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Review of Psychological Services- ACT 6
(names changed)

Patient: Joseph Lerch
Provider: Tom Jones, Ph.D.

Assess reasonableness and necessity of treatment post-MVA.

Finding that the reviewed materials lack appropriate information-gathering, diagnoses and a supportive psychometric foundation of information that identifies treatment of MVA-related sequelae as opposed to other psychiatric and pre-existing medical conditions, it is my professional opinion that services rendered on and after the psychological evaluation of 7/1/97 (i.e., psychological testing, EMG scan) were not warranted. Treatment pursuant to that date appears equally unwarranted, excessive and, as they stand, neither reasonable or necessary. Further services would also be considered unnecessary. Consequently, the psychological evaluation (90801) alone should be considered for payment as other services were contingent upon this and are unsupported in their need or appropriateness.

At the time of intake, patient was 39 year old divorced Caucasian who, on
8/29/96 reported being stopped and struck from behind in parking lot by car moving into his lane in which his body was "jolted" leading to back pain. Patient is unemployed and on disability. On intake sheet he reports diabetes, sleep difficulty, trouble breathing, stomach problems, chronic back pain and "worries." Patient did not circle depression.

The primary physician's, Dr. Crow, notes describe "emotional state poor," but without detail. Patient is taking Desyrel, Paxil and Buspar. This was reported later as being related to pre-event psychiatric treatment the source(s) of which was not clarified in any notes or a report from the treating psychiatrist. However, the medications indicate depression and anxiety pre-MVA.

Past medical history of lumbosacral problems, motor vehicle accidents in 1987 and 1988 (including discectomy) and a slip and fall in 1994. History of diabetes, alcohol abuse and abdominal hernia secondary to cirrhosis of the liver. Present complaints of pain in cervical area, mid--thoracic and lumbosacral. CT scan (9/9/96) indicates no evidence of cervical, dorsal or lumbar/pelvic osseous pathology. Report also states "and is aware that this also affects his low back." MRI of lumbar spine (4/1/97) showed no significant change compared to a study on 6/28/94.

Diagnoses listed as neck sprain, myalgia and myositis, brachial neuritis and thoracic sprain.



(Undated) Intake sheet: patient reports suffering from the following: diabetes, sleep difficulty, trouble breathing, stomach problems, chronic back pain and worries. Patient did not circle depression.


9/5/96 Handwritten office notes, presumably Dr. Crow's. Reiterated details of accident.  Immediate injury described as "body jolted" leading to back pain. Report states "emotional state poor" without indicating more detail as to what objective signs were. Patient taking Desyrel, Paxil and Buspar: this treatment combination suggests the presence of substantial depression and anxiety.


9/9/96 CT scan  (Dr. Lair) indicating no evidence of cervical, dorsal or lumbar/pelvic osseous pathology. The radiologist reports a failure of segmentation at C5/6.


9/27/96 Application for benefits. Date of accident given as 8--29--96.  Patient reports being stopped and struck from behind in parking lot by car moving into his lane. Patient reports no loss of time from work. Patient reports being unemployed.


10/16/96-3/31/97 Physical therapy: Patient described as divorced, currently on disability due to lumbosacral problems. Patient was state employee injured on job.  Past medical history of motor vehicle accidents in 1987 and 1988 and a slip and fall in 1994. These reported to be resolved. History of alcohol abuse and liver problems.  Present complaints of pain in cervical area, mid--thoracic and lumbosacral.


11/6/96--1/29/97 Aquatic Treatment, Inc.:  Letter to Dr. Crow: indicating evaluation of patient.  Patient originally evaluated 11/6/96, participating in two treatments.  Reported exerted himself too much and followed by substantial pain.  Report also states abdominal hernia secondary to cirrhosis of the liver "and is aware that this also affects his low back."  He is reported to demonstrate a "Low level tolerance to low level activity.  He has a long history of spinal problems..." Physical Therapy: report indicates discectomy in 1988 and disability since 1993.  Patient is diabetic, has motor vehicle accident hernia and surgery for this.


3/3/97 Orthopedic Evaluation: Dr. Smith: Physician reiterated symptoms adding that patient motor vehicle accident take medications due to cirrhosis.  Past history includes long low back and neck history including surgery in 1988 and was disabled prior to this accident.  Patient gets physical therapy once or twice per week and aquatic treatment about 3 times per week.  The assessment indicates Chronic Cervical and Low Back Syndrome.  Aggravation of pre--existing condition.


4/1/97  Radiology: Dr. Lest: MRI of lumbar spine.  No significant change compared to a study from Oxford Circle Diagnostic (6/28/94).


7/21/97 Billing Statement: Diagnoses listed as follows: Neck sprain; myalgia and myositis; brachial neuritis; thoracic sprain


1/7/97 Referral form from Dr. Crow for  "Psychological evaluation and electromyographic muscle study to determine the possible benefit of biofeedback therapy."


HCFA  Billing Statements for psychological services signed by Tom Jones, Ph.D. and  Arnold Hady, M.D. (Director).  The diagnostic code used is 309.28--Adjustment Reaction with/mixed emotional features.[1]


5 services performed on 1/7/97.  This suggests that the patient was shuttled from one service to the next without an appropriate interval to examine results, obtain psychiatric information, etc.


EMG and temperature feedback were performed January 8, 15, 22, 29, February 5, 12, 19, 26, March 5, 12. Data reports show EMG and temperature are recorded simultaneously. Why are these are being billed as separate sessions/services rather than a single session with 2 modalities?


From March 19, 26 and April 16 the service changed to "Applied Behavioral Medicine." The 97 Procedure Terminology Manual indicates that 90875 applies to individual psychophysiological therapy incorporating biofeedback training by any modality for approximately 20--30 minutes.


8/5/97 Letter returned to Janet Burl, RN from Alicia Karp, Records with Med-Rehab Associates, Inc. note from "Alicia Karp, Records" indicating that she is a records clerk. On a procedural listing the EMG scan was performed on January 7, 1997 by A. Karp. This material suggests that the EMG assessment may have been performed by an unqualified staff person, then submitted to and signed by Dr. Hady and entered into the psychological report of Dr. Jones.


(Presumably after 1/7/97, undated) Procedure sheet: Indicates that psychological diagnostic services provided included the following:

1    EMG scan 1/7/97:
         This is extremely perplexing as the scan was signed for by A. Karp, who identifies herself later as a clerical worker (see above).
         Further, the muscle scan summary is signed by a psychiatrist (director) with no corresponding signature suggesting that he performed the muscle scan himself.
         It appears that (a) either the records staff person administered the scan which was signed by Dr. Hady or (b) Dr. Hady administered the assessment himself. If the latter is the case, no psychiatric report is found in this record

2      Psychological evaluation 1/7/97 by T. Jones, Ph.D

3      Biofeedback evaluation 1/8/97 by J. Carl, Licensed Social Worker

4      Biofeedback Notes: 1/15/97--7/16/97. These notes are further confusing as they are in handwriting other than Mr. Carl's. It appears that someone else used the biofeedback equipment for treatment and Mr. Carl signed off on this.

1. Mr. Lerch's psychological services began with a psychological evaluation performed by Dr. Jones.

Not identified as an initial consultation or initial psychological consultation, it is
    a 2.5 page compilation with a very brief history, 4 or 5 clinical impressions,
    abbreviated mental status and abbreviated multiaxial assessment.
2.   Diagnosed are Adjustment Disorder with Mixed Emotional Features and Post-traumatic Stress Disorder. According to the DSM IV:

In Posttraumatic Stress Disorder, the stressor must be of an extreme (i.e., life-threatening) nature. In contrast, in Adjustment Disorder, the stressor can be of any severity. The diagnosis of Adjustment Disorder is appropriate both for situations in which the response to an extreme stressor does not meet the criteria for Posttraumatic Stress Disorder (or another specific mental disorder) and for situations in which the symptom pattern of Posttraumatic Stress Disorder occurs in response to a stressor that is not extreme (e.g., spouse leaving, being fired).

It is irregular to use both as Axis I diagnoses as PTSD characteristics exceed and replace those of an adjustment disorder.

3. Secondly, since DSM IV publication (1994), the adjustment disorder specified has been altered to 309.28 With Mixed Anxiety and Depressed Mood. This subtype should be used when the predominant manifestation is a combination of depression and anxiety..[2]

4. Dr. Jones signs his report as “Licensed Psychologist,” without identifying his area of specialty.
As he is apparently overseeing all others involved, other than Dr. Hady, his
    credentials for this supervision is important.

Dr. Jones states that Mr. Lerch is in treatment with a psychiatrist and
    identifies his medications.

It was most important to obtain a psychiatric report. Why was a report from
    that physician not requested and does it not appear in this record?

The mental status was highly abbreviated, limited to only 5 or 6 statements.
    The initial consultation lacks a complete mental status examination.

A history is lacking.
The American psychiatric Association DSM-IV has been available since 1994.
    Dr. Jones' reference is to the DSM-III-R which preceded it.

Rather than use the full, five axis standard multiaxial diagnostic, Dr. uses
    only 3 and in a questionable manner.

Apparently, with a history of spinal injuries, a divorce, disability, cirrhosis of
    the liver and a history of alcohol abuse, more detail should have been
    provided. Axes II, III, IV and V should have been completed.
I. The GAF score--Axis V--is particularly important as it provides some
    indication of a patient’s level of functioning and an index of change. This is
    not provided.

 Axis III: Incident related injury and pain as per referral. This is vague and
    an inappropriate method of reporting.
[4] Without substantially verifying the
    existence of PTSD, Dr. Jones makes only general recommendations for pain
    control and generalized relaxation.

5. According to reviewed materials, the patient never received a full DSM IV [5] multiaxial diagnosis from any source, including the Director, Dr. Hady, who is a psychiatrist. The DSM IV states:

“A multiaxial system involves an assessment on several axes, each of which refers to a different domain of information that may help the clinician plan treatment and predict outcome. The multiaxial system facilitates comprehensive and systematic evaluation with attention to the various mental disorders and general medical conditions, psychosocial and environmental problems, and level of functioning that might be overlooked if the focus were on assessing a single presenting problem. A multiaxial system provides a convenient format for organizing and communicating clinical information, for capturing the complexity of clinical situations, and for describing the heterogeneity of individuals presenting with the same diagnosis.

6. In testing, only the Beck Depression Inventory, the Beck Anxiety Inventory and McGill-Melzack Pain Questionnaire were given, this without discovering or stating why Mr. Lerch was receiving psychiatric treatment.
This approach eliminated consideration of other, personality factors or psychosocial effects.
All measures used do not consider exaggeration, distortions, or have validity scales and are easily subject to intentional or unintentional manipulation.

7. Biofeedback
EMG scan performed by A. Karp, who we later learn is a records clerk.
This raises a serious question regarding who actually performed the assessment, their qualifications and the data Dr. Jones' incorporates into his report.
Why does Dr. Hady's signature appear on this report alone, as if he performed it?
Regarding the EMG scan in question:

  • Activation only reaches the Mild level and is posturally-related, disappearing when standing.

  • Sites of activation are those in which earlier accidents/injuries and possible surgery occurred.

  • It should also be noted that use of wide filter causes higher readings than those using narrow.

  • Considering the history of earlier injury, both filters should have been used for comparison and some discrimination made by the clinician as to the etiology of the measurements.

E. On 1/8/97 a biofeedback "screening" is performed by Mr. Carl, a licensed social worker with no indication of his biofeedback credentialing.
· How does his "screening" differ from the scan performed a day earlier by A. Karp?

F. During biofeedback training sessions:


We do not know whether wide or narrow filters are used.


Looking at electrode placements, placement start on the frontalis
(high or low not specified) and are later moved to the
"cervical," without specifying side(s) or anatomical site. No l rationale is presented for the change.


No reason for temperature feedback is offered.


Average EMG readings increase from 6.8 mvs on 1/22/97 to 28 mvs
on 7/16/97. Scores are extremely variable over the period
and suggest that other factors may be operating.


Pain estimate scores begin in April, '97 and go to July, '97,
indicating little to no change in stress or pain.


Perhaps the above is related to the insufficient fund of clinical information gathered earlier before intervention.
According to Jeffery Cram, Ph.D.
[7] an expert on biofeedback treatment, not all patients are appropriate for biofeedback training.[8]

               Without appropriate interviews and diagnostics, it becomes only speculation that the patient is appropriate.[9] Dr. Cram states that, in interpreting data, it is important to assess the dynamics of the patient relative to areas beyond the immediate complaints including family dynamics that would maintain a patient’s level of pain and disability.  In situations of this type, Dr. Cram recommends dealing with the factors supporting pain rather than biofeedback therapy.

Because insufficient data was gathered through the initial consultation and inadequate testing used, the presence of these other factors were not identified. This confounds the clear need for treatment and/or treatment of this type.

      Dr. Jones provides insufficient clinical observations and history with only some indication of the patient’s mental status and test data presented. There is no broad foundation of understanding gained by thoroughly assessing this man’s situation.

Psychiatric diagnostic interview examination including history, mental status, or disposition (may include communication with family or other sources, ordering and medical interpretation of laboratory or other medical diagnostic studies. In certain circumstances other informants will be seen in lieu of the patient) Consultation for psychiatric evaluation of a patient includes examination of a patient and exchange of information with primary physician and other informants such as nurses or family members, and preparation of report.”

2.      Pre- and post- accident personality factors are not considered.

3.      Dr. Jones ignores axes IV and V, psychosocial stressors (very significant in this situation) and the GAF, or numerical, rating of the patient’s level of functioning. These axes are helpful as certain stressors would be expected to appear and the GAF is needed to reflect the patient’s level of dysfunction and subsequent improvement.

4.      Psychological testing is scant, particularly in the light of this man’s medical and psychiatric history. It includes tests and scales that take minutes to give and score, that ignore test-taking attitude, motivation in answering, and truthfulness and consistency of answers. In litigation situations where secondary motives must be considered, these tests are appropriate only when given with an empirically objective and validated types, such as the MMPI 2. Otherwise they may represent utterly subjective responses. Objective, psychometric testing was not done to validate or explore clinical impressions.

5.      The role of personality was never explored.

6.      The possible role of various forms of secondary gain (e.g. attention, remuneration, etc.) was never addressed.

7.      Assumptions of causation and treatment were made prior to a full gathering of background information.

8.      No effort was made to differentiate organic from psychogenic pain. (see Kaplan & Sadock)[11]

9.      Little effort was made to comprehensively assess complaints of pain as being possibly false, exaggerated due to other factors or consistent in contrast to other pain patients.

10.   Kaplan & Sadock [12] state the limited usefulness of biofeedback.

11.  No post—or interim—re-testing with the Becks was presented to document progress.


                        1.22 Delegation to and Supervision of Subordinates.

(a) Psychologists delegate to their employees, supervisees, and research assistants only those responsibilities that such persons can reasonably be expected to perform competently, on the basis of their education, training, or experience, either independently or with the level of supervision being provided.

(b) Psychologists provide proper training and supervision to their employees or supervisees and take reasonable steps to see that such persons perform services responsibly, competently, and ethically.

(c) If institutional policies, procedures, or practices prevent fulfillment of this obligation, psychologists attempt to modify their role or to correct the situation to the extent feasible.

                        1.23 Documentation of Professional and Scientific Work.

(a) Psychologists appropriately document their professional and scientific work in order to facilitate provision of services later by them or by other professionals, to ensure accountability, and to meet other requirements of institutions or the law.

(b) When psychologists have reason to believe that records of their professional services will be used in legal proceedings involving recipients of or participants in their work, they have a responsibility to create and maintain documentation in the kind of detail and quality that would be consistent with reasonable scrutiny in an adjudicative forum. (See also Standard 7.01, Professionalism, under Forensic Activities.)

Finding that the reviewed materials lack appropriate information-gathering, diagnoses and a supportive psychometric foundation of information that identifies treatment of MVA-related sequelae as opposed to other psychiatric and pre-existing medical conditions, it is my professional opinion that services rendered on and after the psychological evaluation of 7/1/97 (i.e., psychological testing, EMG scan) were not warranted. Treatment pursuant to that date appears equally unwarranted, excessive and, as they stand, neither reasonable nor necessary. Further services would also be considered unnecessary. Consequently, the psychological evaluation (90801) alone should be considered for payment as other services were contingent upon this and are unsupported in their need or appropriateness.

The opinions expressed in this report are based solely on materials provided to me. Reports by allied health professionals (e.g., psychiatrist) were not provided. The final decision regarding payment is solely and exclusively the responsibility of the insurance carrier.


[1] Although mentioned in Dr. Jones' evaluation, Post-traumatic Stress Disorder does not appear on these forms.

[2] 1994 American Psychiatric Association, Washington, DC

[3] H. I. Kaplan & B. J. Sadock (1991). Synopsis of Psychiatry (6th Ed.). Baltimore: Williams & Wilkins. “The MSE is the part of the clinical assessment that describes the sum total of the examiner’s observations and impressions of the psychiatric patient at the time of the interview. Whereas the patient’s history remains stable, the patient’s mental status can change from day to day or hour to hour. The MSE is the description of the patient’s appearance, speech, actions, and thoughts during the interview. Even when a patient is mute or incoherent or refuses to answer questions, one can obtain a wealth of information through careful observation. Although practitioners’ organizational formats for writing up the MSE vary slightly, formats must contain certain categories of information.”

[4] When an individual has more than one clinically relevant Axis III diagnosis, all should be reported. For examples, see p. 33. If no Axis III disorder is present, this should be indicated by the notation "Axis III: None." If an Axis III diagnosis is deferred, pending the gathering of additional information, this should be indicated by the notation "Axis III: Deferred."

[5] (1996)Diagnostic & Statistical Manual of Mental Disorders, Washington: American Psychiatric Association.

[6] A comprehensive, objective, psychological test was not used. Instead, quick (about 5 minute) specialized anxiety and depression measures were given. These are more commonly used as a pre- and post-treatment measure of anxiety or one that assesses progress in each session rather than as a stand-alone diagnostic tool. This very short questionnaire assumes that the respondent is both accurate and truthful.  There is no validity scale to assess truthful as is found in more substantial and widely used tests (such as the Minnesota Multiphasic Personality Inventory) . In this situation, other clinical syndromes and personality factors may have been involved that were overlooked due to the lack of information gathered and specificity of the tool. In light of the delay in entering psychological treatment and patient complaints of overeating and nightmares, other important factors not measured by this test were likely overlooked. This is particularly important as Mr. Lerch was already in psychiatric treatment.

[7]Cram, Jeffrey (1986).  Clinical EMG: Muscle Scanning for Surface Recordings.  Seattle: J. & J.

[8]Qualls, P.J. & Sheehan, P.W. (1979). Capacity for absorption and relaxation during electromyograph biofeedback and no-feedback conditions. Journal of Abnormal Psychology, 88, 652-662.

Qualls, P.J. & Sheehan, P.W. (1981a). Imagery encouragement, absorption capacity, and relaxation during electromyograph feedback. Journal of Personality & Social Psychology, 41, 370-379.

Qualls, P.J. & Sheehan, P.W. (1981b). Role of the feedback signal in electromyograph feedback: The relevance of attention. Journal of Experimental Psychology: General, 110, 204-216.

[9] One—to—One  on Quality ( September, 1996, Vol. 1, Issue 3) Treating acute uncomplicated low back pain AHCPR (Agency for Health Care Policy and Research). Treatment guidelines recommendations were developed by an expert panel of health care professionals.  Using scientific literature and combining their own experience and clinical judgment to develop specific recommendations for patient assessment and management, biofeedback is not recommended for treating uncomplicated low back pain as it has not yet been proven effective.

[10] 1997 Procedure Terminology Manual, Pennsylvania Blue Shield

[11] Kaplan & Sadock (1991)

[12] Kaplan & Sadock (1991) Synopsis of Psychiatry (6th Ed.). Baltimore: Williams & Wilkins.

[13] Copyright © 1995 American Psychological Association.

[14] These issues are also addressed in Knapp, S. & Tepper, A.M. (1996) Legal and Ethical Issues in Supervision Samuel Knapp, Ed.D., The Pennsylvania Psychologist Quarterly, May 1996.