be appropriate 
since the services of a doctor will be required to stabilize the injured worker 
in an emergency. The comment was also made that the allowance of a three hour 
evaluation without preauthorization was in direct contradiction to the current 
preauthorization rule. 
 RESPONSE: The commission agrees. Except in an emergency situation, a mental 
health evaluation and mental health treatment will continue to require referral 
from a treating doctor, and preauthorization will be as required in the 
commission's preauthorization rule. 
 COMMENT: Concern was expressed that no charge was provided for the initial 
evaluation and that this lack of a dollar value would lead to increased costs 
for the insurance carrier. 
 RESPONSE: The commission disagrees. The codes which would be used to describe 
the initial evaluation and any recommended costs for that evaluation would be 
included in the Medical Fee Guideline or any subsequent revision of that 
guideline. 
 COMMENT: The three hour evaluation was intended to serve as a brief evaluation 
to assess a patient's readiness for work hardening without preauthorization. 
 RESPONSE: The commission disagrees. Although a mental health evaluation prior 
to initiation of a work hardening program may be warranted, the treating doctor 
is responsible for determining the need for this type of evaluation and 
obtaining preauthorization for this evaluation. 
 COMMENT: The original recommendation was that a total of five hours of mental 
health evaluation be allowed without preauthorization. The follow-up language is 
missing which indicates that evaluations beyond those time limits are allowed 
only if preauthorized. 
 RESPONSE: The commission disagrees. Except in an emergency situation, a mental 
health evaluation of any timeframe and mental health treatment will continue to 
require referral from a treating doctor, and preauthorization will be required 
as stated in the commission's rule on preauthorization. Revisions have been made 
in the guideline to reflect the intent that a mental health evaluation was 
allowed without preauthorization. 
 COMMENT: In subsection (i)(4)(J), it appears that this rule would provide for 
treatment guidelines for mild or transient disorders lasting longer than acute 
stress reactions that occur in individuals of any age with any apparent pre-
existing mental disorder. It is felt that treatment for these types of 
conditions should not be allowed unless the mental condition is prolonged. It is 
felt that this part of the guideline will lead to abuse of the system and an 
increase in costs to employers and insurers. Deletion of this section is 
recommended. 
 RESPONSE: The commission disagrees. Adjustment reactions [now in (h)(5)(J)] are 
diagnosable mental disorders requiring significant symptoms of emotional 
distress lasting at least two weeks but not more than six months. Withholding 
treatment "unless the mental condition is prolonged" not only deprives the 
injured worker of his/her right to treatment but is antithetical to cost 
containment strategies. Early intervention when the condition is relatively less 
severe allows for more rapid, cost effective treatment. In addition, the 
guideline does require that the condition is documented to be causally related 
to the compensable injury. 
 COMMENT: Subsection (j)(2)(C)(iv) appears to allow treatment for unrelated 
services. The section specifically states that one of the criteria for referral 
to a chronic pain management program is "Chronic pain linked to adverse 
interpersonal relationships which interfere with rehabilitation." 
 RESPONSE: The commission disagrees. As is clearly stated in subsection (f) (8), 
"Any factor which does not arise from the compensable injury will not be 
considered as rationale for the reasonableness or necessity of care under the 
Act." In other sections of the document, it is clearly outlined that the 
provider is required to assess the injured worker for the presence of a history 
of mental disorders, substance abuse, and other factors to determine whether the 
current symptoms are causally related to the compensable injury or to a pre-
existent or non-related disorder and to document this determination. 
 COMMENT: Concern is expressed regarding subsection (g)(2)(J), regarding the 
apparent endorsement of family and conjoint therapy and the potential liability 
for such therapy by the insurance carrier. 
 RESPONSE: The commission disagrees. The commission acknowledges the concern 
expressed by the commenter regarding the apparent expansion of treatment options 
for mental health contained within this segment of the guideline. However, as is 
stated in both this subsection [now (f)] and throughout the guideline, those 
treatments which are provided must be demonstrated to be causally related to the 
compensable injury or the mental disorder must be demonstrated to be causing a 
hindrance to the recovery of the injured worker. Once the mental disorder is 
demonstrated to no longer interfere with the ability of the injured worker to 
return to work, obtain employment, or participate in other physical treatment, 
this type of intervention would no longer be compensable under the Workers' 
Compensation system. 
 COMMENT: A suggestion was made to clarify the rationale for termination of 
treatment as outlined in subsection (g)(7)(A)(vi). The suggestion was made to 
revise the statement to read: "patient noncompliant to all mental health  
treatment." 
 RESPONSE: The commission agrees. The language in (f)(7)(A)(vi) has been revised 
to include the phrase recommended by the commenter. 
 COMMENT: A suggestion was made by the commenter that the indicator listed in 
subsection (h)(2)(B)(iv) be re-worded to read as follows: "the regular use of 
alcohol or any use of illegal drugs ..." 
 RESPONSE: The commission disagrees. The indicator, as listed within the context 
of this section of the guideline [now (g)], is a symptom of the inappropriate 
use of either alcohol or illegal drugs to relieve pain or stress. It is the 
intention of this guideline to promote treatment of this type of problem, if 
causally related to the compensable injury, or if hindering the continued 
recovery from the compensable injury before it becomes a serious problem 
requiring prolonged therapy. 
 COMMENT: A suggestion was made by the commenter to reword subsection (h)(3) (B) 
to include the phrase "and preauthorization". 
 RESPONSE: The commission disagrees. The use of the guideline does not preclude 
the need for preauthorization of those services listed in the preauthorization 
rule. The guideline is only a tool whose use and recommendations may make the 
process for obtaining preauthorization for those required services easier. 
 COMMENT: Concern was expressed by a commenter regarding the separation of work 
hardening and intensive, one-to-one mental health treatment. The specific 
concerns expressed were as follows: 
 (1) Mental health services which were considered to be separate from the work 
hardening program were not separately reimbursed. 
 (2) Mental health services were not reimbursed because the services were not 
preauthorized. 
 (3) The reimbursement rate for work hardening, inclusive of mental health 
services, is too low. 
 (4) Mental health services were no longer being offered as a part of work 
hardening due to the low reimbursement rate. 
 Recommendations were made by the commenter as follows: 
 (1) Mental health group therapy, as a part of a work hardening program, does 
not require preauthorization. 
 (2) Three hours of mental health evaluation be allowed without 
preauthorization, to be reimbursed at the rate established by the Medical Fee 
Guideline. 
 (3) Preauthorization be required for all other mental health services and 
provide reimbursement at the rate established by the Medical Fee Guideline. 
 RESPONSE: The commission disagrees. The commission acknowledges the concerns 
expressed regarding the limitations placed upon the provision of mental health 
services within the current work hardening programs due to monetary limitations. 
However, this issue has been addressed in the proposed revisions to the Medical 
Fee Guideline and has also been addressed on a case-by-case basis in Dispute 
Resolution. The commission also disagrees with the necessity to make a three 
hour mental health evaluation available to the injured worker without first 
receiving a referral from his/her treating doctor and preauthorization for such 
an evaluation. Except in an emergency situation, a mental health evaluation and 
mental health treatment will continue to require a referral from a treating 
doctor, and preauthorization will be as required in the commission's rule on 
preauthorization. Finally, reimbursement for all mental health services is not a 
part of this guideline and will be addressed in the revisions for the Medical 
Fee Guideline. 
 COMMENT: The language in subsection (g)(2)(A), as originally written, was 
struck and largely replaced. Concern was expressed that the current revision 
does not clearly outline the indications as did the previous version. 
 RESPONSE: The commission disagrees. A previously noted comment stated that this 
specific subparagraph was confusing regarding the need for preauthorization. The 
revised subparagraph, as written, clearly indicates when preauthorization is and 
is not required. 
 COMMENT: It appears that a large portion of subsection (g)(2)(C) was deleted in 
the most recent revision. Concern was expressed that this deletion would result 
in less clarity regarding the peri-operative mental health evaluation and post-
operative mental health evaluation. 
 RESPONSE: The commission agrees. The deletion of the subparagraph referred to 
was a typographical error and has been corrected in the most recent revision of 
the guideline. 
 The following comments were received regarding documentation requirements for 
assessment/evaluation and ongoing treatment. 
 COMMENT: Subsection (h)(4) appears to be a good outline of the information 
which should be contained in the patient's records. 
 RESPONSE: The commission agrees. 
 COMMENT: Support has been expressed for the initial evaluation, including the 
format given for presenting those findings. However, the format for subsequent 
documentation, as outlined in subsection (h)(6)(B), references problem oriented 
documentation. This format may or may not be the type of documentation most 
commonly used. It would be preferable to either provide alternative formats for 
documentation or to eliminate the specific requirement for format altogether. 
 RESPONSE: The commission disagrees. In an effort to balance the need for the 
confidentiality of the injured worker's records with the need of the carrier to 
determine the effectiveness of the provided therapy, specific documentation 
requirements were developed. The documentation requirements as outlined in this 
guideline create a consistent standard which ensures that all parties involved 
are using the same format. Although several documentation formats exist, they 
are all based on the same premises and can be modified to meet the documentation 
requirements in this guideline. The commission acknowledges that this format may 
not be currently used by all providers; however, the format in the guideline was 
deemed to be a reasonable compromise to accommodate the needs of all parties. 
 COMMENT: The requirement in subsection (i)(6)(B)(ii), to change the treatment 
plan if no response is noted within 30 to 60 days is good. If the patient is 
unresponsive to treatment, it is reasonable to require a change in the treatment 
plan to accommodate the patient's response. In addition, all of subsection 
(i)(6) and subsection (g)(2)(I), appear to require the provision of reasonable 
information for bill review. 
 RESPONSE: The commission agrees. 
 COMMENT: The development of treatment parameters, as outlined in subsection 
(i), helps protect the patient, the provider, and the carrier by defining, in an 
objective manner, reasonable expectations of the course that treatment should 
follow. Concern was expressed that the guideline would be used by the insurance 
carriers as the sole determinant regarding the appropriateness of treatment for 
the injured worker. 
 RESPONSE: The commission disagrees. It is very clearly stated throughout the 
document that the guideline is not to be viewed as prescriptive or to be used as 
the sole basis for denial of services. 
 The following comments were received regarding pain mangaement. 
 COMMENT: Concern was expressed that pain management was not addressed in the 
acute phase of the injury. It was suggested that a section on pain management, 
other than that of chronic pain syndrome, be addressed either in this guideline 
or in a separate guideline. 
 RESPONSE: The commission disagrees. The primary focus of this guideline was the 
treatment of the injured worker's mental health needs. Pain management was not 
an issue that was felt should be covered in this guideline. 
 The following comments were received regarding the rule as a whole. 
 COMMENT: Use the DSM-IV and ICD-10 (newer coding manuals) when presenting this 
guideline for final adoption. 
 RESPONSE: The commission disagrees. According to the TWCC electronic claims 
specifications (Medical Forms Database), the ICD-9 diagnosis codes are to be 
submitted. Portions of this guideline are based on the information generated 
from the TWCC billing database which captures ICD-9 diagnosis codes from the 
medical bills. 
 COMMENT: Typographical errors were noted in the following sections: 
 (1) In subsection (g)(2)(F), the last line should read "See subsections (i) (1) 
and (3)", not "(1) and (2)". 
 (2) In subsection (g)(3)(B)(ii), the line should read "factitious disorder". 
 (3) In subsection (c), Peri-operative Mental Health Evaluation, there are two 
typographical errors. The word "poor" needs to be inserted prior to the word 
"outcome". The words "and its" should be inserted between "functioning" and 
"potential". 
 (3) In subsection (g)(4)(R), the reference should be to subsection (f)(7). 
 (4) In subsection (i)(3)(A), the following sentence should be inserted after 
the first sentence-"These figures do not include biofeedback sessions (See 
subsection (f)(6) for maximum weekly frequency.)" 
 (5) In subsection (h)(3), at the end of paragraph (D), following (ii), a 
sentence has been omitted. This sentence should read "both acute events and 
enduring circumstances should be specified for the psychosocial stressor scale. 
" CPT codes 90900 through 90915 should be deleted since biofeedback is no longer 
included in the maximum weekly threshold tables in this portion of the document. 
 (6) In subsection (h)(4)(A), a statement is needed that these thresholds do not 
include biofeedback. The reader should be directed to subsection (f)(6). 
 (7) In subsection (h)(4)(C), there is a sentence with an asterisk that is 
erroneously placed. This sentence should be at the bottom of Figure 1: 
"Catastrophic level of severity is a strong indication for possible inpatient 
treatment." This reference should also be found at the end of Figure 2. 
 (8) In subsection (h)(4)(K)(ii), there is an unnecessary parenthesis mark after 
the word "disorders" in the second line. 
 (9) In subsection (h)(6)(A)(i), in the sixth line of this paragraph, the 
reference to "subparagraph (B)(2)" should be "(B)(ii)". 
 RESPONSE: The commission agrees. All noted typographical errors have been 
corrected in the revised guideline. 
 COMMENT: Concern was expressed that the guideline did not address the issue of 
the injured worker returning to work. The concern was expressed that the 
transition back to work was poorly coordinated and that many workers were unable 
to return to either limited or full employment due to the lack of coordination 
between state agencies and the fact that the insurance carriers were not 
responsible for ensuring that the injured worker received such assistance. 
 RESPONSE: The commission disagrees. The commission acknowledges the concern 
expressed by the commenter regarding the need to better coordinate the injured 
worker's return to work. However, the Act does state in Texas Labor Code, 
sec.408.150 that the commission "shall refer an employee to the Texas 
Rehabilitation Commission with a recommendation for appropriate services if the 
commission determines that an employee entitled to supplemental income benefits 
could be materially assisted by vocational rehabilitation or training in 
returning to employment or returning to employment more nearly approximating the 
employee's pre-injury employment." In addition, one of the reasons for 
termination, as stated in the guideline, is that the mental disorder no longer 
interferes with the injured worker's ability to return to work. 
 COMMENT: Concern was expressed that the guideline did not clearly delineate the 
definition of a Qualified Mental Health Professional, nor discuss the rate of 
reimbursement to be allowed for different levels of qualifications. 
 RESPONSE: The commission disagrees. The definition of Qualified Mental Health 
Provider, as outlined in subsection (e)(1)(A), clearly indicates the type of 
health care provider allowed to provide services under the auspices of this 
guideline. Reimbursement of the different levels of care is not a part of this 
guideline, but is addressed in the Medical Fee Guideline. 
 COMMENT: A recommendation has been made to add the phrase "within the scope of 
practice defined by their applicable practice Act." to the definition of 
"doctor" as outlined in subsection (d), citing the Act, Texas Labor Code, 
Chapter 401, Subchapter B, sec.401.011, General Definitions. 
 RESPONSE: The commission disagrees. To alter the wording of this quotation 
would require a change in the current Act. The intent of this citation was to 
provide a common definition of terms used throughout the guideline, not to 
provide an expansion or alteration of that definition. However, this limiting 
language is included in the definition of a Qualified Mental Health Provider in 
subsection (e)(1)(A). 
 COMMENT: A recommendation has been made to revise the reference to the 
Physician's Current Procedural Terminology to refer to the most current edition 
(September, 1993). 
 RESPONSE: The commission agrees. The guideline has been revised in (f)(5) to 
reference the most current, i.e., September, 1993, edition of the Physician's 
Current Procedural Terminology. 
 COMMENT: A recommendation has been made to change the wording of subsection 
(d)(1)(B)(III) to read "psychological services prescribed by a doctor." 
 RESPONSE: The commission agrees. Upon examination of the Act, Texas Labor Code, 
sec.401.012(19)(C), the quote is as stated in the recommendation and has been 
corrected in the guideline revision [now (c)(1)(B)(ii)(III)]. 
 COMMENT: A recommendation has been made to change the wording of subsection 
(d)(1)(C) to read "the only mental disorders eligible for coverage under the Act 
are those which are causally linked to a compensable injury." 
 RESPONSE: The commission disagrees. The section to which the commenter refers 
is a direct quote from the Act, specifically Texas Labor Code, sec.408. 006, 
Mental Trauma Injuries. It is not the intention of the guideline to re-write the 
Act. 
 COMMENT: Support was expressed regarding the contents of the Mental Health 
Treatment Guideline. 
 RESPONSE: The commission agrees. 
 COMMENT: The commission received a verbal and written request that a definition 
of "Mental Emergency" be added to the guideline. The definition requested was "A 
Mental Emergency includes one or more of the following: dangerousness to self or 
others, or significant risk of potential dangerousness; or marked or severe 
deterioration of mental/emotional functioning (including hallucinations, 
delusions, illusions, as well as verbal, cognitive, thought, or behavioral 
disorganization, including, but not limited to, psychosis and/or mania)." 
 RESPONSE: The commission agrees and this definition has been added to the 
guideline in subsection (f)(1)(A). 
 COMMENT: The definition of a Qualified Mental Health Professional, as outlined 
in the guideline, allows the non-licensed individual to provide services under 
the supervision of a doctor. Although this definition is consistent with the 
law, the concern is that the definition may be potentially abused, since the 
definition of doctor is not limited to only those qualified to deliver mental 
health care. 
 RESPONSE: The commission agrees. The definition of Qualified Mental Health 
Provider has been revised to read as follows: "A Qualified Mental Health 
Provider (QMHP) is defined as someone who is independently licensed to provide 
mental health services, within the scope of practice defined by their applicable 
practice Act. A nonlicensed individual is not a QMHP but may provide services 
defined in this guideline under the direction or supervision of a QMHP." 
 COMMENT: In subsection (e)(3), the language regarding the application of the 
guideline by the Medical Review Division has been largely deleted. The commenter 
felt that the original format was more specific. 
 RESPONSE: The commission disagrees. A recommendation was made by TWCC 
Commissioner Snyder to consolidate the list into a single paragraph, since the 
specific subsections listed were repetitive. 
 The new rule is adopted under the Texas Labor Code, sec.402.061, which 
authorizes the commission to adopt rules necessary to administer the Act, the 
Texas Labor Code, sec.413.011, which directs the commission to establish by rule 
medical policies and guidelines relating to necessary treatments for injuries, 
and the Texas Labor Code, sec.413.013, which directs the commission to establish 
by rule a program for prospective, concurrent, and retrospective review and 
resolution of a dispute regarding health care treatments and services; and to 
establish by rule a program for the systematic monitoring of the necessity of 
treatments administered and fees charged and paid for medical treatments or 
services, including the authorization of prospective, concurrent, or 
retrospective review under the medical policies of the commission to ensure that 
the medical policies or guidelines are not exceeded. 
 This rule affects the Texas Labor Code, sec.sec.402.061, 413.011, and 413.013. 
 
 
  sec.134.1000. Mental Health Treatment Guideline. 
 
  (a) Table of Contents. The following headings and their corresponding 
subdivisions comprise a table of contents for this rule. 
 
  (1) Introduction-subsection (b). 
   
  (2) Applicable Sections of the Texas Labor Code and Commission Rules-
subsection (c). 
 
  (A) Review of Texas Labor Code-subsection (c)(1). 
   
  (B) Review of Texas Workers' Compensation Commission Rules-subsection (c)(2). 
     
  (3) Confidentiality-subsection (d). 
 
  (A) Introduction-subsection (d)(1). 
   
  (B) Requests for, and Submission of, Confidential Information -subsection 
(d)(2). 
   
  (C) Informed Consent-subsection (d)(3). 
     
  (4) Concepts and Governing Principles for Involved Parties -subsection (e). 
   
  (5) Ground Rules-subsection (f). 
 
  (A) Requirement for Intervention in Mental Disorders -subsection (f)(1) . 
   
  (B) General Ground Rules-subsection (f)(2). 
   
  (C) Mental Disorders with Limited Eligibility for Intervention -subsection 
(f)(3). 
   
  (D) Claimants Clinical Condition/Direction of Treatment -subsection (f) (4). 
   
  (E) CPT Code-subsection (f)(5). 
   
  (F) Biofeedback-subsection (f)(6). 
   
  (G) Termination of Treatment-subsection (f)(7). 
   
  (H) Consideration of Injury Related/Non-Injury Related Factors-subsection 
(f)(8). 
     
  (6) Assessment/Evaluation-subsection (g). 
 
  (A) Introduction-subsection (g)(1). 
   
  (B) Indications for Assessment/Evaluation-subsection (g)(2). 
   
  (C) Parameters for Assessment/Evaluation-subsection (g)(3). 
   
  (D) Documentation Requirements for Assessment/Evaluation -subsection (g)(4). 
     
  (7) On-Going Treatment-subsection (h). 
 
  (A) Introduction-subsection (h)(1). 
   
  (B) Indication for Ongoing Treatment-subsection (h)(2). 
   
  (C) Parameters for Ongoing Treatment-subsection (h)(3). 
   
  (D) Weekly Treatment Tables-subsection (h)(4). 
   
  (E) Treatment Durations-subsection (h)(5). 
 
  (i) Organic Brain Impairment Resulting from Drug Toxicities -subsection 
(h)(5)(A). 
   
  (ii) Psychotic Disorders-subsection (h)(5)(B). 
   
  (iii) Affective Disorders-subsection (h)(5)(C). 
   
  (iv) Anxiety Disorders-subsection (h)(5)(D). 
   
  (v) Somatoform Disorders-subsection (h)(5)(E). 
   
  (vi) Personality Disorders-subsection (h)(5)(F). 
   
  (vii) Psychosexual Disfunction -subsection (h)(5)(G). 
   
  (viii) Substance Dependence Disorders and Substance Abuse Disorders- 
subsection (h)(5)(H). 
   
  (ix) Acute Reaction-subsection (h)(5)(I). 
   
  (x) Adjustment Reaction-subsection (h)(5)(J). 
   
  (xi) Peri-Operative Algorithm -subsection (h)(5)(K). 
     
  (F) Documentation for On-Going Treatment-subsection (h)(6). 
 
  (i) Guidelines for On-Going Treatment Documentation-subsection (h) (6)(A). 
   
  (ii) Documentation Format and Content-subsection (h)(6)(B). 
       
  (8) Criteria for Referral to Other Programs-subsection (i). 
 
  (A) Criteria for Inpatient Psychiatric Treatment Referral -subsection (i)(1). 
   
  (B) Criteria for Referral to Chronic Pain Management Programs-subsection 
(i)(2) 
     
  (9) Appendices. 
 
  (A) Appendix A: Psychosocial Stressor Scale-subsection (j). 
   
  (B) Appendix B: Global Assessment of Functioning Scale -subsection (k). 
   
  (C) Appendix C: ICD-9/Code Overview-subsection (l). 
   
  (D) Appendix D: ICD-9/Code Table-subsection (m). 
   
  (E) Appendix E: Elements of a Mental Status Examination -subsection (n) . 
     
  (10) Bibliography-subsection (o). 
     
  (b) Introduction. 
 
  (1) This guideline shall be effective for mental health services rendered on 
or after the effective date of this rule. The purpose of this guideline is to 
clarify those services that are reasonable and necessary for mental health care 
for the injured workers of Texas. This guideline is not to be viewed as 
prescriptive or to be used as the sole basis for denial of services. The 
guideline reflects typical courses of intervention. Treatment falling outside 
these parameters will be subject to more careful scrutiny and require additional 
documentation of the special circumstances to justify the need for treatment. 
   
  (2) The primary goals of this document are to: 
 
  (A) ensure quality of health care to the injured workers of Texas; 
   
  (B) assist all parties with regard to the appropriate treatment and management 
of mental disorders in workers' compensation healthcare; 
   
  (C) identify clinically acceptable courses of treatment for specific mental 
disorders; 
   
  (D) establish documentation standards which support the appropriateness of the 
level of service for assessment/evaluation and on-going treatment; 
   
  (E)  establish treatment parameters based on a diagnostic grading system which 
allows for categorization of the manifestation of distress during the current 
phase of injury; 
   
  (F) establish parameters for eligibility and termination of treatment; and 
   
  (G) provide a mechanism of progressive, concurrent, retrospective review of 
efficient and effective utilization of healthcare services. 
     
  (3) A major obstacle in devising such a set of guidelines is the relative 
absence of research regarding treatment of choice for various mental disorders, 
in particular the absence of clear indicators regarding frequency and duration 
of treatment. In the treatment of injured workers, the Qualified Mental Health 
Provider (QMHP) is confronted with a variety of mental and physical problems, 
including traumatic brain injury and permanent loss of functioning due to 
physical trauma, which can require many months of rehabilitation efforts. Even 
in common psychological reactions such as adjustment disorders and depression, 
the exact treatment plan will vary based on the needs of the individual. The 
nature of the physical injury, the amount and duration of lifestyle disruption, 
the person's general psychological well-being, ability to handle stress, and 
other constitutional factors such as biological predisposition to mental illness 
all affect the course of treatment. 
   
  (4) The guideline is designed to apply primarily to outpatient evaluation and 
treatment. This guideline does not apply to treatment involving cognitive 
rehabilitation of traumatic brain injury. General criteria for referral to more 
intensive full or partial psychiatric inpatient settings and rehabilitation/pain 
clinics are included in this guideline. Also, this guideline applies to the 
delivery of services to inpatients on medical-surgical wards, but not to 
inpatient psychiatric hospitals, psychiatric/multidisciplinary outpatient 
programs and pain management programs. 
   
  (5) The diagnostic codes (ICD-9 codes) relating to mental disorders in this 
guideline were chosen based on the frequency with which they occur among injured 
workers and/or due to their importance in treatment planning for specific 
medical conditions. 
   
  (6) Other diagnoses not specifically included on the list are eligible for 
intervention and mental health services provided documentation substantiates the 
causal link of the treatment to the compensable injury. 
     
  (c) Applicable Sections of the Texas Labor Code and Commission Rules. The 
following sections of the Code and specific commission rules address key areas 
pertaining to mental health services. 
 
  (1) Review of Texas Labor Code. 
 
  (A)  Chapter 408, Subchapter B, sec.408.021 Entitlement to Medical Benefits. 
 
  (i) An employee who sustains a compensable injury is entitled to all health 
care reasonably required by the nature of the injury as and when needed. The 
employee is specifically entitled to health care that: 
 
  (I)  cures or relieves the effects naturally resulting from the compensable 
injury; 
   
  (II) promotes recovery; or 
   
  (III) enhances the ability of the employee to return to or retain employment. 
     
  (ii)  Medical benefits are payable from the date of compensable injury. 
   
  (iii) Except in an emergency, all health care must be approved or recommended 
by the employee's treating doctor. 
   
  (iv) An insurance carrier's liability for medical benefits may not be limited 
or terminated by agreement or settlement. 
     
  (B) Chapter 401, Subchapter B, sec.401.011, General Definitions 
 
  (i) A "compensable injury" is defined as an injury that arises out of and in 
the course and scope of employment for which compensation is payable under this 
subtitle. 
   
  (ii) "Health Care" is defined as all reasonable and necessary medical aid, 
medical examinations, medical treatments, medical diagnoses, medical 
evaluations, and medical services. The term does not include vocational 
rehabilitation. The term includes: 
 
  (I) medical, surgical, chiropractic, podiatric, optometric, dental, nursing, 
and physical therapy services provided by or at the direction of a doctor; 
   
  (II) physical rehabilitation services performed by a licensed occupational 
therapist provided by or at the direction of a doctor; 
   
  (III) psychological services prescribed by a doctor; 
   
  (IV) the services of a hospital or other health care facility; 
   
  (V)  prescription drugs, medicines, or other remedy; and 
   
  (VI) a medical or surgical supply, appliance, brace, artificial member or 
prosthesis, including training in the use of the appliance, brace, member or 
prosthesis. 
     
  (iii) "Doctor" is defined as a doctor of medicine, a doctor of osteopathic 
medicine, a doctor of optometry, a doctor of dentistry, a doctor of podiatry, or 
a doctor of chiropractic who is licensed and authorized to practice. 
   
  (iv) "Treating doctor" is defined as the doctor who is primarily responsible 
for the employee's health care for an injury. 
     
  (C)  Chapter 408, Subchapter A, sec.408.006, Mental Trauma Injuries. 
 
  (i)  It is the express intent of the legislature that nothing in this Act 
shall be construed to limit or expand recovery in cases of mental trauma 
injuries. 
   
  (ii) The mental or emotional injury that arises principally from a legitimate 
personnel action, including a transfer, promotion, demotion, or termination is 
not a compensable injury for the purposes of this subtitle. 
       
  (2) Review of Texas Workers' Compensation Commission Rules. 
 
  (A) 28 TAC, Chapter 134, Subchapter G, Treatments and Services Requiring 
Preauthorization. 
 
  (i) All health care providers of mental health treatment must follow the 
preauthorization rule. 
   
  (ii) Preauthorization will be as required in the commission's rule on 
preauthorization. 
     
  (B) 28 TAC, Chapter 134, Subchapter E, Rule 134. 4 Definition of Consulting 
Doctor. The consulting doctor, for purposes of this title, is a licensed doctor 
who examines an injured employee, or the employee's medical record because of a 
request from the treating doctor as described in the Act,  sec.4.64(1). The 
purpose of the consulting doctor's examination is to evaluate the accuracy of 
the diagnosis and appropriateness of the treatment of the injured worker. When 
the consulting doctor delivers health care to the injured worker pertaining to 
the compensable injury or illness at the request of the treating doctor, the 
consulting doctor becomes a referred doctor. Except as provided in sec.133.3(b) 
of this title (relating to Responsibilities of Treating doctor) the consulting 
doctor shall not make referrals without the approval of the treating doctor. 
       
  (d)  Confidentiality. 
 
  (1) Introduction. 
 
  (A) It is generally accepted that communication between a patient and health 
care provider, including any resulting records, are confidential. (These are 
enumerated in the Texas Health and Safety Code, Title 7, Chapter 611, 
sec.sec.611.001-611.005). Two exceptions are: 
 
  (i) requests by insurance carriers and their designated representatives 
(sec.611.004(a)(6)); and 
   
  (ii) requests from the commission (sec.611.004(a)(1)). 
     
  (B)  Throughout this document an effort has been made to balance the injured 
workers' right to confidential mental health care with the need of the 
commission and carrier to have access to information to determine various issues 
including the following: 
 
  (i) compensability of the injury; 
   
  (ii) reasonableness and necessity of treatment; 
   
  (iii)  audit of the medical bills; 
   
  (iv) progression toward treatment goals; and 
   
  (v) compliance. 
     
  (C) The only mental disorders eligible for coverage under the Act are those 
which are causally linked to a work injury. This requirement places a higher 
demand for specific information on the patient and provider than is usually 
required in private health insurance coverage. 
   
  (D) In order to address the needs of all parties, required documentation 
components, timetables for submission, and guidelines on release of information 
have been included. 
     
  (2) Requests for, and Submission of, Confidential Information. 
 
  (A) The required documentation format, content, and timetables specified for 
assessment/evaluation and ongoing treatment, as found in subsections (g)(4) and 
(h)(6) of this section, are deemed to be sufficient as documentation for 
utilization review purposes in the vast majority of cases. 
   
  (B)  Insurance carriers and their designated representatives are not to 
routinely request copies of individual session notes. Only that information 
which is reasonable and necessary to answer a specific question and is pertinent 
to the issues in dispute should be requested (e.g. medical necessity) . 
   
  (C) Individual session notes are only to be requested as part of: 
 
  (i) the informal dispute resolution process; 
   
  (ii) an administrative hearing by the commission; 
   
  (iii) a peer review initiated by the commission (the peer review must be 
conducted by a licensed qualified mental health provider whose scope of practice 
covers the services under review); or 
   
  (iv) a peer review by the carrier ( the peer review must be conducted by a 
licensed qualified mental health provider whose scope of practice covers the 
services under review). 
     
  (D) Other than under subpoena or other appropriate legal action, such as a 
TWCC order to produce documentation, "raw" (not interpreted) psychological test 
data and/or test forms are to be requested and released only when the peer 
reviewer is a licensed psychologist, consistent with the rules of the Texas 
State Board of Examiners of Psychologists which incorporates the Ethical 
Principles of the American Psychological Association. Qualified mental health 
providers who are asked to submit such documents must be given the name of the 
qualified mental health provider conducting the review in order to verify 
qualification and licensure, consistent with the requirements of the governing 
board for that profession. 
   
  (E) Insurance carriers and their designated representatives, or employees may 
not disclose, disseminate, or publish any individual treatment records or any 
other confidential information obtained, except to the extent it is consistent 
with the authorized purposes for which it was first obtained (sec.611.004(d)). 
   
  (F) In addition to the legal remedies specified in  sec.611.005 (relating to 
Legal Remedies for Improper Disclosure), an entity or individual who is guilty 
of improper disclosure under this guideline has committed a Class A 
administrative violation, punishable by fines up to $10,000 per occurrence. 
   
  (G) The Texas Workers' Compensation Commission will address situations where 
federal statutes supersede state statutes regarding confidentiality on a case-
by-case basis. 
     
  (3) Informed Consent. 
 
  (A) Prior to initiating any mental health assessment/evaluation or treatment, 
it is strongly recommended that the health care provider obtain appropriate 
informed consent and authorization to release confidential information from the 
injured employee. 
   
  (B) In addition, providers should be aware that without the required 
documentation (as referenced in subsections (g)(4) and (h)(6) of this section) 
submitted to the insurance carrier or the TWCC, payment for treatment and 
services may be denied. 
       
  (e) Concepts and Governing Principles for Involved Parties. 
 
  (1) Qualified Mental Health Provider (QMHP). The guideline is a tool to 
establish the required elements for all providers to initiate and continue 
treatment. The guideline identifies typical mental health interventions. If, for 
example, a provider's treatment deviates from the guideline, this would require 
documentation of a clearly delineated rationale for medical necessity to 
substantiate the selected treatment. 
 
  (A) A Qualified Mental Health Provider (QMHP) is defined as someone who is 
independently licensed to provide mental health services, within the scope of 
practice defined by their applicable practice Act. A nonlicensed individual is 
not a QMHP but may provide services defined in this guideline under the 
direction or supervision of a QMHP. 
   
  (B) This guideline should be used as a tool which identifies the recommended 
treatment parameters for treatment of injured workers within the workers' 
compensation system. 
   
  (C) It is expected that a subset of patients will be found to be outside the 
parameters of these guidelines. 
   
  (D) This guideline identifies the need to provide documentation which clearly 
explains the reason for treatment and relatedness to the workers' compensation 
injury. 
     
  (2)  Insurance Carriers. The insurance carrier and their designated 
representatives should use this document to compare treatment prospectively, 
retrospectively, and concurrently with the predetermined elements contained in 
the guideline. 
 
  (A) This guideline and its threshold levels or parameters is only a guideline 
and is not to be used as the sole reason for denial of treatments and services. 
   
  (B) This guideline is not intended to be used to direct care toward a specific 
healthcare discipline or to a specific type of treatment. 
   
  (C) It is the responsibility of the insurance carrier and their designated 
representatives to provide specific documentation and the rationale for denial 
of treatment based on the mental health treatment guideline. 
   
  (D) It is expected that a subset of patients will be found to be outside the 
parameters of this guideline. 
     
  (3) Medical Review Division. The Medical Review Division will use the 
guideline as a tool for the basis of their administrative review of prospective, 
concurrent, and retrospective treatment. It will also be used as a tool in 
conducting on-site audits for both the health care providers and insurance 
carriers. 
     
  (f) Ground Rules. 
 
  (1) Requirement for Intervention in Mental Disorders. 
 
  (A) An employee may receive a mental health evaluation for a compensable 
mental disorder that has resulted from, or was exacerbated by, a compensable 
injury, including a mental trauma injury caused by a sudden and ascertainable 
traumatic event(s) that is traceable to a definite time, place, and cause on the 
job. 
   
  (B)  Documentation of the mental disorder must demonstrate that either: 
 
  (i) it presently interferes with, or is expected to interfere with recovery, 
compliance with treatment, or ability to benefit from treatment or; 
   
  (ii) presently limits, or is expected to limit, the patient's ability to 
return to and/or retain employment. 
     
  (C) If the referral by the treating doctor does not clearly state the 
indications for assessment/evaluation as described in subsection (g)(2) or 
ongoing treatment as described in subsection (h)(2) of this section the health 
care provider must contact the referral source to clarify the reason for the 
mental health intervention. 
   
  (D) The assessment and/or reasonable treatment must be consistent with the 
Texas Labor Code (as cited in subsection (c)(1) of this section). 
     
  (2) General Ground Rules. 
 
  (A) The guideline is not to be used as fixed treatment protocols by either the 
health care provider or insurance carrier. The guideline reflects typical 
courses of intervention. It is acknowledged in atypical cases, treatment falling 
outside this guideline will occasionally be necessary. However, those cases that 
exceed the guideline's level of treatment will be subject to more careful 
scrutiny and review and will require documentation of the special circumstances 
that justify the treatment. 
   
  (B) This guideline should not be seen as prescribing the type and frequency or 
length of intervention. Treatment must be based on patient need and professional 
judgment. 
   
  (C) Treatment parameters described in this guideline represent typical courses 
of intervention for a given group of diagnoses. Actual treatment plans will vary 
with the level of severity of symptomatology, level of stressors, and diagnoses. 
   
  (D) The patient must have a diagnosable mental disorder which must be 
identified by ICD-9-CM codes and descriptions. 
   
  (E) When deciding level of service, two indicators, the Severity of 
Psychosocial Stressor Scale (PSS) and the Global Assessment of Functioning Scale 
(GAF) must be included in establishing rationale for level of service and 
treatment plan. The Severity of Psychosocial Stressor Scale (Appendix A) 
describes levels of acute and enduring stressors effecting current 
symptomatology. The Global Assessment of Functioning Scale (Appendix B) 
describes the patient's current ability to function in the presence of the 
illness. Both of these scales are derived from the Diagnostic and Statistical 
Manual III-R (DSM-III-R) of the American Psychiatric Association. Diagnosis 
codes must follow ICD-9 format only. 
   
  (F) If the Global Assessment of Functioning score is 40 or less, this may be a 
strong indication for more intensive levels of treatment (i.e. partial or full 
hospitalization) (See subsection (i)(1) and (3) of this section). 
   
  (G) The level of service should be the same as the health care provider's 
usual and customary level of service regardless of the payor system. 
   
  (H) Mental health interventions should include assessment/evaluation and may 
include on-going treatment. 
   
  (I) All services must have sufficient documentation to justify the level of 
service provided and the relationship of the services to a compensable injury. 
This includes, but is not limited to, initial evaluations, treatment plans, and 
subsequent reports (see subsections (g)(4) and (h)(6) of this section for 
documentation requirements). 
   
  (J) Documentation must support the reason for concurrent conjoint and family 
psychotherapy. 
     
  (3) Mental Disorders with Limited Eligibility for Intervention. 
 
  (A) Personality disorders are eligible for intervention only if the 
personality disorder interferes with the ability to cooperate with medical 
treatment regimens for the compensable injury. Treatment for the interfering 
personality disorder will be discontinued when this barrier is removed and 
cooperation with medical treatment for the injury is obtained, and/or no further 
progression in removing the interference of the personality disorder is 
anticipated. Subsequent treatment of the personality disorder may require 
referral outside of the workers' compensation system. Examples of maladaptive 
behaviors associated with personality disorders might include the following: 
 
  (i)  noncompliance with treatment; 
   
  (ii) missed appointments; 
   
  (iii) controlling, manipulative, deceitful, entitled, and/or unstable 
interpersonal relationships; 
   
  (iv) seclusive, suspicious, hostile, passive-aggressive, and/or dependent 
behaviors; and 
   
  (v)  unstable swings of mood or affect. 
     
  (B) Assessment/evaluation is appropriate for uncovering and identifying the 
following conditions (however, following diagnosis and identification, these 
conditions are not eligible for on-going mental health treatment.): 
 
  (i) malingering; 
   
  (ii) factitious disorder; 
   
  (iii) anti-social personality disorder; and 
   
  (iv) non-compensable diagnoses. 
     
  (C) Post traumatic stress disorder, or other mental disorders not accompanying 
a physical injury, are eligible for intervention provided the disorder has 
resulted from or was exacerbated by a compensable injury, including a mental 
trauma injury caused by a sudden and ascertainable traumatic event(s) that is 
traceable to a definite time, place, and cause on the job. 
     
  (4) Claimant's Clinical Condition/Direction of Treatment. The following 
requirements apply to the claimant's clinical condition and direction of 
treatment: 
 
  (A) the patient's condition must have the potential for restoration of 
function and/or improvement; and 
   
  (B) the treatment must be specific to the mental disorder arising from, or 
exacerbated by the injury, and: 
 
  (i) provide for potential improvement of the patient's condition, and 
   
  (ii) the development of compensatory or adaptive skills, and/or 
   
  (iii) prevention of relapse/regression 
       
  (5) CPT Codes. The Texas Workers' Compensation Commission identifies the five 
digit numeric codes obtained from the  Physician's Current Procedural 
Terminology, Fourth Edition, Copyright September 1993, for reporting medical 
services and procedures. For a complete listing of all appropriate Texas 
Workers' Compensation Commission/CPT codes for medical services, refer to the 
current Medical Fee Guideline. (The CPT codes in the current Medical Fee 
Guideline should be used. The CPT codes listed in this paragraph should not be 
used until they are adopted into a current Medical Fee Guideline.) When a 
service or procedure is provided that is not specifically listed in the Medical 
Fee Guideline, the fee charge must be substantiated by documentation of 
procedure (DOP). 
 
  (A) The CPT codes for initial mental health services may include: 
 
  (i) Office Visit series 99201-99205 (new patients) and 99211-99215 
(established patients); 
   
  (ii)  Consultation codes 99241-99245, or 99271-99275; 
   
  (iii) CPT code 90801 for initial office visit psychiatric diagnostic interview 
examination including history), this code will be reimbursed at hourly 
increments up to three hours. Interviews exceeding this three hour timeframe 
will require documentation to substantiate the length of service; and 
   
  (iv) CPT code 90825 for review of records. 
     
  (B) The CPT codes for psychological testing may include the following: 
 
  (i)  All psychological testing will be billed as code 90830 (psychological 
testing by physician, with written report by the hour). 
   
  (ii)  Neuropsychological assessment may be billed using codes 90830 
(psychological testing) or 95880-95883 (assessment of higher cerebral function 
with medical interpretation, aphasia, developmental, cognitive testing, 
neuropsychological test battery). 
     
  (C) CPT codes for mental health treatment may include: 
 
  (i) Psychiatric Therapeutic Procedures 90835-90880, 90899; and 
   
  (ii) Biofeedback 90900-90915. 
     
  (D)  CPT codes for management, ancillary, and administrative services may 
include: 
 
  (i) Other psychiatric services 90882-90899; 
   
  (ii)  Team conferences 99361-99362; 
   
  (iii) Telephone calls 99371-99373; 
   
  (iv) After hours and emergency office services 99050-99058; and 
   
  (v) Miscellaneous services 99071-99082. 
       
  (6)  Biofeedback. 
 
  (A) All Psychophysiological Profile Assessment (PPA) biofeedback procedures 
must be provided by a licensed provider or their supervisee whose scope of 
practice includes the provision of biofeedback services. 
   
  (B) A single routine session of biofeedback should be limited to: 
 
  (i) at least one biofeedback modality 90900-90915 minimum duration of 30 
minutes for each of the above range of modalities, maximum duration is one hour; 
   
  (ii) no more than two biofeedback modalities will be reimbursed per session 
(an exception to this reimbursement is the initial Psychophysiological Profile 
Assessment (PPA), which cannot exceed four modalities); 
   
  (iii) no more than one training session per day; and 
   
  (iv) treatment of more than one patient simultaneously; the group 
psychotherapy CPT codes 90853 and 90857 should be used to bill for treatment. 
     
  (C) The typical length of optimal biofeedback treatment is limited to three 
months of bi-weekly sessions with an additional three months of intermittent 
sessions not to exceed two per month. Two booster sessions at six month 
intervals for one year after termination of continuous or intermittent treatment 
may occur. If booster sessions show significant increase in readings and 
symptoms, only two to three sessions maximum to be approved to regain benefits. 
Supportive documentation will be required for more intensive treatment when 
patient has reached booster stages. 
   
  (D) There are certain nonmental health related medical conditions which are 
appropriate for biofeedback treatment. These and other compensable disorders 
will be considered based on a clear causal link established through clinical 
rationale. ICD-9 DESCRIPTION 333 Abnormal Movement Disorders 342 Hemiplegic 
Syndrome 344 Paralytic Syndromes 344.61 Neurogenic bladder 345 Epilepsy (EEG 
only) 346.9 Migraine Headaches 353 Nerve Root and Plexus Disorders 354 
Mononeuritis of Upper Limb and Multiplex 355 Mononeuritis of Lower Limb 367 
Spasms 388.3 Tinnitus 524.6 TMJ 715 Osteoarthrosis and Related Disorders 719.4 
Joint Pain 722 Intervertebral Disc Disorders 728 Disorders of Muscle Ligament 
and Fascia 738.4 Acquired Spondylolisthesis 780.5 Sleep Disturbances 781.2 Gait 
and Posture Disorders 786.0 Dyspnea and Respiratory Abnormalities 847 Sprains 
and Strains 
     
  (7) Termination of Treatment. 
 
  (A) The criteria for terminating mental health treatment should be rationally 
related to the reason for initiating the mental health treatment. Termination 
criteria should be specified at the outset of treatment in the treatment plan 
(See subsections (g)(4)(Q) and (h)(2)(B)(C) and (D) of this section). The 
following criteria are general reasons to terminate treatment: 
 
  (i) treatment goals have been met; 
   
  (ii) treatment has returned the patient to a pre-injury level of mental 
functioning; 
   
  (iii)  the mental disorder no longer interferes with the ability to: 
 
  (I)  return to work; 
   
  (II) obtain employment; or 
   
  (III)  participate in other physical treatment; 
     
  (iv) no further improvement can be expected, unless it can be clearly 
documented that ongoing intervention is necessary to maintain current level of 
functioning or prevent relapse/regression; 
   
  (v) the patient no longer fulfills diagnostic criteria for any mental 
disorder; or 
   
  (vi) patient non-compliance to all mental health treatment. It is essential 
the patient understand his or her role in the recovery and return to work 
process. 
       
  (8)  Consideration of Injury Related/Non Injury Related Factors. Liability for 
payment of mental health care treatments and services is limited to mental 
disorders where the factors contributing to the mental disorders are related to 
the compensable injury. Any factor which does not arise from the compensable 
injury will not be considered as rationale for the reasonableness or necessity 
of care under the Act. 
 
  (A) Factors are defined as: 
 
  (i) injury related (e.g. increase in pain level or increase in depression); or 
   
  (ii) non-injury related (e.g. death of significant others, other catastrophic 
event) 
     
  (B) Health care providers must identify these factors in their documentation. 
   
  (C) In situations where a combination of injury related and non injury related 
factors exist, only the injury related factors are considered eligible within 
the workers compensation system, as outlined in this subsection. 
       
  (g)  Assessment/Evaluation of Mental Disorders. 
 
  (1) Introduction. Assessment/evaluations are for the purpose of determining: 
 
  (A)  diagnosis; 
   
  (B) appropriate treatment; and 
   
  (C) factors that are injury related and non-injury related. 
     
  (2) Indications for Assessment/Evaluation. 
 
  (A) Two or more of the following general indications for assessment/evaluation 
must be suspected or present prior to performing the assessment/evaluation: 
 
  (i) clinical signs of significant mental stress including, but not limited to: 
 
  (I) anxiety; 
   
  (II) agitation; 
   
  (III) depression (including reports of neurovegetative symptoms of 
depression); 
   
  (IV) suicidal ideation; 
   
  (V) delusions; 
   
  (VI) hallucinations; 
   
  (VII) disrupted thought processes; 
   
  (VIII) psychophysiological correlates of affect and stress; or 
   
  (IX) sleep disturbances; 
     
  (ii) concern that the patient's mental status is having an adverse impact on 
his or her ability to participate in, or respond to, appropriate medical 
treatment. (this includes issues of medication compliance, lack of motivation 
and effort, and difficulty participating in appropriate rehabilitation efforts); 
   
  (iii)  overuse or inappropriate use of narcotics, tranquilizers, or sedative-
hypnotic medications; 
   
  (iv) the use of alcohol or any illegal drugs, particularly for pain relief or 
relief of stress symptoms; 
   
  (v) functional disability considered to be out of proportion to severity of 
injury/diagnosed damage; 
   
  (vi) inconsistency between objective medical findings and patient's symptom 
presentation, including, but not limited to, "nonorganic" or "nonphysiological" 
responses to physical examination, pain/sensory changes in non-dermatome 
patterns, unusual reports of pain and loss of functioning, and "conversion 
reactions"; 
   
  (vii)  suspicion of symptom exaggeration and/or malingering due to primary or 
secondary gain issues; 
   
  (viii) hostile or belligerent behavior by the patient projected onto others 
secondary to pain complaints; 
   
  (ix)  reports of increased family discord secondary to injury-related stress; 
   
  (x) persistent, excessive use of the health care system or excessive, 
inappropriate seeking of diagnostic testing/surgical intervention; 
   
  (xi) desire on the part of the treating doctor for input regarding treatment 
planning, in particular whether referral for mental health treatment or referral 
to comprehensive rehabilitation/pain management program is appropriate; 
   
  (xii) concern about the effects of a closed head injury, toxic poisoning, or 
other neurological or neuropsychological injury, especially the cognitive, 
functional, or psychological aspects of the actual or suspected brain disorder; 
or 
   
  (xiii) a patient with pain extending beyond the primary intervention phase (0-
3 months) with continued significant impairment in daily functioning and failure 
to return to work and/or progress adequately in healthcare treatments. 
     
  (B) Peri-Operative Mental Health Evaluation. In addition to the indications 
noted in subparagraph (A) of this paragraph, mental health assessment/evaluation 
is appropriate when a patient is a candidate for surgical intervention and the 
treating doctor and/or surgeon has determined there is a need to assess the 
patient's psychological suitability for surgery and risk of poor outcome. The 
general rationale for such an assessment/evaluation is observation of a mental 
disorder and/or concerns about the patient's mental functioning, and it's 
potential adverse effect on the patient's understanding of surgery, potential 
outcome, compliance, and post-surgical adjustment. Specific indications may 
include, but are not limited to the following: 
 
  (i) observed presence of a mental disorder and/or clinical signs of 
significant mental stress (subparagraph (B) (i) of this paragraph); 
   
  (ii) presence of, or evidence of, a somatoform disorder; 
   
  (iii) concern that impairment in cognitive functioning and/or intelligence 
will limit the patient's understanding of the surgery, post-surgical 
instructions, and compliance; 
   
  (iv) the presence of psychological, emotional, coping, or personality styles 
that may interfere with the patient's ability to comply with temporary or 
permanent restrictions on activity following surgery, which could lead to re-
injury or the necessity of repeat surgery; 
   
  (v) concern about unrealistic expectations of surgical recovery, pain relief, 
recovery of functioning, or physical limitations resulting from the surgery; 
   
  (vi) chemical dependency/abuse; 
   
  (vii) possible presence of familial, financial, or other secondary gain issues 
that may interfere with the patient's appropriate activation or rehabilitation 
following surgery; or 
   
  (viii)  presence of asymptomatic and/or symptomatic pre-injury factors and 
occupational factors as outlined in the Peri-Operative Algorithm found in 
subsection (h)(5)(K) of this section. 
     
  (C) Post-Operative Mental Health Evaluation. Mental health evaluation may be 
requested by the surgeon in cases where post-operatively, the patient shows 
signs of depression, anxiety, or confusion which may interfere with post-
operative progress. 
 
  (i)  Onset of symptoms, post-operatively, while hospitalized will be 
considered an emergency situation. 
   
  (ii) The surgeon will need to document that an emergency evaluation is 
necessary based on observation of clinical signs, such as dramatic pain 
complaints, bouts of crying, lack of cooperation with hospital staff, etc. 
       
  (3) Parameters for Assessment/Evaluation. 
 
  (A) Introduction. Due to the great variation in the reasons for 
assessment/evaluation, the type and extent of the assessment/evaluation needs to 
be individualized. Some factors to be considered in determining the 
appropriateness, duration, frequency, or degree of service rendered includes, 
but is not limited to: 
 
  (i) the length and complexity of the medical and/or mental history; 
   
  (ii)  reason for referral; 
   
  (iii) sign and symptom presentation; 
   
  (iv) ability of the patient to give a coherent and accurate history; 
   
  (v) availability and cooperation of collateral history sources (spouse, 
family, etc.); or 
   
  (vi) amount and type of psychological testing. 
     
  (B) Components. The following are typical components of a mental health 
assessment/evaluation, along with typical maximum frequencies and durations for 
adequate assessments. Services exceeding the parameters listed in items (i)-(v) 
of this subparagraph will not be reimbursed without documentation of need and 
are subject to further review. 
 
  (i) Patient Interviews. The assessment/evaluation interview with the patient 
may be up to, but not exceed, three hours. In the case of patients who are 
extremely mentally disorganized and/or have extremely long and complex medical 
histories, up to two additional hours may be allowed, providing the clinical 
rationale for additional interview time is documented. 
   
  (ii)  Collateral Interviews. The assessment/evaluation interview with a 
spouse, significant other, and/or the family may be up to, but not exceed, two 
hours total. 
   
  (iii) Review of Records. The review of medical, psychological, educational, 
and/or vocational records may not exceed one hour. Review of records may exceed 
one hour in the case of complex cases with lengthy records, provided that the 
length of time is documented and a brief summary of the review is provided. 
   
  (iv) Psychological Testing. Once criteria for evaluation has been met, the 
amount and type of psychological testing should be based on a clinical rationale 
including the reasons for referral; sign and symptom presentation; and assisting 
in treatment planning decisions. 
 
  (I) Psychological Testing may be up to, but not exceed three hours. This 
service includes the following types of tests: 
 
  (-a-) personality testing (MMPI, MBHI, SCL 90, Rorschach, TAT, etc.); and 
   
  (-b-) pain, disability, and function inventories (Sickness Impact Profile, 
Oswestry, McGill, Dallas Pain Drawing Grid, Million, etc.). 
     
  (II)  Intelligence Testing may be up to, but not exceed 1.5 hours. Such 
testing should be conducted only if the patient's intellectual capacity has some 
clear and direct bearing on the development of his or her treatment plan. 
   
  (III)  A full neuropsychological battery consists of: 
 
  (-a-) up to a total of three hours initial clinical interview with patient and 
or caretakers; 
   
  (-b-) ten hours of face-to-face test administration to include interpretation 
of test data and preparation of report; 
   
  (-c-) two hours of feedback to patient and family using code 90887 up to two 
units (refer to Ground Rules in subsection (f)(5)(D) of this section); and 
   
  (-d-) a full neuropsychological battery initial clinical interview, test 
administration and feedback to the patient and family, and interpretation of the 
report, not to exceed 15 hours. 
       
  (v) Consultation. Doctors coordinating verbal or telephone consultation with 
other providers involved in patient treatment up to, but not to exceed one 15 
minute increment per provider every 30 days or when recommendations for changes 
in treatment can be documented, (for example, needed changes in medication or 
sudden withdrawal from medications). 
   
  (vi) Psychophysiological Profile Assessment (PPA). 
 
  (I) Assessment/evaluation is to determine if patient will likely benefit from 
biofeedback, or if barriers to biofeedback are present. Prior to a PPA, a 
comprehensive mental health assessment/evaluation must occur (see paragraphs (2) 
and (3) of this subsection). The components of PPA include one or more of the 
following: 
 
  (-a-) resting baseline; 
   
  (-b-) physiological levels of muscle activity; 
   
  (-c-) skin temperature or peripheral blood flow; 
   
  (-d-) skin conductance; 
   
  (-e-) heart rate or blood pressure; or 
   
  (-f-) other physiological parameters. 
     
  (II) Clinical response to one or more stressors or challenge tasks and latency 
of return to baseline levels following challenge must be documented to support a 
dysregulation or abnormality. The purpose of PPA is to: 
 
  (-a-) establish baseline psychophysiological responses; 
   
  (-b-) establish the existence of psychophysiological dysregulation or 
abnormality; 
   
  (-c-) determine that the dysregulation or abnormality is consistent with the 
history of the individual's symptoms; and 
   
  (-d-) utilize the knowledge gained from assessment for the development of a 
treatment plan. 
     
  (III) The psychophysiological assessment (PPA) using biofeedback equipment may 
last from 1 to 1.5 hours. This assessment consists of several modalities (see 
Ground Rules for Biofeedback, subsection (f)(6) of this subsection) to assess 
chronic changes, such as muscular spasm function of sympathetic arousal and 
changes in blood flow. A report addressing PPA results and a treatment plan for 
biofeedback therapy must be submitted following the biofeedback assessment. In 
addition, a treatment plan specific for biofeedback therapy must be submitted 
consistent with documentation requirements (see paragraphs (4)(p), (q), (r), and 
(s) of this subsection). 
       
  (C) Frequency of assessment/evaluation. 
 
  (i) Reasons for repeating an assessment/evaluation. Assessment/evaluation may 
be repeated based on the following reasons: 
 
  (I) referral to a new QMHP or facility; 
   
  (II) documented response to treatment; 
   
  (III)  elapsed time since last administration exceeds frequency guidelines 
listed in this subparagraph; and 
   
  (IV) documented need for change in type or level of service. 
     
  (ii) Interviews. Initial interviews and consultations at duration levels 
indicated in paragraph (B)(iv) of this subsection, with the patient, spouse, 
family, or significant others are appropriate whenever being evaluated by a new 
mental health provider or entering a new treatment setting. 
   
  (iii) Psychological testing. 
 
  (I) Major personality tests (MMPI, MBHI, SCL 90, Rorschach, TAT, etc.) should 
be administered no more than once every three months, unless there are 
significant intervening life events or changes in mental status requiring re-
evaluation. Brief symptoms inventories (Beck, Zung, Hamilton, etc.) may be 
repeated up to weekly to monitor symptom progress, especially during initial 
phases of psychopharmacology treatment. 
   
  (II) Pain, disability, and function inventories should generally be 
administered no more than weekly. 
   
  (III) Intelligence testing should be administered no more frequently than once 
every six months. 
   
  (IV) Comprehensive neuropsychological testing may be repeated annually. 
Testing of selected cognitive function (e.g., memory only) may be repeated on a 
more frequent basis if justified and documented. 
     
  (iv) Psychophysiological Profile Assessments (PPA). PPAs are typically 
performed at the onset of biofeedback treatment and at termination of 
biofeedback treatment. 
       
  (4) Documentation Requirements for Assessment/Evaluation. As part of the 
assessment/evaluation of the patient by the Qualified Mental Health Provider, a 
report must be prepared containing enough information to document the level of 
assessment provided. This report must include: 
 
  (A) reason for referral; 
   
  (B) history of present injury; 
   
  (C) past medical history and treatment; 
   
  (D)  past assessment and treatment of pre-existing mental disorders; 
   
  (E)  past and present substance abuse history, if any; 
   
  (F) current and past medication; 
   
  (G) history of head injury or other neuropsychological insult, past or 
present; 
   
  (H) social history including pertinent family, educational, vocational 
information, etc; 
   
  (I)  current factors and/or significant lifestyle changes contributing to 
symptomatology which are injury related (see subsection (f)(8) of this section) 
; 
   
  (J) factors and/or significant lifestyle changes, contributing to 
symptomatology which are non-injury related (the period of time reviewed should 
include the six months preceding the injury and the two years prior to the date 
of the current evaluation); 
   
  (K) present mental/emotional symptoms, including clinically pertinent elements 
of a mental status exam (see appendix E in subsection (n) of this section); 
   
  (L) results of any psychological, cognitive, pain/disability, or 
neuropsychological testing administered; 
   
  (M) ICD-9-CM diagnosis; 
   
  (N) Global Assessment of Functioning/Psychosocial Stressor Scale Score; 
   
  (O) details of a causal link of present mental/emotional status to the 
compensable injury (a clear statement regarding whether or not the injury has 
caused or exacerbated a diagnosable mental disorder and how the mental diagnosis 
is injury related) (refer to subsection (f)(1) and (8) of this section); 
   
  (P) a problem list comprised of a behavioral description of the diagnosis 
and/or the problem(s) identified during the assessment/evaluation; 
   
  (Q) the rationale or justification for initiating, continuing, changing, 
modifying or discontinuing treatment based on: 
 
  (i) a statement on how treatment is likely to have a detectable positive 
effect on the patient's overall condition, course of recovery (see subsections 
(c)(1)(A)(i) and (f)(1) and (4) of this section and subparagraphs (O) and (P) of 
this paragraph); 
   
  (ii) ability to participate in and benefit from treatment; or 
   
  (iii) ability to return to/retain employment; 
     
  (R)  goals/termination criteria of treatment (see Ground Rules, subsection (f) 
(7) of this section); and 
   
  (S) a plan of treatment, including: 
 
  (i) type of intervention/treatment modality; 
   
  (ii)  frequency of treatment; 
   
  (iii) expected duration of treatment; 
   
  (iv) expected clinical response to treatment; and 
   
  (v) specification of a re-evaluation timeframe. 
         
  (h)  Ongoing Treatment Requirements. 
 
  (1) Introduction. This section enumerates the number of sessions per week and 
duration of treatment for the majority of mental disorders arising in 
conjunction with compensable injuries. This guideline also applies to the 
delivery of services to inpatients on medical-surgical wards, but not inpatient 
psychiatric hospital units, psychiatric/multidisciplinary day treatment 
programs, and multidisciplinary pain management programs. 
   
  (2) Indications for Ongoing Treatment. 
 
  (A) In order for on-going treatment of a mental disorder to be considered 
reasonable and necessary, the patient must already meet the criteria listed in 
subsection (f)(1) (Requirement for Intervention and Mental Disorder) and 
subsection (f)(3) (Mental Disabilities with Limited Eligibility for 
Intervention) of this rule. 
   
  (B) Prior to initiation of ongoing treatment, an assessment/evaluation which 
satisfies the documentation requirements of subsection (g)(4) of this section, 
must already have been performed within the last six months. 
   
  (C) The patient must have a treatment plan either as part of a previous 
assessment/evaluation or if a new Qualified Mental Health Provider (QMHP) is 
employed. The new Qualified Mental Health Provider (QMHP) must develop a 
treatment plan and is subject to the criteria listed in subsection (g)(3)(C) of 
this section for repeat assessment/evaluation. 
   
  (D) The treatment plan must include criteria in subsection (g)(4)(P)-(S) of 
this section. 
     
  (3) Parameters for Ongoing Treatment. 
 
  (A) The figures in this paragraph represent the estimated typical maximum 
number of sessions per week and duration of treatment. These figures do not 
include biofeedback sessions (see subsection (f)(6) for maximum weekly 
frequency). It is anticipated there will be injured workers who require less 
treatment, and other injured workers who will require more treatment. This 
document serves as a guideline and should not be used as a reason for denial of 
treatment services. It is acknowledged that in severe cases, treatment falling 
outside this guideline will occasionally be necessary. However, these instances 
will be subject to more careful scrutiny and review, and require clear 
documentation of the special circumstances that justify the need for treatment 
which exceeds this guideline. 
   
  (B) This guideline should not be seen as prescribing the number of sessions 
per week or the duration of treatment. These must be based on patient need, 
professional judgement, and efforts toward cost containment. 
   
  (C) The general philosophy used in developing these guidelines is the number 
of sessions per week and duration of treatment should be based on the severity 
of the disorder. The severity is indicated by: 
 
  (i) the mental disorder diagnosis; 
   
  (ii) delineation of specific symptoms; 
   
  (iii) the Psychosocial Stressors Scale (See Appendix A in subsection (j) of 
this section) ; or 
   
  (iv) the Global Assessment of Functioning Scale (See Appendix B in subsection 
(k) of this section). 
     
  (D) As specified in subsection (f)(2) and (3) of this section, when deciding 
on level of service, severity of the Psychosocial Stressor Scale (PSS), and 
Global Assessment of Functioning Scale (GAF) must be included in establishing 
rationale for level of service and treatment plan. For the purposes of this 
guideline, the following definitions apply (both acute events and enduring 
circumstances should be specified for the psychosocial stressor scale): 
 
  (i)  Global Assessment of Functioning Scale: 
 
  (I) 90-61=Mild; 
   
  (II) 60-41=Moderate; or 
   
  (III) 40-1=Severe, Extreme, or Catastrophic; and 
     
  (ii) Psychosocial Stressor Scale: 
 
  (I)  1-2=Mild; 
   
  (II) 3=Moderate; or 
   
  (III) 4-6=Severe, Extreme, or Catastrophic. 
       
  (E) Another factor affecting the treatment plan is the existence of more than 
one mental disorder (co-morbidity). Having more than one mental diagnosis, 
particularly if psychosis, substance abuse, personality disorder, or major 
affective disorders, will increase the complexity of the case, and therefore, 
the complexity of the treatment plan. 
   
  (F) The following interventions are considered common and appropriate for 
mental health services for injured workers. The number of sessions per week 
listed in this paragraph apply only to these direct clinical services, and do 
not include management or administrative services listed in subparagraph (G) of 
this paragraph. 
 
  (i) 90835 Narcosynthesis; 
   
  (ii) 90841 Individual Psychotherapy, time unspecified; 
   
  (iii)  90842 Individual Psychotherapy 75-80 minutes; 
   
  (iv) 90843 Individual Psychotherapy 20-30 minutes; 
   
  (v) 90844 Individual Psychotherapy 45-50 minutes; 
   
  (vi) 90845 Medical Psychoanalysis; 
   
  (vii) 90846 Family Psychotherapy, without patient present; 
   
  (viii) 90847 Family Psychotherapy (conjoint psychotherapy); 
   
  (ix) 90849 Multiple Family Group Psychotherapy; 
   
  (x)  90853 Group Medical Psychotherapy; 
   
  (xi) 90855 Interactive Individual Psychotherapy; 
   
  (xii) 90857 Interactive Group Psychotherapy; 
   
  (xiii) 90862 Pharmacologic Management; 
   
  (xiv) 90870 Electroconvulsive Therapy-Single Seizure; 
   
  (xv) 90871 Electroconvulsive Therapy-Multiple Seizures per day; 
   
  (xvi) 90880 Hypnotherapy; 
   
  (xvii) 90899 Unlisted Psychiatric Service; 
   
  (xviii) 97540 Training in activities of daily living (self care skills and/or 
daily life management skills); 
   
  (xix) 99050 Services requested after office hours services in addition to 
basic service; 
   
  (xx) 99052 Services requested between 10:00 pm and 8:00 am in addition to 
basic service; 
   
  (xxi) 99054 Services requested on Sundays and holidays in addition to basic 
service; 
   
  (xxii) 99056 Services provided at request of patient in a location other than 
physician's office which are normally provided in the office; and 
   
  (xxiii) 99058 Office services provided on an emergency basis. 
     
  (G) The following services involve management of a patient's care, but not 
direct treatment of the patient. Provision of these services is subject to the 
Ground Rules in the Medical Fee Guideline sec.134.201 of this title, (relating 
to Medical Fee Guideline). Units of these services are not included in the 
maximum number of sessions per week in this section. 
 
  (i)  90882 Environmental intervention with agencies, employers, or 
institutions; 
   
  (ii) 90887 Interpretation or explanation of results of examinations, 
procedure, or data to family or other responsible persons; 
   
  (iii) 90889 Preparation of report of patient's psychiatric status, history, or 
progress other than for legal or consultative purposes for other physicians, 
agencies, or insurance carriers; 
   
  (iv) 90899 Unlisted psychiatric service or procedure; 
   
  (v) 99071 Educational supplies such as books, tapes, and pamphlets, provided 
by the physician for the patient's education at cost to physician; 
   
  (vi) 99075 Medical testimony; 
   
  (vii) 99078 Physician educational services rendered to patients in a group 
setting (e.g., prenatal, obesity, or diabetic instructions) ; 
   
  (viii) 99080 Special reports such as insurance forms or the review of medical 
data to clarify a patient's status-more than the information conveyed in the 
usual medical communications or standard reporting form; 
   
  (ix) 99082 Unusual travel (e.g., transportation and escort of patient); 
   
  (x) 99361 Medical conference with interdisciplinary team approximately 30 
minutes; 
   
  (xi) 99362 Medical conference with interdisciplinary team approximately 60 
minutes; 
   
  (xii) 99371 Telephone call, simple or brief; 
   
  (xiii) 99372 Telephone call, intermediate; and 
   
  (xiv) 99373 Telephone call, complex or lengthy. 
       
  (4) Weekly Treatment Tables. 
 
  (A) The number of sessions per week listed in this subsection apply only to 
clinical services rendered directly to patients (subsection (h)(3)(F) of this 
section). The number of sessions per week listed in this subsection do not 
include biofeedback sessions (see subsection (f)(6) for biofeedback). The 
provision of specific services to a patient depend on the patient's diagnostic 
status, symptom cluster, response to treatment, overall treatment plan, and 
coordination with other healthcare providers. The relative emphasis of various 
clinical services will vary with the specifics of the case, and should be 
clearly specified in the treatment plan and ongoing documentation. 
 
  (i) The number of sessions per week of treatment suggested in these tables 
would be used primarily when the patient first comes to the attention of the 
qualified mental health provider. It is expected that the number of sessions per 
week will decrease over time as the patient's symptoms abate. Change in symptoms 
and accompanying change in treatment plan should be clearly documented in 
monthly and quarterly progress reports as specified in subsection (h)(6)(A) and 
(B) of this section. 
   
  (ii)  If a patient is receiving intensive outpatient treatment consisting of 
several services, and there is a clinical need to exceed the maximum thresholds 
noted above, this situation is an indication to seriously consider referring the 
patient to a more intensive level of service than outpatient care. This could 
include psychiatric or multidisciplinary care programs in either a day treatment 
or inpatient setting. In deciding between intensive outpatient, day treatment, 
or inpatient care, consider criteria described in subsection (i) of this 
section. Issues of convenience, compliance, coordination of care, efficiency of 
delivery of services, and cost should be considered. 
   
  (iii) Number of sessions per week beyond the parameters in this section may be 
indicated in an acute crisis and/or due to individual patient needs. This should 
be documented in the daily notes (problem oriented documentation-POD), as well 
as, monthly and quarterly treatment summaries, (see paragraph (6) of this 
subsection). When frequency of treatment is increased beyond the parameters 
noted in this subsection, such documentation should specify: 
 
  (I) the nature of the crisis (i.e. outpatient detoxification, significant 
change in emotional status, fear of unexpected change in medical treatment, 
etc.); 
   
  (II) reasons increased number of sessions per week will benefit the patient; 
and 
   
  (III) an estimate of expected treatment duration. 
       
  (B) The following steps are to be employed in determining maximum treatment 
thresholds. 
 
  (i)  Determine the patient's ICD-9-CM mental disorder diagnosis from 
assessment/evaluation. 
   
  (ii) Find the diagnosis in paragraph (5) of this subsection (relating to 
treatment durations). Diagnoses are grouped by similarity of symptoms and 
duration of treatment. 
   
  (iii) Determine the number of sessions per week of treatment from Tables I and 
II in subparagraph (C) of this paragraph based on (all three indices must be 
taken into consideration): 
 
  (I) type of diagnosis; 
   
  (II) Global Assessment of Functioning Scale; and 
   
  (III) Psychosocial Stressors Scale. 
       
  (C) The following tables exclude biofeedback sessions, to determine maximum 
weekly session thresholds for biofeedback refer to subsection (f)(6) of this 
section. 
 
  (i) Table I. Use with all mental disorder diagnoses except with diagnosis of 
personality disorder or psychosexual disorder. (See Figure 1 in the Tables and 
Graphics Section of this issue of the Texas Register.) 
           
  Figure 1: 28 TAC sec.134.100(h)(4)(C)(i) 
 
  (ii) Table II. Use only if mental disorder is either personality disorder or 
psychosexual disorder. (See Figure 2 in the Tables and Graphics Section of this 
issue of the  Texas Register.) 
     
  Figure 2: 28 TAC sec.134.1000(h)(4)(C)(ii) 
 
  (5) Treatment Durations. 
 
  (A) Organic Brain Impairment Resulting From Drug Toxicities. Organic mental 
symptoms which are due to consumption of drugs and/or solvents. The drug should 
be identified, and a diagnosis of drug dependence should be recorded, if 
present. 
 
  (i) Diagnosis. 293.8 Transient Organic Mental Disorders 
   
  (ii) Level of Severity. 
 
  (I) Global Assessment of Functioning Scale. 
 
  (-a-) 90-61=Mild 
   
  (-b-) 60-41=Moderate 
   
  (-c-) 40  514>=Severe, Extreme, or Catastrophic 
     
  (II)  Psychosocial Stressor Scale. 
 
  (-a-) 1-2=Mild 
   
  (-b-) 3=Moderate 
   
  (-c-) 4-6=Severe, Extreme, or Catastrophic 
       
  (iii) Treatment Duration. The duration of treatment may be up to six months. 
   
  (iv)  Ground Rules. 
 
  (I) The treatment duration will vary in correlation with the level of severity 
of symptomatology and stressors. 
   
  (II) Both indicators (GAF & PSS) must be considered, and documentation must 
support the levels of service. 
   
  (III) A GAF score of 40 or less is a strong indication for possible inpatient 
treatment. 
       
  (B)  Psychotic Disorders. Mental disorders in which impairment of mental 
function has developed to a degree that interferes grossly with insight, ability 
to meet some ordinary demands of life or to maintain adequate contact with 
reality. It is not an exact or well defined term. Mental retardation is 
excluded. 
 
  (i) Diagnosis. 
 
  (I) 296.9 Other and Unspecified Affective Psychosis 
   
  (II) 298.0 Psychotic Reactive Depression 
   
  (III) 298.8 Other and Unspecified Reactive Psychosis 
     
  (ii)  Level of Severity. 
 
  (I) Global Assessment of Functioning Scale. 
 
  (-a-) 90-61  514>=Mild 
   
  (-b-) 60-41  514>=Moderate 
   
  (-c-) 40  514>=Severe, Extreme, or Catastrophic 
     
  (II)  Psychosocial Stressor Scale. 
 
  (-a-) 1-2  514>=Mild 
   
  (-b-) 3  514>=Moderate 
   
  (-c-) 4-6  514>=Severe, Extreme, or Catastrophic 
       
  (iii)  Treatment Durations. 
 
  (I) 296.9, 298.0-six months. 
   
  (II)  298.8-14 days (If psychotic symptoms extend beyond two weeks, a change 
in diagnosis is warranted). 
     
  (iv) Ground Rules. 
 
  (I) The treatment duration will vary in correlation with the level of severity 
of symptomatology, stressors and diagnosis. 
   
  (II) Both indicators (GAF & PSS) must be considered, and documentation must 
support the levels of service. 
   
  (III) A GAF score of 40 or less is a strong indication for possible inpatient 
treatment. 
       
  (C) Affective Disorders. Mental disorders, mild or moderate, in which there is 
a disturbance of mood (mostly compounded with depression and anxiety, but may be 
manifested as elation and excitement) which may be accompanied by one or more of 
the following: disturbance in sleep patterns, decreased appetite, decreased 
energy, inability to derive pleasure, low self esteem, impaired concentration, 
and hopelessness. There may be a strong tendency to suicide. The affective mood 
disorders may be so severe as to present disturbances with contact with reality 
as evidenced by disorder of perception and behavior; hallucinations; and 
delusions. All affective disorders must have documentation which provides a 
clinical rationale to establish a direct link to the on-the-job injury. Manic 
and bipolar disorders are treatable only if a clinical rationale clearly 
establishes a direct link to the on-the-job injury. 
 
  (i) Diagnosis. 
 
  (I) 296.0 Manic Disorder, Single Episode 
   
  (II) 296.2 Major Depressive Disorder, Single Episode 
   
  (III) 296.3 Major Expressive Disorder, Recurrent Episode 
   
  (IV) 296.7 Bipolar Affective Disorder, Unspecified 
   
  (V) 296.80 Manic Depressive Reaction, Unspecified 
   
  (VI) 300.4 Depression, Reactive 
   
  (VII) 311 Depressive Disorder, Not Elsewhere Classified 
     
  (ii) Level of Severity. 
 
  (I) Global Assessment of Functioning Scale. 
 
  (-a-) 90-61  514>=Mild 
   
  (-b-) 60-41  514>=Moderate 
   
  (-c-) 40  514>=Severe, Extreme, or Catastrophic 
     
  (II)  Psychosocial Stressor Scale. 
 
  (-a-) 1-2  514>=Mild 
   
  (-b-) 3  514>=Moderate 
   
  (-c-) 4-6  514>=Severe, Extreme, or Catastrophic 
       
  (iii)  Treatment Duration. The duration of treatment may be up to 15 months 
(treatment should be completed based on the fifth digit specificity). 
   
  (iv) Ground Rules. 
 
  (I) Treatment duration will vary in correlation with the level of severity of 
symptomatology, stressors and diagnosis. 
   
  (II) Both indicators (GAF & PSS) must be considered, and documentation must 
support the levels of service. 
   
  (III) A GAF score of 40 or less is a strong indication for possible inpatient 
treatment. 
       
  (D) Anxiety Disorders. Apprehension, tension, or uneasiness that stems from 
the anticipation of danger, the source of which may be largely unknown or 
unrecognized. The anxiety symptoms may be constant and persistent or may occur 
episodically as a reaction to a known object or situation, or they may occur 
without any apparent precipitant. The anxiety may occur in a sudden and 
overwhelming fashion with a number of physiological symptoms, e.g., shortness of 
breath, tightness in the chest, increased heart rate, profuse sweating, light-
headedness, accompanying feeling of impending death, increased muscle tension, 
restlessness, gastrointestinal symptoms, and trembling. The episodic anxiety 
disorder may be so frightening that the person may significantly alter/limit 
their lifestyle to avoid these anxiety provoking episodes. 
 
  (i) Diagnosis. 
 
  (I) 300.00 Anxiety State, Reaction 
   
  (II) 300.01 Panic Disorder 
   
  (III) 300.02 Generalized Anxiety Disorder 
   
  (IV) 300.20 Phobia Unspecified 
   
  (V) 300.21 Agoraphobia w/Panic Attacks 
   
  (VI) 300.29 Isolated or Simple Phobias Specific to Work Related Situations or 
Places 
     
  (ii) Level of Severity. 
 
  (I) Global Assessment of Functioning Scale. 
 
  (-a-) 90-61  514>=Mild 
   
  (-b-) 60-41  514>=Moderate 
   
  (-c-) 40  514>=Severe, Extreme, or Catastrophic 
     
  (II)  Psychosocial Stressor Scale. 
 
  (-a-) 1-2  514>=Mild 
   
  (-b-) 3  514>=Moderate 
   
  (-c-) 4-6  514>=Severe, Extreme, or Catastrophic 
       
  (iii)  Treatment Duration. The duration of treatment may be up to six months. 
   
  (iv) Ground Rules. 
 
  (I) Treatment duration will vary in correlation with the level of severity of 
symptomatology, stressors and diagnosis. 
   
  (II) Both indicators (GAF & PSS) must be considered, and documentation must 
support the levels of service. 
   
  (III) A GAF score of 40 or less is a strong indication for possible inpatient 
treatment. 
       
  (E) Somatoform Disorders. A variety of physical symptoms or types of 
physiological disorders of physical and/or mental origin which may or may not 
involve tissue damage. Due to the diagnostic complexity of these disorders, they 
continue to be recalcitrant to medical care involving a trend toward over-
medication and overly frequent use of medical services, and the adoption of a 
disabled lifestyle. These may be non-organic disturbances of speech or limb. 
These conditions may give an unrealistic interpretation of physical signs, and 
the belief that one has a more serious injury than medical data warrants. The 
following diagnoses present a complex mixture of physical and mental challenges 
which can readily give rise to over utilization of medical services. 
 
  (i) Diagnosis. 
 
  (I) 300.11 Conversion Disorder 
   
  (II) 307.80 Psychogenic Pain, Site Unspecified 
   
  (III) 307.81 Tension Headache 
   
  (IV) 307.89 Psychalgia, Other 
   
  (V) 316.0 Psychic Factor Associate W/Diseases Classified Elsewhere 
   
  (VI) 306 Physiological Malfunctions Arising From Mental Factors 
     
  (ii) Level of Severity. 
 
  (I) Global Assessment of Functioning Scale. 
 
  (-a-) 90-61  514>=Mild 
   
  (-b-) 60-41  514>=Moderate 
   
  (-c-) 40  514>=Severe, Extreme, or Catastrophic 
     
  (II)  Psychosocial Stressor Scale. 
 
  (-a-) 1-2  514>=Mild 
   
  (-b-) 3  514>=Moderate 
   
  (-c-) 4-6  514>=Severe, Extreme, or Catastrophic 
       
  (iii)  Treatment Duration. The duration of treatment may be up to 45 days to 
complete initial evaluation and treatment. If symptoms continue, re-evaluation 
will be necessary for possible continuation of treatment up to 3 months. 
   
  (iv) Ground Rules. 
 
  (I) Treatment duration will vary in correlation with the level of severity of 
symptomatology, stressors and diagnosis. 
   
  (II) Both indicators (GAF & PSS) must be considered, and documentation must 
support the levels of service. 
   
  (III) A GAF score of 40 or less is a strong indication for possible inpatient 
therapy. 
   
  (IV)  Due to the complex nature of these disorders, re-evaluation may include 
a longer duration of treatment. Documentation must substantiate any increase in 
level of care and duration of treatment. 
       
  (F) Personality Disorders. Deeply ingrained maladaptive patterns of behavior 
generally recognizable by the time of adolescence or earlier and continuing 
throughout most of adult life, although often becoming less obvious in middle or 
old age. The personality is abnormal either in the balance of its components, 
their quality and expression, or in its total aspect. Because of this deviation 
or psychopathology, the patient suffers or others have to suffer, and there is 
an adverse effect upon the individual or on society. It includes what is 
sometimes called psychopathic personality, but if this is determined primarily 
by malfunctioning of the brain, it should be classified as one of the non-
psychotic organic brain syndromes. When the patient exhibits an anomaly of 
personality directly related to his neurosis or psychosis, e.g., schizoid 
personality and schizophrenia, the relevant neurosis or psychosis which is in 
evidence should be diagnosed in addition. Documentation must demonstrate this 
diagnosis interferes with the ability to cooperate with treatment, e.g. 
noncompliance with medications, inability to keep appointments. Examples of 
pathological maladaptive behavior include noncompliance with treatment; missed 
appointments; controlling, manipulative, deceitful, entitled, unstable 
interpersonal relationships; seclusive, suspicious, hostile, passive-aggressive, 
and/or dependent behaviors; and unstable swings of mood or affect. 
 
  (i) Diagnosis. 
 
  (I) 301.0 Paranoid Personality Disorder (see clause (iv)(I)-(IV) of this 
subparagraph for ground rules on this diagnosis code). 
   
  (II) 301.2 Schizoid Personality Disorder (see clause (iv)(I)-(IV) of this 
subparagraph for ground rules on this diagnosis code). 
   
  (III) 301.4 Compulsive Personality Disorder (see clause (iv)(I) -(IV) of this 
subparagraph for ground rules on this diagnosis code). 
   
  (IV)  301.5 Histrionic Disorder (see clause (iv)(I)-(IV) of this subparagraph 
for ground rules on this diagnosis code). 
   
  (V) 301.6 Dependent Personality Disorders (see clause (iv)(I)-(IV) of this 
subparagraph for ground rules on this diagnosis code). 
   
  (VI) 301.7 Antisocial Personality Disorder (see clause (iv)(V) of this 
subparagraph for the ground rules on this diagnosis code). 
   
  (VII) 301.8 Other Personality Disorders (see clause (iv)(I)-(IV) of this 
subparagraph for ground rules on this diagnosis code). 
   
  (VIII) 301.83 Borderline Personality (see clause (iv)(I)-(IV) of this 
subparagraph for ground rules on this diagnosis code). 
     
  (ii) Level of Severity. 
 
  (I) Global Assessment of Functioning Scale. 
 
  (-a-) 90-61  514>=Mild 
   
  (-b-) 60-41  514>=Moderate 
   
  (-c-) 40  514>=Severe, Extreme, or Catastrophic 
     
  (II)  Psychosocial Stressor Scale. 
 
  (-a-) 1-2  514>=Mild 
   
  (-b-) 3  514>=Moderate 
   
  (-c-) 4-6  514>=Severe, Extreme, or Catastrophic 
       
  (iii)  Treatment Duration. The duration of treatment may be up to 12 months 
(see clause (iv)(VI) of this subparagraph for ground rules on treatment 
duration). 
   
  (iv) Ground Rules. 
 
  (I) Treatment duration will vary in correlation with the level of severity of 
symptomatology, stressors and diagnosis. (This applies to the diagnosis of 
Paranoid Personality Disorder; Schizoid Personality Disorder; Complulsive 
Personality Disorder; Histrionic Disorder; Dependent Personality Disorders; 
Other Personality Disorders; and Borderline Personality, found in clause (i)(I)-
(V), (VII), and (VIII), respectively, of this subparagraph.) 
   
  (II) Both indicators (GAF & PSS) must be considered, and documentation must 
support the levels of service. (This applies to the diagnosis of Paranoid 
Personality Disorder; Schizoid Personality Disorder; Complulsive Personality 
Disorder; Histrionic Disorder; Dependent Personality Disorders; Other 
Personality Disorders; and Borderline Personality, found in clause (i)(I)-(V), 
(VII), and (VIII), respectively, of this subparagraph.) 
   
  (III) A GAF score of 40 or less is a strong indication for possible inpatient 
treatment. (This applies to the diagnosis of Paranoid Personality Disorder; 
Schizoid Personality Disorder; Complulsive Personality Disorder; Histrionic 
Disorder; Dependent Personality Disorders; Other Personality Disorders; and 
Borderline Personality, found in clause (i)(I)-(V), (VII), and (VIII), 
respectively, of this subparagraph.) 
   
  (IV) To be used as a secondary diagnosis in conjunction with a primary ICD-9. 
(This applies to the diagnosis of Paranoid Personality Disorder; Schizoid 
Personality Disorder; Complulsive Personality Disorder; Histrionic Disorder; 
Dependent Personality Disorders; Other Personality Disorders; and Borderline 
Personality, found in clause (i)(I)-(V), (VII), and (VIII), respectively, of 
this subparagraph.) 
   
  (V) Flag these for prospective review or concurrent review. Flags alert review 
for potential abuse of situation. Psychotherapy not indicated, appropriate for 
evaluation only. (This applies to the diagnosis of Antisocial Personality 
Disorder, clause (i)(VI) of this subparagraph). 
   
  (VI) Emphasis is to remove barriers to treatment posed by the Personality 
Disorder rather than treat the Personality Disorder. Treatment should be 
discontinued when Personality Disorder no longer interferes with medical 
treatment and/or no further progression is noted. (This applies to treatment 
duration as described in clause (iii) of this subparagraph.) 
       
  (G) Psychosexual Dysfunction. A group of disorders in which there is recurrent 
and persistent dysfunction encountered during sexual activity. The dysfunction 
must be acquired as a causal result of the compensable injury or arise secondary 
to a compensable physical or mental complication. This dysfunction will usually 
be a secondary diagnosis and documentation must demonstrate a causal 
relationship with the compensable injury. A routine medical screening must occur 
prior to psychological or psychiatric therapy to rule out a medical diagnosis. 
 
  (i)  Diagnosis. 302.70-Psychosexual Dysfunction, Unspecified 
   
  (ii)  Level of Severity. 
 
  (I) Global Assessment of Functioning Scale. 
 
  (-a-) 90-61  514>=Mild 
   
  (-b-) 60-41  514>=Moderate 
   
  (-c-) 40  514>=Severe, Extreme, or Catastrophic 
     
  (II)  Psychosocial Stressor Scale. 
 
  (-a-) 1-2  514>=Mild 
   
  (-b-) 3  514>=Moderate 
   
  (-c-) 4-6  514>=Severe, Extreme, or Catastrophic 
       
  (iii)  Treatment Duration. The duration of treatment may be up to 12 weeks. 
   
  (iv) Ground Rules. 
 
  (I) Treatment duration will vary in correlation with the level of severity of 
symptomatology and stressors, diagnosis. 
   
  (II) Both indicators (GAF & PSS) must be considered, and documentation must 
support the levels of service. 
       
  (H) Substance Dependence Disorders and Substance Abuse Disorders. 
 
  (i) Substance Dependence Disorders. A substance dependence disorder is defined 
as a state, psychic and sometimes also physical, resulting from taking a drug, 
characterized by behavioral and other responses that always include a compulsion 
to take a drug on a continuous or periodic basis in order to experience its 
psychic effects, and sometimes to avoid the discomfort of its absence. Tolerance 
may or may not be present. A person may be dependent on more than one drug. 
Documentation must demonstrate that these conditions interfere with the 
treatment regimen, e.g., non-compliance in treatment, failure to inability to 
participate in treatment due to intoxication. 
   
  (ii) Substance Abuse Disorders. A substance abuse disorder includes cases 
where an individual, for whom no other diagnosis is possible, has come under 
mental health care because of the maladaptive effect of a drug on which he/she 
is not dependent (see substance dependence) and that he/she has taken on his/her 
own initiative to the detriment of his/her health or social functioning. When 
drug abuse is secondary to mental disorder, record the disorder as an additional 
diagnosis. Documentation must demonstrate that these diagnoses interfere with 
the treatment regimen, e.g., non-compliance in treatment, over sedation, 
inability to participate in treatment due to intoxication. 
   
  (iii) Diagnosis. 
 
  (I) 303 Alcohol Dependence Syndrome 
   
  (II) 303.0 Alcohol Dependence Syndrome, Acute 
   
  (III) 303.9 Alcohol Dependence Syndrome, Chronic 
   
  (IV) 304.0 Opioid Type Dependence 
   
  (V) 304.1 Barbiturate/Sedative/Hypnotic Dependence 
   
  (VI) 304.7 Combinations of Opioid Drug W/Other 
   
  (VII)  304.8 Combinations of Drug Dependence Excluding Opioid 
   
  (VIII) 304.9 Unspecified Drug Dependence 
   
  (IX) 305.0 Alcohol Abuse 
   
  (X) 305.9 Other Mixed or Unspecified Drug Abuse 
     
  (iv)  Level of Severity. 
 
  (I) Global Assessment of Functioning Scale. 
 
  (-a-) 90-61  514>=Mild 
   
  (-b-) 60-41  514>=Moderate 
   
  (-c-) 40  514>=Severe, Extreme, or Catastrophic 
     
  (II)  Psychosocial Stressor Scale. 
 
  (-a-) 1-2  514>=Mild 
   
  (-b-) 3  514>=Moderate 
   
  (-c-) 4-6  514>=Severe, Extreme, or Catastrophic 
       
  (v)  Treatment Duration. The duration of treatment may be up to six months. 
   
  (vi) Ground Rules. 
 
  (I) Treatment duration would vary in correlation with the level of severity of 
symptomatology, stressors, and diagnosis. 
   
  (II) Both indicators (GAF & PSS) must be considered, and documentation must 
support the levels of service. 
   
  (III) A GAF score of 40 or less is a strong indication for possible inpatient 
treatment. 
       
  (I) Acute Reaction. Acute transient disorders of any severity and nature of 
emotions, consciousness, and psychomotor states (single or in combination) which 
occur in individuals, without any apparent pre-existing mental disorder, in 
response to exceptional physical or mental stress, such as natural catastrophe 
or battle, and which usually subside within hours or days. 
 
  (i) Diagnosis. 
 
  (I) 308.0 Predominant Disturbance of Emotions 
   
  (II) 308.3 Other Acute Reactions to Stress 
   
  (III)  308.4 Mixed Disorders as Reaction to Stress 
   
  (IV) 308.9 Unspecified Acute Reaction to Stress 
     
  (ii) Level of Severity. 
 
  (I) Global Assessment of Functioning Scale. 
 
  (-a-) 90-61  514>=Mild 
   
  (-b-) 60-41  514>=Moderate 
   
  (-c-) 40  514>=Severe, Extreme, or Catastrophic 
     
  (II)  Psychosocial Stressor Scale. 
 
  (-a-) 1-2  514>=Mild 
   
  (-b-) 3  514>=Moderate 
   
  (-c-) 4-6  514>=Severe, Extreme, or Catastrophic 
       
  (iii)  Treatment Duration. 
 
  (I) 308.0, 308.4, 308.9-14 days. 
   
  (II) 308.3-six months (Brief or acute post traumatic stress disorder) . 
     
  (iv) Ground Rules. 
 
  (I) Treatment duration will vary in correlation with the level of severity of 
symptomatology, stressors and diagnosis. 
   
  (II) Both indicators (GAF & PSS) must be considered, and documentation must 
support the levels of service. 
   
  (III) A GAF score 40 or less is a strong indication for possible inpatient 
treatment. 
       
  (J)  Adjustment Reaction. Mild or transient disorders lasting longer than 
acute stress reactions which occur in individuals of any age with any apparent 
pre-existing mental disorder. Such disorders are often relatively circumscribed 
or situation-specific, are generally reversible, and usually last only a few 
months. They are usually closely related in time and content to stresses such as 
bereavement, migration, or other experiences. Reactions to major stress that 
last longer than a few days are also included. 
 
  (i)  Diagnosis. 
 
  (I) 309.0 Brief Depressive Reaction 
   
  (II)  309.1 Prolonged Depressive Reaction 
   
  (III) 309.24 Adjustment Reaction W/Anxious Mood 
   
  (IV) 309.28 Adjustment Reaction W/Mixed Emotional Features 
   
  (V) 309.81 Prolonged Post-Traumatic Stress Disorder 
   
  (VI) 309.82 Adjustment Reaction W/Physical Symptoms 
   
  (VII) 309.83 Adjustment Reaction W/Withdrawal 
   
  (VIII) 309.89 Other Adjustment Reaction 
   
  (IX) 309.9 Unspecified Adjustment Reaction 
     
  (ii) Level of Severity. 
 
  (I) Global Assessment of Functioning Scale. 
 
  (-a-) 90-61  514>=Mild 
   
  (-b-) 60-41  514>=Moderate 
   
  (-c-) 40  514>=Severe, Extreme, or Catastrophic 
     
  (II)  Psychosocial Stressor Scale. 
 
  (-a-) 1-2  514>=Mild 
   
  (-b-) 3  514>=Moderate 
   
  (-c-) 4-6  514>=Severe, Extreme, or Catastrophic 
       
  (iii)  Treatment Duration. The duration of treatment may be up to six months. 
For prolonged post-traumatic stress disorder (code 309.81), the duration of 
treatment may be up to 12 months. 
   
  (iv) Ground Rules. 
 
  (I)  Treatment duration will vary in correlation with the level of severity of 
symptomatology, stressors and diagnosis. 
   
  (II) Both indicators (GAF & PSS) must be considered, and documentation must 
support the levels of service. 
   
  (III) A GAF score of 40 or less is a strong indication for possible inpatient 
treatment. 
       
  (K) Peri-Operative Algorithm. 
 
  (i) A pre-surgical mental health evaluation may be obtained. An MMPI is 
strongly recommended. 
   
  (ii) If the patient is deemed a good surgical candidate based on results of an 
evaluation (he or she has no major mental disorders, a realistic understanding 
of the outcome, no concerns about his or her ability to comply with 
rehabilitation, and no concerns about chemical dependency/abuse), the health 
care provider may proceed with surgery as indicated by a surgical diagnostic 
work-up and appropriate surgical algorithms. 
   
  (iii) If the patient is deemed a poor surgical candidate and surgery is 
medically indicated, the health care provider may proceed with pre-surgical 
mental health interventions. The length of time for pre-surgical mental health 
interventions will vary with the severity and type of mental disorder, the 
patient's response to intervention, and the urgency of surgical intervention. 
Except in cases of severe mental disorders, generally six to eight weeks of one 
to two times per week of psychotherapy/behavioral intervention should be 
sufficient to prepare the patient for surgery. If surgery cannot be delayed due 
to the emergent nature of the patient's medical status, an appropriate mental 
health intervention should be initiated as quickly as possible following 
surgery. This may begin while the patient is still hospitalized with subsequent 
intensive follow-up post-surgery. 
   
  (iv)  If surgery is deemed unnecessary, the health care provider may proceed 
to appropriate rehabilitation such as specific physical reconditioning, work 
hardening, a pain management program, outpatient medical and/or mental health 
treatment and/or referral to vocational rehabilitation. 
   
  (v) A medical-surgical hospitalization follow-up may be indicated in cases 
where surgery is scheduled and psychosocial factors remain, such as anxiety, 
fear of catastrophic surgical outcome, difficulty focusing on instructions, etc. 
Peri-operative treatment may include, but is not limited to the following: 
 
  (I) one individual psychotherapy session per day; 
   
  (II)  psychotherapy sessions, which may consist of one hour or 30 minute 
sessions based on professional judgement and patient need; and 
   
  (III)  instructions or interventions with family members, as indicated. 
     
  (vi)  Peri-Operative Algorithm. (See Figure 3 in the Tables and Graphics 
Section of this issue of the Texas Register.) 
         
  Figure 3: 28 TAC sec.134.1000(h)(5)(K)(vi) 
 
  (6) Documentation Requirements for Ongoing Treatment. 
 
  (A) Guidelines for Ongoing Treatment Documentation. 
 
  (i) For patients receiving ongoing mental health services, a progress note 
meeting criteria in subparagraph (B) of this paragraph must be generated every 
session. The only report which must be submitted to the treating doctor is the 
30-60 day clinical summary at least once every 60 days and no more than once 
every 30 days and upon termination of treatment (see subparagraph (B)(ii) of 
this section for 30-60 day clinical summary outline). However, progress notes 
per session must be maintained in the patient's clinical chart in the event that 
circumstances require the Qualified Mental Health Provider (QMHP) to produce 
documentation see subsection (d)(2) of this section). 
   
  (ii) For patients with ongoing treatment extending past 90 days, a more 
thorough reevaluation must be submitted. In addition to the monthly 
documentation requirements, this quarterly review should contain information 
justifying the need for continued treatment, how continued treatment is likely 
to have a positive effect on the overall course of recovery, eventual return to 
work, and any change in diagnosis. 
   
  (iii) When the patient completes/terminates treatment prematurely or is 
discharged, the fact that treatment has ceased and reasons for the cessation of 
treatment should be reflected in the final progress note. Any follow-up needs, 
including occasional re-checks and/or medication follow-up should also be noted. 
     
  (B) Documentation Format and Content. 
 
  (i) Problem oriented documentation (POD). Problem oriented documentation (POD) 
is the prescribed format and content of the daily progress notes for all 
Qualified Mental Health Providers (QMHP) to follow. This specified format 
provides for a standardized structure of daily progress notes satisfying 
documentation standards of all mental health treatment in workers' compensation. 
The structure of the documentation has three sections. 
 
  (I)  Section I-Problem List (see subsection (g)(4)(P) of this section). 
Section I is comprised of: 
 
  (-a-) diagnoses; and 
   
  (-b-) presenting symptomatology. 
     
  (II) Section II-Treatment/Intervention. Section II is comprised of: 
 
  (-a-) treatment techniques used; 
   
  (-b-) actual dates of services; and 
   
  (-c-) treatment rendered from other provider sources, if known. 
     
  (III) Section III-Clinical Status. Progress/changes/regression may include: 
 
  (-a-) current status of problems; 
   
  (-b-) behavioral observations/brief mental status exam; 
   
  (-c-) symptom reports; 
   
  (-d-) activities of daily living; and 
   
  (-e-) self-report and behavior inventory (see subsection (g)(3)(B)(i)(I) (-a-) 
and (-b-); and (g)(3)(C)(iii)(I) and (III) of this section for type and 
frequency) 
       
  (ii) 30-60 Day Clinical Summary. This report must include all of the elements 
found in clause (i) of this subparagraph, as well as, response to treatment, 
progress, and overall improvement of symptoms since the last 30-60 day clinical 
summary along with a rationale for continued treatment. Any failure to respond 
to treatment within the 30-60 day timeframe should be documented and followed by 
a change in the plan of treatment. 
       
  (i) Criteria for Referral for Other Programs. 
 
  (1) Criteria for Inpatient Psychiatric Treatment Referral/Inpatient Chronic 
Pain Management Referral. It is assumed that the vast majority of mental 
disorders arising from/out of compensable injuries will be treatable on an 
outpatient basis, particularly if recognized early in the patient's course of 
recovery. However, certain serious situations will require inpatient treatment, 
either because it is necessary for the patient's safety and well-being, or 
because intensive intervention provides the most effective treatment. Inpatient 
hospitalization may take place in a medical/surgical hospital, free-standing 
psychiatric unit, or rehabilitation hospital, depending on the patient's 
individual needs and the services available at the specific facility. Criteria 
for inpatient treatment includes a GAF of 40-1 and a PSS of 4-6. Any 
inconsistencies between the GAF/PSS score when inpatient treatment is 
recommended, must be supported by documentation. The following situations are 
considered appropriate for referral to inpatient psychiatric treatment 
environments once a causal relationship to the compensable injury is 
established: 
 
  (A) severe depression that is unresponsive to outpatient treatment, 
particularly if there is suicidal risk; 
   
  (B) marked to severe deterioration in mental/emotional functioning including 
hallucinations, delusions, illusions, as well as behavioral, verbal, cognitive, 
or thought disorganization including, but not limited to psychosis and/or mania; 
   
  (C) dangerousness to self and/or others including assaultive behavior, 
significant risk of potential danger to others, suicide attempt, suicidal 
ideation requiring suicide precautions, and other self-injurious/self-mutilative 
behavior; 
   
  (D)  detoxification for alcohol, prescription medications, or street drugs, 
when the chemical abuse/dependency has arisen secondary to, or has been 
exacerbated by, a compensable injury; 
   
  (E) inpatient treatment of chemical abuse/dependency (may also be necessary 
when the abuse/dependency is chronic, intense, and unremitting, and the patient 
has failed to improve with outpatient treatment or there is a presence of a 
concomitant illness rendering outpatient detoxification medically dangerous); 
   
  (F) to stabilize a patient on psychoactive medication, when it is considered 
unsafe to attempt this on an outpatient basis due to the patient's other medical 
or emotional conditions; and 
   
  (G) any patient who meets the referral criteria under paragraph (3) of this 
subsection, but requires inpatient care due to a GAF of 40-1. 
     
  (2) Because of the diversity of mental disorders and types of services found 
in inpatient psychiatric settings, there is no attempt made in this document to 
address treatment parameters for these settings. This guideline only focuses on 
appropriate criteria for referral to these facilities. 
   
  (3) Criteria for Referral to Chronic Pain Management Programs. 
 
  (A) A subset of patients with chronic or complex medical conditions, such as 
chronic pain, will not respond to outpatient psychotherapy conducted in 
conjunction with primary and secondary phases of treatment. These patients will 
require referral to a treatment program with multidisciplinary, individualized 
and intensive treatment to deal with the complex mixture of medical and mental 
problems associated with chronic disability. 
   
  (B)  The majority of patients requiring referral for chronic pain can be 
adequately treated as outpatients in some type of day or partial day treatment, 
with the patients returning to their homes or other lodging in the evening. The 
following criteria are considered appropriate for referral to outpatient 
treatment programs of this type: 
 
  (i) a Global Assessment of Functioning (GAF) rating of 40-90 with any 
psychosocial stressor (PSS) rating; 
   
  (ii) the patient has not responded to primary or secondary stages of 
outpatient physical therapy and/or mental health treatment in a reasonable 
period of time (e.g. within four to six months) and/or; 
   
  (iii) the patient exhibits pain behavior, functional limitations, and/or 
mental/emotional dysfunction, which are disruptive to their activities of daily 
living, and two or more of the following: 
 
  (I) the patient is facing significant, permanent loss of functioning that 
requires major physical, vocational, and psychological readjustment; 
   
  (II) diagnostic findings are insufficient to explain the pain or further 
invasive medical treatment is not an option; 
   
  (III) pain has persisted beyond the expected tissue healing time; 
   
  (IV) the patient has chronic pain linked to adverse interpersonal 
relationships which interfere with rehabilitation; 
   
  (V)  the patient has physical/mental impairment greater than expected on the 
basis of the diagnosed medical condition and treatment or differential diagnosis 
and treatment required in a more structured/supervised setting; 
   
  (VI) documented history of inappropriate and excessive use of healthcare 
services by the injured worker such as frequent emergency room visits; 
   
  (VII) documented history of inappropriate and excessive use of narcotic 
sedative/hypnotic medications, or alcohol; 
   
  (VIII) the patient continues to express unrealistic expectations regarding 
outcome of medical/psychiatric intervention in relief of their own 
symptomatology; or 
   
  (IX) referral to such programs is also appropriate earlier in treatment in 
order to prevent later development of an excessively disabled lifestyle role if 
the patient is judged to be at risk for developing such problems. 
       
  (C) A small percentage of chronic pain patients will require referral to 
inpatient chronic pain management care. Referral to such treatment requires that 
the patient meet criteria for both paragraph (1) of this subsection (criteria 
for inpatient psychiatric treatment) and this paragraph. Because such treatment 
centers are multidisciplinary by definition, there is no attempt made in this 
document to address treatment parameters for these comprehensive treatment 
programs. 
       
  (j) Appendix A. 
 
  (1)  Severity of Psychosocial Stressors Scale: Adults (American Psychiatric 
Association (1987). DIAGNOSTIC AND STATISTICAL MANUAL OF MENTAL DISORDERS (3rd 
ed., revised). Washington, D.C.,: Author; pg 11, 19.). (See Figure 4 in the 
Tables and Graphics Section of this issue of the Texas Register .) 
       
  Figure 4: 28 TAC sec.134.1000(j)(1) 
 
  (2) Rating the severity of the stressor. The rating of the severity of the 
stressor should be based on the clinician's assessment of the stress an 
"average" person in similar circumstances and with similar socio-cultural values 
would experience from the particular psychosocial stressor(s). This judgement 
involves consideration of the following: the amount of change in the person's 
life caused by the stressor, the degree to which the event is desired and under 
the person's control, and the number of stressors. For example, a planned 
pregnancy is usually less stressful than an unwanted pregnancy. Even though a 
specific stressor may have greater impact on a person who is especially 
vulnerable or has certain internal conflicts, the rating should be based on the 
severity of the stress itself, not on the person's vulnerability to the 
particular stressor. The specific psychosocial stressor(s) should be noted and 
further specified as either: 
 
  (A) predominantly acute event (duration less than six months); or 
   
  (B) predominantly enduring circumstance (duration greater than six months). 
     
  (k) Appendix B. 
 
  (1)  Global Assessment of Functioning Scale (GAF Scale) (American Psychiatric 
Association (1987). DIAGNOSTIC AND STATISTICAL MANUAL OF MENTAL DISORDERS (3rd 
ed., revised). Washington, D.C.,: Author; pg 12.). Consider psychological, 
social, and occupational functioning on a hypothetical continuum of mental 
health-illness. Do not include impairment in functioning due to physical (or 
environmental) limitations (Use intermediate codes when appropriate, e.g., 45, 
68, 72). 
   
  (2) Codes. 
 
  (A) 90-81 Absent or minimal symptoms (e. g., mild anxiety before an exam), 
good functioning in all areas, interested and involved in a wide range of 
activities, socially effective, generally satisfied with life, no more than 
everyday problems or concerns (e.g., an occasional argument with family 
members). 
   
  (B) 80-71 If symptoms are present, they are transient and expectable reactions 
to psychosocial stressors (e.g., difficulty concentrating after family 
argument); no more than slight impairment in social, occupational, or school 
functioning (e.g., temporarily falling behind in school work). 
   
  (C) 70-61 Some mild symptoms (e.g., depressed mood and mild insomnia) OR some 
difficulty in social, occupational, or school functioning (e.g., occasional 
truancy, or theft within the household) , but generally functioning pretty well, 
has some meaningful interpersonal relationships. 
   
  (D) 60-51 Moderate symptoms (e.g., flat affect and circumstantial speech, 
occasional panic attacks) OR moderate difficulty in social, occupational or 
school functioning (e.g., few friends, conflicts with co-workers). 
   
  (E) 50-41 Serious symptoms (e.g., suicidal ideation, severe obsessional 
rituals, frequent shoplifting) OR any serious impairment in social, 
occupational, or school functioning (e.g., no friends, unable to keep a job). 
   
  (F) 40-31 Some impairment in reality testing or communication (e.g., speech is 
at times illogical, obscure, or irrelevant) OR major impairment in several 
areas, such as work or school, family relations, judgment, thinking, or mood 
(e.g., depressed man avoids friends, neglects family, and is unable to work; 
child frequently beats up younger children, is defiant at home, and is failing 
in school). 
   
  (G) 30-21 Behavior is considerably influenced by delusions or hallucinations 
OR serious impairment in communication or judgment (e.g., sometimes incoherent, 
acts grossly inappropriately, suicidal preoccupation) OR inability to function 
in almost all areas (e.g., stays in bed all day; no job, home, or friends). 
   
  (H)  20-11 Some danger of hurting self or others (e.g., suicide attempts 
without clear expectation of death, frequently violent, manic excitement) OR 
occasionally fails to maintain minimal personal hygiene (e.g., smears feces) OR 
gross impairment in communication (e.g., largely incoherent or mute). 
   
  (I) 10-1 Persistent danger of severely hurting self or others (e.g., recurrent 
violence) OR persistent inability to maintain minimal personal hygiene OR 
serious suicidal act with clear expectation of death. 
   
  (J)  0 Inadequate information. 
       
  (l) Appendix C. 
 
  (1) ICD-9 CODES OVERVIEW. 
 
  (A) ICD-9-CM Mental Disorders included in Mental Health Treatment Guideline. 
The most frequently occurring disabling and costly ICD-9's were identified by 
the panel of experts and the commission staff in addition to the TWCC billing 
database. The vast majority of mental disorders treated under Workers' 
Compensation will most likely fall in the following general categories: ICD-9 
DESCRIPTION 293 Organic Brain Impairment due to Drug Toxicity 296/298 Psychotic 
Disorders 296/300/311 Affective Disorders 300 Anxiety Disorders 
300/302/306/307/317 Somatoform Disorders 301 Personality Disorders 302 
Psychosexual Dysfunction 303 Alcohol Dependence 303/304/305 Substance 
Dependence/Substance Abuse 308 Acute Reaction 309 Adjustment Reaction 
   
  (B) While these will be the most frequently diagnosed mental disorders, given 
the wide variety of individual reactions that may occur, all other ICD-9-CM 
mental disorders are included, with the exception of those specifically 
excluded. (See Ground Rules, subsection (f)(3) of this section). 
       
  (m) Appendix D-ICD-9 CODES. (See Figure 5 in the Tables and Graphics Section 
of this issue of the Texas Register.) 
     
  Figure 5: 28 TAC sec.134.1000(m) 
 
  (n) Appendix E-Elements of a Mental Status Examination. 
 
  (1) Presentation. 
 
  (A) Grooming and Appearance 
   
  (B) Personal Hygiene and Dress 
     
  (2) Behavior. 
 
  (A) Psychomotor Activity 
   
  (B) Appropriate to Situation 
     
  (3) Mood. 
   
  (4) Affect. 
   
  (5) Sensorium. 
 
  (A)  Alert 
   
  (B) Orientation-Time, Place, and Person 
     
  (6) Memory. 
 
  (A) Recent 
   
  (B) Remote 
     
  (7) Speech. 
   
  (8)  Thought Process. 
 
  (A) Thought Process 
   
  (B) Thought Content 
     
  (9) Hallucinations. 
   
  (10) Delusions. 
   
  (11) Thoughts of Harm to Self or Others. 
 
  (A) Violence 
   
  (B) Incidence 
     
  (12) Judgment. 
   
  (13) Insight. 
     
  (o) Bibliography. The following publications comprise a bibliography for this 
treatment guideline: 
 
  (1) American Psychiatric Association (1987). DIAGNOSTIC AND STATISTICAL MANUAL 
OF MENTAL DISORDERS (3rd ed., revised). Washington, D.C.: Author.; 
   
  (2) American Psychiatric Association; Practice Guideline for Major Depressive 
Disorder in Adults, THE AMERICAN JOURNAL OF PSYCHIATRY, Vol. 150, 4, April 
1993.; 
   
  (3) Aronoff, G.M.; EVALUATION AND TREATMENT OF CHRONIC PAIN, Urban & 
Schwarsenberg, 1985; 
   
  (4) Backman, M.E.; THE PSYCHOLOGY OF THE PHYSICALLY ILL PATIENT (CLINICIAN'S 
GUIDE), Plenum Press, 1989; 
   
  (5) Barber, J., & Adrian, C. (1982). Psychological approaches to the 
management of pain. New York: Brunner/Mazel.; 
   
  (6) Barrows, G., Elton, D., Stanley, G.; PSYCHOLOGICAL CONTROL OF PAIN, Grune 
& Stratton, 1983; 
   
  (7) Beck, A.T., Emery, G., Rush, A.J., Shaw, B.F.; COGNITIVE THERAPY OF 
DEPRESSION, Guilford Press, New York, 1987; 
   
  (8) Beck, A.T., Ward, C.H., Mendelson, M., Mock, J., Erbaugh, J. (1961). An 
inventory for measuring depression. ARCHIVES OF GENERAL PSYCHIATRY, 4, 53-63.; 
   
  (9) Blacher, R. S.; The Psychological Experience of Surgery, John Wiley and 
Sons, New York, 1987; 
   
  (10) Block, A.R.: Multidisciplinary treatment of chronic low back pain: A 
review. REHABIL PSYCHOL 1982: 27: 51-63.; 
   
  (11) Blumer, D. , & Heilbrown, M. (1982). Chronic pain as a variant of 
depressive illness. The pain prone disorder. JOURNAL OF NERVOUS AND MENTAL 
DISEASE, 170, 381-406.; 
   
  (12) Bonica, J.J. (1959). The management of pain. Philadelphia: Lea & 
Febiger.; 
   
  (13) Cameron, O.G. (1990). Guidelines for diagnosis and treatment of 
depression in patients with medical illness. JOURNAL OF CLINICAL PSYCHIATRY, 51 
(7), 49-54.; 
   
  (14) Cashion E.L. & Lynch W.J., Personality factors and results of lumbar disc 
surgery, NEUROSURGERY 1979 4: 141-145.; 
   
  (15) Chaplin, E.R.(1991). Chronic pain: a sociobiological problem. In Walsh, 
N.E. (ed), Physical medicine and rehabilitation: State of the art reviews, 5(1), 
pp 1-47. Philadelphia, Henley & Belfus.; 
   
  (16)  Deardorff, W.W., Rubin, H.S., Scott, D.W.: Comprehensive 
multidisciplinary treatment of chronic pain: a follow-up study of treated and 
non-treated groups. PAIN 1991: 45: 35-43.; 
   
  (17) Doxey, N.C. & Dzobia, R.B.: A prospective investigation into the 
orthopedic and psychological predictors of outcome of first lumbar surgery 
following industrial injury, SPINE 1984: 6: 614-623.; 
   
  (18) Doxey, N., Dzobia, R.D., Mitson, C.L., Lacroix, J.M.: Predictors of 
outcome in back surgery candidates. J Clin Psych 1988: 44: 661-622.; 
   
  (19) Elkind, G., Large, R.G., Peters, J.: Follow-up results from a randomised 
controlled trial evaluating in- and out-patient pain management programmes. PAIN 
1992: 50: 41-50.; 
   
  (20) Enders, P.L., The Value of Psychological Testing with Chronic Pain 
Patients. Evaluation and Treatment of Chronic Pain. Chapter 36, 589-595; 
   
  (21) Flor, H., Fydrich, T., Turk, D.C.: Efficacy of multidisciplinary pain 
treatment centers: a meta-analytic review. PAIN 1992: 49: 221-230.; 
   
  (22) Freedman, A.M., Kaplan, H.I., Sadock, B.J.; MODERN COMPREHENSIVE TEXTBOOK 
OF PSYCHIATRY, Williams and Wilkins Company, Baltimore; 
   
  (23) Gatchel, Baum, Krantz; AN INTRODUCTION TO HEALTH PSYCHOLOGY, 2nd Edition, 
Random House, New York, 1989; 
   
  (24) Genest, M., Meichenbaum, D., Turk, D.C.; PAIN & BEHAVIORAL MEDICINE (A 
COGNITIVE BEHAVIORAL PERSPECTIVE), Guilford Press, 1983; 
   
  (25) Hamilton, M. (1960). A rating scale for depression. JOURNAL OF NEUROLOGY, 
NEUROSURGERY, AND PSYCHIATRY, 23, 56-61.; (1) 
   
  (26) Hendler, N.H., The psychiatrist's role in pain management. (1993) In 
Weiner, R.S. (ed), Innovations in pain management: A practical guide for 
clinicians. (1) pp 6.1-36, Orlando, PM Deutsh Press.; 
   
  (27) Holzman, A.D. & Turk, D.C.; PAIN MANAGEMENT (HANDBOOK OF PSYCHOLOGICAL 
TREATMENT APPROACHES), Pergamon Press, 1986; 
   
  (28) Horowitz, M.J.; STRESS RESPONSE SYNDROME, 2nd Edition, Jason Aronson, New 
Jersey, 1986; 
   
  (29) Jacobs, D.F. 1982, December. Toward a formula for professional survival 
in troubled times. PUBLIC SERVICE PSYCHOLOGY, December, 1983.; 
   
  (30) Katon, W., Egan, K., Miller, D. (1985). Chronic pain: Lifetime 
psychiatric diagnoses and family history. AMERICAN JOURNAL OF PSYCHIATRY, 142, 
1156-1160.; 
   
  (31) Krishnan, K.R., France, R.D., Houpt, J.L. (1985). Chronic low back pain 
and depression. PSYCHOSOMATICS, 26, 289-294.; 
   
  (32) Krishnan, K.R., France, R.D., Pelton, S., McCann, U.D., Davidson, J., 
Urban, B.J. (1985a). Chronic pain and depression. I: Classification of 
depression in chronic low back patients. PAIN, 22, 279-287.; 
   
  (33) Krishnan, K.R., France, R.D., Pelton, S., McCann, U.D., Davidson, J., 
Urban, B.J. (1985b). Chronic pain and depression. II: Symptoms of anxiety in the 
chronic low back pain patients and their relationship to subtypes of depression. 
PAIN, 22, 289-294.; 
   
  (34) Krueger, D.W.; EMOTIONAL REHABILITATION OF PHYSICAL TRAUMA AND 
DISABILITY, S P Medical & Scientific Books, 1984; 
   
  (35) Krupnick, J., Pincus, H., The Cost-Effectiveness of Psychotherapy: A Plan 
for Research, AMERICAN JOURNAL OF PSYCHIATRY, 149:10, October 1992; 
   
  (36) Linton, S.J., Bradley, L.A., Jensen, I., Spangfort, E., Sundell, L. , The 
Secondary Prevention of Low Back Pain: A Controlled Study with Follow-up, PAIN, 
36 197-207, 1989; 
   
  (37) Lipchik, G.L., Milles, K., Covington, E., The Effects of 
Multidisciplinary Pain Management Treatment on Locus of Control and Pain Beliefs 
in Chronic Non-Terminal Pain, THE CLINICAL JOURNAL OF PAIN, Vol. 9, No. 1, 1993; 
   
  (38) Main, C.J.; CLINICAL PSYCHOLOGY AND MEDICINE, Plenum Press, 1982; 
   
  (39) Mayer, T.G. & Gatchel, R.J. (1988). FUNCTIONAL RESTORATION FOR SPINAL 
DISORDERS: THE SPORTS MEDICINE APPROACH. Philadelphia: Lea & Febiger.; 
   
  (40) Mayer, T.G., Mooney, V., Gatchel, R.J., CONTEMPORARY CONSERVATIVE CARE 
FOR PAINFUL SPINAL DISORDERS, Lea & Febiger, Philadelphia, 1991; 
   
  (41) Melzack, R. & Wall, P.D. (1965). Pain mechanisms: A new theory. SCIENCE, 
150, 971-979.; 
   
  (42) Million, R., Hall, W., Haauvik, N., Baker, R., Jayson, M. (1982). 
Assessment of the progress of the back pain patient. SPINE, 7, 204-212.; 
   
  (43) Morse, R.H. (1983) Pain and emotions. In Brena, S.F., Chapman, S.L. 
(eds), Management of patients with chronic pain. pp 47-54. New York, Spectrum. ; 
   
  (44) Mumford, E., Schlesinger, H.J., Glass, G.V., 1982. The effects of 
psychological interventions on recovery from surgery and heart attacks: A review 
of the literature. AMERICAN JOURNAL OF PUBLIC HEALTH, 72. 141-151.; 
   
  (45) Polatin, P,B,, Kinney, R.K., Gatchel, R.J., Lillo, E., Mayer, T.G. 
(1993). Psychiatric illness and chronic low-back pain: The mind and the spine-
which goes first. SPINE, 18 (1), 66-71.; 
   
  (46) Price, D.D.; PSYCHOLOGICAL AND NEURAL MECHANISMS OF PAIN, Raven Press, 
1988; 
   
  (47) Rowat, D. (1981) Living with chronic pain: The spouses perspective. PAIN, 
23 (3): 259-271.; 
   
  (48) Schlesinger, H.J., Mumford, E., Glass, G.V., Patrick, C., Sharfstein, S., 
1983. Mental health treatment and medical care utilization in a fee-for-service 
system: Outpatient mental health treatment following the onset of chronic 
disease. AMERICAN JOURNAL OF MENTAL HEALTH, 73, 422-429.; 
   
  (49) Schwarts, D., Appropriate Referral to Inpatient vs Outpatient Pain 
Management Program: A Clinician's Guide, PAIN DIGEST, 1: 2-6, 1991; 
   
  (50) Scrignar, C.B.; POST TRAUMATIC STRESS DISORDER, 2nd Edition, Bruno Press, 
New Orleans, 1988; 
   
  (51) Shealy, C.M., Cady RX (1993) Multidisciplinary pain clinics: Current 
status. In Weiner, R.S. (ed), Innovations in pain management: A practical guide 
for clinicians. (1) pp 4.1-20. Orlando, PM Deutsh Press.; 
   
  (52) Simmons, J.W., Avant, Jr., W.S., Demski, J., Parisher, D., Determining 
Successful Pain Clinic Treatment through Validation of Cost Effectiveness, 
Presented at the Second Annual Meeting of the North American Spine Society, June 
25-28, 1987, Banff, Alberta, Canada.; 
   
  (53) Spengler, D.M., Ouellette, E.A., Battie, M., Zeh, J. (1991) Elective 
discectomy for herniation of a lumbar disc, THE JOURNAL OF BONE AND JOINT 
SURGERY, 72-A.2, 230-237.; 
   
  (54) Sternbach, R.A.; PAIN PATIENTS (TRAITS & TREATMENT), Academic Press, 
1974; 
   
  (55) Sullivan, M.J.L., Reesor, K., Mikail, S., Fisher, R., The Treatment of 
Depression in Chronic Low Back Pain: Review and Recommendations, PAIN, 50, 5-13, 
1992; 
   
  (56) Texidor, M.S., The non-pharmacological management of chronic pain via the 
interdisciplinary approach. (1993) In Weiner, R.S. (ed), Innovations in pain 
management: A practical guide for clinicians, (1) pp 7.1-17, Orlando, PM Deutsh 
Press.; 
   
  (57) Tollinson, C.D. (1987). Managing chronic pain. New York: Gardner Press.; 
   
  (58) Tollinson, C.D., Kriegel, M.L., Satterthwaite, J.R., Hinnant, D.W., & 
Turner, K.P. (1989). Comprehensive pain center treatment of low back workers 
compensation injuries. ORTHOPEDIC REVIEW, 10, 1115-1125.; 
   
  (59) Tollinson, C.D.(1983). The magnitude of the pain problem: The problem is 
perspective. In Weiner, R.S. (ed), Innovations in pain management: A practical 
guide of clinicians. (1) pp 1.1-9, Orlando, PM Deutsh Press.; 
   
  (60) Turk, D. & Flor, H. (1984). Ideological theories and treatment for 
chronic back pain, II: Psychological models and interventions, PAIN, 19(3): 209-
233.; 
   
  (61) Turner, J.A. (1982). Comparison of group progressive-relaxation training 
and cognitive-behavioral group therapy for chronic low back pain. JOURNAL OF 
CONSULTING AND CLINICAL PSYCHOLOGY. 50.5, 757-765.; 
   
  (62) Turner, R.S., Leiding, W.C. (1985). Correlation of the MMPI with 
lumbosacral spine fusion results prospective study. SPINE, 10.10, 932-936.; and 
   
  (63) Ward, N.G., Bloom, V.L., Friedel, R.O. (1979). The effectiveness of 
tricyclic antidepressants in the treatment of coexisting pain and depression. 
PAIN, 7, 331-341. 
 
  This agency hereby certifies that the rule as adopted has been reviewed by 
legal counsel and found to be a valid exercise of the agency's legal authority. 
 Issued in Austin, Texas, on December 27, 1994. 
 TRD-9452882 
  Susan Cory 
 General Counsel 
 Texas Workers' Compensation Commission 
    Effective date: March 1, 1995 
 Proposal publication date: June 24, 1994 
 For further information, please call: (512) 440-3700 
         
                     
  TITLE 31. NATURAL RESOURCES AND CONSERVATION 
 Part II. Texas Parks and Wildlife Department 
  Chapter 57. Fisheries 
  
  The Texas Parks and Wildlife Commission in a regularly scheduled public 
hearing, August 25, 1994, adopted amendments to sec.57.42, sec.57.45 (concerning 
Shell Dredging on the Texas Gulf),  sec.sec.57.62-57.73 (concerning Issuance of 
Marl, Sand and Gravel Permits) and sec.57.101 (concerning Price of Sand, Shell, 
Gravel and Marl). Section 57.101 is adopted with changes to the proposed text as 
published in the July 19, 1994, issue of the Texas Register (19 TexReg 5605). 
Sections 57.42, 57.45, 57.62, and 57.73 are adopted without changes and will not 
be republished. 
 New sec.57.101(a) proposed a base price of $.63 per cubic yard of sand, gravel 
and marl removed from the beds of state-owned waterways. Annual adjustments to 
the price were proposed to reflect changes in the Producer Price Index for 
Industry, 1442, Construction Sand and Gravel, as prepared by the U. S. 
Department of Labor. As a result of public comments, the Commission adopted a 
minimum and percent royalty on sand, shell and gravel instead of the proposed 
flat rate of $.63 per ton. 
 The Commission adopted a minimum royalty at $0.20 per ton or a percent royalty 
of 6.25% of the average selling price per ton sold, which ever is higher. The 
percent royalty will increase to 8.0% on September 1, 1996. 
 Weighing of sand and gravel presented logistical problems for operators taking 
these resources on barges or dredges. The Commission adopted sec.57. 101(a)(1) 
to allow these operators to convert more easily measured cubic yards to tons 
through use of an industry standard conversion. 
 The Commission set the rate for payment of sand, gravel and marl for personal 
use at the minimum royalty of $.20 per ton in adopted sec.57.101(a)(2). 
 Proposed amended sec.57.101(b)-(d) were adopted without change. 
 Parks and Wildlife Code, sec.sec.86.001, et seq, establishes the authority of 
the Commission to manage, control, and protect marl and sand of commercial value 
and all gravel, shell, and mudshell located within the state-owned waterways. 
The price of marl, and of sand and gravel, had not been adjusted since 1971 and 
1973, respectively, and the existing price of $0.20 per cubic yard undervalued 
the market value of this resource. Amended sec.57.101(a) fairly represents the 
value of these state-owned resources. 
 Amended rules, as adopted, set a fair value for sand, gravel and marl taken 
from the beds of state-owned waterways. In addition, it is anticipated that 
auditing of sand, shell and gravel permittees will be simplified, enforcement of 
permit provisions will be more effective, and revenues to the state from sale of 
these resources may increase, more accurately reflecting the market value of 
these resources. 
 Two commenters suggested that a price increase be implemented through a royalty 
system rather than as a flat rate increase. One commenter stated that this would 
allow operators to be competitive in their local communities and would result in 
a more equitable system; Two commenters suggested that a price increase be 
phased-in over several years; Three commenters suggested that overhead costs of 
dredging in a state-owned waterway were equal to or greater than costs 
associated with upland dredging and suggested that determination of the amount 
of royalty should reflect these overhead costs; One commenter stated that 
implementation of the proposed flat rate royalty may cause an increase in 
unemployment; Two commenters supported the $.05 per ton minimum royalty increase 
and the 6.25% royalty and stated the belief that industry could adjust to the 
increase; Three commenters suggest that the alternative to waterway dredging 
would result in the taking of bottomland areas which would be more harmful to 
the state's resources than current waterway dredging practices; One commenter 
suggested that an operator who is mining both private upland areas and the bed 
of a state-owned waterway may mix the materials from these sources and have 
difficulty determining the correct royalty amount; One commenter suggests that 
there will be significant impacts on local governments from the implementation 
of this rule. 
 Comments both in favor of and against the rules as proposed were received from 
the General Land Office. 
 Agency response to comments will be addressed using a numerical sequence which 
coincides with the comments sequence above: Department staff agreed with this 
comment and others in proposing a minimum and percent royalty system; The 
department agreed with this comment and the Commission adopted a two-year phase-
in for the percent royalty from 6.25% to 8.0% royalty. The phase-in period 
allows operators time to renegotiate private contracts for lease and access to 
public waterways; The department considered this comment and others in lowering 
the payment required for materials dredged from a state-owned waterway; 
Department staff agreed with this comment and others in proposing a royalty 
system which is anticipated to result in lower payments to the state than would 
have resulted from the proposed flat rate increase; Department staff considered 
this comment and others in proposing the minimum and percent royalty; Department 
staff agrees that one alternative to waterway dredging is the use of upland pits 
which may be located in bottomland areas. Whether this would be more harmful to 
the state's resources than waterway dredging would be dependent on the specific 
operations and areas involved. The department made no change to the rule as a 
result of the comment; Under the rule, the operator continues to be responsible 
for determining the amount of material dredged from the river. The department is 
available to provide technical assistance to the permittee in implementing an 
appropriate accounting method for materials removed from separate sources. The 
department made no change to the rule as a result of the comment; As stated in 
the preamble to the proposed rule, local governments are exempt from price 
increases. Under sec.86.013 of the Texas Parks and Wildlife Code, sec.86.013 a 
county, subdivision of a county, city, or town that has a permit to take marl, 
sand, gravel, shell, or mudshell taken and used for roads and streets is not 
required to make payment to the department. A county, subdivision of a county, 
city, or town that purchases these materials for use on roads and street from a 
holder of a permit who has purchased the material from the commission may 
receive a refund of the amount paid by the permit holder by submitting a sworn 
itemized account. The State Highway Commission may receive a refund of the 
amount paid to the commission for the purchase of these materials used by the 
State Highway Commission on public roads. The department made no change to the 
rule as a result of the comment. 
 Interpretation of How Provisions Authorize or Require the Rules. 
   
  Shell Dredging on the Texas Gulf Coast 
 
  31 TAC sec.57.42, sec.57.45 
 
  The amendments are adopted under the authority of sec. sec.86.001 et seq, 
which sets out the authority of the commission to manage, control, and protect 
marl and sand of commercial value and all gravel, shell, and mudshell located 
within the state-owned waterways. 
 
  This agency hereby certifies that the rule as adopted has been reviewed by 
legal counsel and found to be a valid exercise of the agency's authority. 
 Issued in Austin, Texas, on December 21, 1994. 
 TRD-9452923 
  Paul M. Shinkawa 
 Acting General Counsel 
 Texas Department of Wildlife and Department 
    Effective date: January 18, 1995 
 Proposal publication date: July 19, 1994 
 For further information, please call: 1-800-792-1112, Ext. 4433 or (512) 389-
4433 
         
         
  Issuance of Marl, Sand, and Gravel Permits 
 
  31 TAC sec.57.62, sec.57.73 
 
  The amendments are adopted under the authority of sec. sec.86.001 et seq, 
which sets out the authority of the commission to manage, control, and protect 
marl and sand of commercial value and all gravel, shell, and mudshell located 
within the state-owned waterways. 
 
  This agency hereby certifies that the rule as adopted has been reviewed by 
legal counsel and found to be a valid exercise of the agency's authority. 
 Issued in Austin, Texas, on December 21, 1994. 
 TRD-9452924 
  Paul M. Shinkawa 
 Acting General Counsel 
 Texas Department of Wildlife and Department 
    Effective date: January 18, 1995 
 Proposal publication date: July 19, 1994 
 For further information, please call: 1-800-792-1112, Ext. 4433 or (512) 389-
4433 
         
         
  Price of Fill Material 
 
  31 TAC sec.57.91 
 
  The Texas Parks and Wildlife Commission in a regularly scheduled public 
hearing, August 25, 1994, adopted repeal of sec.57.91, concerning pricing of 
marl, without changes to the text as published in the July 19, 1994, issue of 
the Texas Register  (19 TexReg 5606). 
 The Parks and Wildlife Department adopted new rules, concomitant to repeal of 
this section, which included marl pricing in pricing of sand, shell and marl. 
Adoption of these rules rendered  sec.57.91 redundant. 
 Repeal of sec.57.91 will remove redundancy from the Texas Administrative Code. 
Further, implementation of new pricing structures will provide consistent 
regulation of sand, shell and marl pricing. 
 The agency received no public comments concerning repeal of this section. 
 The repeal of sec.57.91 is adopted under the authority of sec.86.012 of the 
Texas Parks and Wildlife Code which authorizes the commission, with the approval 
of the governor, to sell sand, gravel, and marl for not less than four cents a 
ton. 
 
  This agency hereby certifies that the rule as adopted has been reviewed by 
legal counsel and found to be a valid exercise of the agency's authority. 
 Issued in Austin, Texas, on December 21, 1994. 
 TRD-9452922 
  Paul M. Shinkawa 
 Acting General Counsel 
 Texas Parks and Wildlife Department 
    Effective date: January 18, 1995 
 Proposal publication date: July 19, 1994 
 For further information, please call: 1-800-792-1112, extension 4433 or (512) 
389-4433 
         
         
  Price of Sand, Shell, Gravel and Marl 
 
  31 TAC sec.57.101 
 
  The amendment is adopted under the authority of sec.86.012 of the Texas Parks 
and Wildlife Code, which authorizes the commission, with the approval of the 
governor, to sell sand, gravel, and marl for not less than four cents a ton. 
 
 
  sec.57.101. Prices. 
 
  (a) The commission, with the approval of the governor, establishes a minimum 
royalty of $.20 ton for sand, gravel, and marl. The permittee shall pay the 
minimum royalty or a percent royalty of 6.25% on the average selling price per 
ton sold calculated on a monthly basis, whichever is higher. The percent royalty 
shall increase to 8.0% on September 1, 1996. 
 
  (1) Where the permittee uses a floating dredge and barge or does not have 
access to a scale, measurement of materials sold may be made in cubic yards and 
converted into tons according to industry standard prior to payment. 
   
  (2) Payment for materials dredged solely for personal use may be based on the 
minimum royalty. 
     
  (b) The commission, with approval of the governor, establishes a price of 
$1.25 per cubic yard on all grades of shell removed from state-owned submerged 
tidelands. The price of shell will hereafter be adjusted semiannually, starting 
October 1, 1981, to reflect any increase or decrease (percent of change) in the 
Consumer Price Index of retail sales as prepared by the Bureau of Labor 
Statistics, U.S. Department of Labor (using the National Consumer Price Index, 
all urban consumers, 1967 equals 100) except that any adjustment for the six-
month period starting October 1, 1981, will be based upon the Consumer Price 
Index statistics compiled for the six months ending June 30, 1981, and each 
succeeding six-month period will be adjusted in the same manner in order to 
provide permittees advanced notice of price adjustments, and except that the 
price of shell per cubic yard will be rounded off to the nearest whole cent and 
will not be adjusted in any six-month period to less than the base price of 
$1.25 per cubic yard as established in this section. 
   
  (c) In addition, 5.0% of all shell dredged from state-owned submerged 
tidelands will be delivered to points designated by the department in Texas bays 
and spread at permittee's expense for reef enhancement. Except that when 
permittee is required to deliver and spread shell at a point greater than 50 
statute miles (computed using the nearest water route through public 
navigational channels) from the dredge site, the director is authorized to 
adjust the amount of shell permittee is required to deliver and spread to a 
quantity less than 5.0% in order to offset permittee's increased delivery cost 
for the distance over 50 miles. Permittee will not be required to pay for the 
shell used for reef enhancement. 
   
  (d) The department's actual cost of monitoring the dredging operations from 
state-owned submerged tidelands, not to exceed $50,000, will be assessed against 
each permittee in proportion to the quantity (percentage of the total) shell 
removed by each permittee; provided however the maximum monitoring cost of 
$50,000 will be adjusted each fiscal year using the Consumer Price Index (CPI-U) 
for the preceding 12-month period except that in no event will the maximum 
monitoring cost be adjusted below $50,000. The director is authorized to 
determine the methods and terms for payment of the monitoring cost. 
 
  This agency hereby certifies that the rule as adopted has been reviewed by 
legal counsel and found to be a valid exercise of the agency's authority. 
 Issued in Austin, Texas, on December 21, 1994. 
 TRD-9452925 
  Paul M. Shinkawa 
 Acting General Counsel 
 Texas Department of Wildlife and Department 
    Effective date: January 18, 1995 
 Proposal publication date: July 19, 1994 
 For further information, please call: 1-800-792-1112, Ext. 4433 or (512) 389-
4433 
         
                   
  TITLE 37. PUBLIC SAFETY AND CORRECTIONS 
 Part III. Texas Youth Commission 
  Chapter 85. Admission and Placement 
  
  Commitment and Reception 
 
  37 TAC sec.sec.85.3, 85.5, 85.7 
 
  (Editor's Note: The following adopted amendments submitted by the Texas Youth 
Commission were inadvertently omitted from the December 20, 1994, issue of the 
Texas Register. The effective date of these amendments is January 4, 1995.) 
   
  The Texas Youth Commission (TYC) adopts amendments to sec. sec.85.3, 85.5, and 
85.7, concerning admission process, assessment/evaluation, and mentally retarded 
youth. Section 85.3 is adopted with changes to the proposed text as published in 
the November 4, 1994, issue of the Texas Register (19 TexReg 8754). The changes 
to the proposed text in sec.85.3 are edits only for clarification and do not 
change the meaning. Section 85.5 and sec.85.7 are adopted without changes and 
will not be republished. 
 The justification for amending the section is to allow more efficient use of 
the TYC facility in South Texas. 
 The amendments will allow the new diagnostic intake unit at Evins Regional 
Juvenile Center in Edinburg, Texas to perform intake functions for youth served 
by South Region with the exception of all females and youth under a determinate 
sentence and youth likely to be classified as Type A violent offenders. 
 No comments were received regarding adoption of the amendments. 
 The amendments are adopted under the Human Resources Code, sec.61.071, which 
provides the Texas Youth Commission with the authority to examine and make a 
study of each child committed to it as soon as possible after commitment. The 
proposed rule implements the Human Resource Code, sec.61.034. 
 
 
  sec.85.3. Admission Process. 
 
  (a) Policy. Intake activities, including receipt of the youth from the 
committing county and orienting the youth to new surroundings, are performed by 
Texas Youth Commission (TYC) diagnostic intake units, Statewide Reception Center 
(SRC) at Brownwood and Evins Regional Juvenile Center (ERJC) diagnostic unit at 
Edinburg. 
   
  (b) Rules. 
 
  (1) The diagnostic intake units serve different youth and counties. 
 
  (A) The ERJC Diagnostic Unit in Edinburg, Texas receives youth each Tuesday 
between the hours of 8:00 a.m and 5:00 p.m. Youth may be received at other times 
if prior arrangements are made. The unit does not serve females or male youth 
who are under a determinate sentence or are likely to be classified as type A 
violent offenders. Such youth are served by the statewide reception center. The 
ERJC unit serves the following counties: Aransas, Jim Hogg, Nueces, Zapata, Bee, 
Jim Wells, Refugio, Brooks, Kenedy, San Patricio, Cameron, Kleberg, Starr, 
Duval, Live Oak, Webb, Hidalgo, McMullen, Willacy. 
   
  (B) The statewide reception center in Brownwood, Texas receives youth 
committed to TYC five days per week, between 8:00 a.m. and 5:00 p.m. Youth may 
be received after 5:00 p.m. only if prior arrangements are made. The reception 
center serves all counties not served by the ERJC unit, all females, all 
sentenced offenders, and all youth likely to be classified as type A violent 
offenders. 
     
  (2) Youth are allowed to have a limited number of personal possessions while 
at the diagnostic units. Personal items beyond basic necessities are inventoried 
and returned to the county transporter. The transporter is asked to sign a 
receipt for items returned to his care. Items a youth is allowed to keep are 
inventoried and a receipt issued to the transporter. 
   
  (3) Parents are notified of youth's admission and TYC's medical consent 
authority, and advised of procedures for mail and visits. 
   
  (4) The statewide reception center assigns each youth an official TYC 
registration number. 
   
  (5) Staff completes personal data and commitment information. 
   
  (6) A youth is assigned to a dormitory and caseworker. 
   
  (7) Orientation to the admissions process and the TYC system is provided and 
documented as required in GOP.53.05,  sec.87.55 of this title (relating to Youth 
Orientation). 
   
  (8) Routine admission procedures include but are not limited to the following. 
 
  (A) Each youth and his possessions are searched. 
   
  (B) Youth property including clothing is inventoried. 
   
  (C) A body identification form (CCF-006) is completed, each youth showers, is 
screened for pediculosis, and receives treatment if indicated. 
   
  (D) Initial health screening is performed for each youth. 
   
  (E) Clothing is laundered if necessary. Clothing is issued as necessary. 
   
  (F) Personal hygiene articles are made available as needed. 
     
  (9) In addition to assessment and placement activities, counseling is provided 
at both sites. Academic education is provided at the statewide reception center. 
   
  (10) Intake staff identify the home parole officer according to the agency 
assignment system based on zipcode area and county. The staff forwards to the 
home parole officer, within five working days of admission, the following: 
 
  (A) copy of the court order; 
   
  (B) copy of the Common Application (CCF-002); 
   
  (C) county social summary; and 
   
  (D) immediate notification when a youth is stating that he or she refuses to 
live at home when residential placement is complete. 
     
  (11) Reception staff or regional transporters transports youth to their 
initial placements and notify the families, the region parole officer, 
committing court, prosecuting attorney, chief probation officer and others as 
needed of the placement location. 
 
  This agency hereby certifies that the rule as adopted has been reviewed by 
legal counsel and found to be a valid exercise of the agency's legal authority. 
 Issued in Austin, Texas, on December 14, 1994. 
 TRD-9500009 
  Steve Robinson 
 Executive Director 
 Texas Youth Commission 
    Effective date: January 4, 1995 
 Proposal publication date: November 4, 1994 
 For further information, please call: (512) 483-5244 
         
                     
  TITLE 40. SOCIAL SERVICES AND ASSISTANCE 
 Part III. Texas Commission on Alcohol and Drug Abuse 
  Chapter 150. Licensure of Chemical Dependency Counselors 
  
  Counselor Licensure Rules 
 
  40 TAC sec.150.10 
 
  The Texas Commission on Alcohol and Drug Abuse adopts the repeal of 
sec.150.10, concerning licensure requirements for chemical dependency licensure 
standards, without changes to the proposed text as published in the October 21, 
1994, issue of the Texas Register (19 TexReg 8434). 
 This section describes the counselor licensure standards. This rule is being 
replaced with new sec.150.10. 
 No comments were received regarding adoption of the repeal. 
 The repeal is adopted under the Texas Civil Statues, Article 4512o, which 
provide the Texas Commission on Alcohol and Drug Abuse with the authority to 
adopt rules and standards for licensure of chemical dependency counselors. 
 
  This agency hereby certifies that the rule as adopted has been reviewed by 
legal counsel and found to be a valid exercise of the agency's legal authority. 
 Issued in Austin, Texas, on December 29, 1994. 
 TRD-9452942 
  J. Ben Bynum 
 Executive Director 
 Texas Commission on Alcohol and Drug Abuse 
    Effective date: January 19, 1995 
 Proposal publication date: October 21, 1994 
 For further information, please call: (512) 867-8720 
         
     
  The Texas Commission on Alcohol and Drug Abuse adopts new sec.150.10, 
concerning licensure requirements for chemical dependency licensure standards, 
without changes to the proposed text as published in the October 21, 1994, issue 
of the  Texas Register (19 TexReg 8434). 
 This section describes guidelines for accessing the eligibility of persons with 
a history of criminal convictions pursuant to Texas Civil Statues, Article 6252-
13c. 
 This section sets the guidelines and requirements for chemical dependency 
counselor licensure standards. 
 No comments were received regarding adoption of the new section. 
 The new section is adopted under the Texas Civil Statutes, Article for 4512o, 
which provide the Texas Commission on Alcohol and Drug Abuse with the authority 
to adopt rules and standards for licensure of chemical dependency counselors. 
 
  This agency hereby certifies that the rule as adopted has been reviewed by 
legal counsel and found to be a valid exercise of the agency's legal authority. 
 Issued in Austin, Texas, on December 27, 1994. 
 TRD-9452941 
  J. Ben Bynum 
 Executive Director 
 Texas Commission on Alcohol and Drug Abuse 
    Effective date: January 19, 1995 
 Proposal publication date: October 21, 1994 
 For further information, please call: (512) 867-8720