Neurocognitive Testing in the Metabolic Clinic …moving from concept to practice Presented at the New England Consortium of Metabolic Programs Annual Meeting.

Neurocognitive Testing in the Metabolic Clinic…moving from concept to practice

Presented at the New England Consortium of Metabolic Programs Annual Meeting

Susan WaisbrenSheryn HonestOctober 21, 2011

Moving neurocognitive screening from concept to practice requires tests, education, and reimbursement

• The concept– Burden of illness in well-treated PKU remains significant for some patients– Chronic monitoring of neurocognitive status required for early identification of potential

issues– Prompt referral to mental health professionals, diagnosis, and treatment improves patient

outcomes

• Successful implementation– Patients complete validated screening test while they are in the waiting room during routine

clinic visits• Appropriate education materials (patient, provider, payer) support rationale for testing and how

results fit into overall care plan– Test is scored and results are available real-time

• Negative screen requires no additional action• Positive score results in referral to mental health professional

– Administration of screening test generates additional clinic reimbursement– Prompt referral to mental health professionals, diagnosis and treatment improves patient

outcomes

• Proposed approach

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Criteria for the successful screening test…

• Simple to ADMINISTER and SCORE– Does not require having psychologist/psychiatrist on staff– Taken by patient (caretaker) during routine visits to the metabolic clinic– Test is scored and results are available real-time

• Negative screen requires no additional action• Positive score results in referral to mental health professional

• Generates additional clinic reimbursement to cover costs

• Other criteria?

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A group of psychologists has recommended a uniform assessment method for screening PKU patients

DOMAIN INFANTS

(0-2 YRS)

CHILDREN

(3-17 YRS)

ADULTS

(18+ YRS)

Adaptive Behavior ABAS-II ABAS-II ABAS-II

Executive Functioning

-- BRIEF BRIEF

Social/Emotional Functioning

-- BASC-II BDI-II & BDI-II

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Abbreviations and sources

• ABAS-II : Adaptive Behavior Assessment System-Second Edition (Harrison, Oakland, 2003)

• BRIEF: Behavior Rating Inventory of Executive Function (Gioia, Isquith, Guy, Kenworthy, 2000)

• BASC-II: Behavior Assessment System for Children-Second Edition (Reynolds, Kamphus, 2004)

• BAI: Beck Anxiety Inventory (Beck, Steer, 1993)

• BDI-II: Beck Depression Inventory-Second Edition (Beck, Steer, Brown, 1996)

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Other tests for consideration…

• Pediatric Symptom Checklist (PSC) – for children– 35–item form– Scored NEVER (0), SOMETIMES (1) of OFTEN (2)– Obtain on-line through Massachusetts General No Charge

• Brief Symptom Inventory (BSI) – for adults– 53-items– 5 point rating scale– Scoring Options:

• Q™ Local Software• Mail-in Scoring Service• Hand Scoring• Optical Scan Scoring

– Obtained through Pearson Assessments

• Other suggestions?

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Potential for reimbursement…

• General consensus that these tests can be administered by anyone in the Genetic/Metabolic Clinic

• When obtaining prior authorizations with health plans, test results can support justification of referral to Psychologist/Psychiatrist

• Reimbursement can be obtained through the possible increase of Evaluation and Management visit level, billed by Geneticist, on day of office visit

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Documentation of time and services essential to justify additional payment….

• Reimbursement for Evaluation & Management (E&M) codes varies depending on what happens during the patient visit. Components defining the level of an E&M code

– History– Examination– Medical decision making– Counseling– Coordination of care– Nature of presenting problem– Time

• Three codes available for billing services provided during patient visits– Included in the coding scheme for “Established Patient Visits”– Codes 99213, 99214, 99215– Requirements for these individual codes detailed in the Appendix

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Proposed next steps: Subteams to…

• Review proposed tests and develop detailed protocol for implementation?

• Develop education materials that clinic can provide to patients?– Describes why clinic is giving screening tests– Discusses what happens with a positive test result

• Create billing and reimbursement guide supporting implementation of screening tests?

• Other?

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Thank You

Appendix:More on Reimbursement and Coding

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Evaluation & Management Codes (Established Patient Visits 99213 – 99215)

Components that define the level of an Evaluation & Management (E&M) code:• History• Examination• Medical decision making• Counseling• Coordination of care• Nature of presenting problem• Time

Criteria for an Established Patient – Level 3 Visit:99213 Office or other outpatient visit for the evaluation and management of an established patient, whichrequires at least 2 of these 3 key components:

– An expanded problem focused history; – An expanded problem focused examination; – Medical decision making of low complexity.

– Counseling and coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs.

– Usually, the presenting problem(s) are of low to moderate severity. – Physicians typically spend 15 minutes face-to-face with the patient and/or family

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Evaluation & Management Codes (Established Patient Visits 99213 – 99215)

Criteria for an Established Patient – Level 4 and 5 Visit:99214 Office or other outpatient visit for the evaluation and management of an established patient, whichrequires at least 2 of these 3 key components:

– A detailed history; – A detailed examination; – Medical decision making of moderate complexity.

– Counseling and coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs.

– Usually, the presenting problem(s) are of moderate to high severity. – Physicians typically spend 25 minutes face-to-face with the patient and/or family

99215 Office or other outpatient visit for the evaluation and management of an established patient, whichrequires at least 2 of these 3 key components:

– A comprehensive history; – A comprehensive examination; – Medical decision making of high complexity.

– Counseling and coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs.

– Usually, the presenting problem(s) are of moderate to high severity. – Physicians typically spend 40 minutes face-to-face with the patient and/or family

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Components of Selecting an E&M Code

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HISTORYHPI (History of Present Illness) ROS (Review of Systems) PFSH (Past, Family, Social, History) Type of History

Brief (1 – 3 elements) N/A N/A Problem Focused

Brief (1 – 3 elements) Problem Pertinent N/A Expanded Problem Focused

Extended (4+ elements) Extended (2 – 9 elements) Pertinent (1 of 3 areas) Detailed

HPI Elements ROS ElementsLocation Constitutional Symptoms (e.g., fever, weight loss)Quality EyesSeverity Ears, Nose, Mouth, ThroatDuration CardiovascularTiming RespiratoryContext Gastrointestinal

Modifying factors GenitourinaryAssociated signs and symptoms Musculoskeletal

Integumentary (skin and/or breast)NeurologicalPsychiatricEndocrine

Hematologic/LymphaticAllergic/Immunologic

PFSH ElementsPast history (patient’s past experiences with illnesses, operations, injuries, and treatment)

Family history (review of medical events in patient’s family)

Social history (age appropriate review of past and current activities)

Components of Selecting an E&M Code

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EXAMINATION

BODY AREAS ORGAN SYSTEMS Head, including face Eyes

Neck Ears, Nose, Mouth, and Throat Chest, including breasts and axilla Cardiovascular

Abdomen Respiratory Genitalia, groin, buttocks Gastrointestinal

Back Genitourinary Each extremity Musculoskeletal

Skin Neurologic Hematologic/Lymphatic/Immunolo

gic Psychiatric

Multi-System Exam Single Organ Exam Type of Exam

1 – 5 elements in 1 or more organ systems

1 – 5 elements for the single organ Problem Focused

At least 6 elements in 1 or more organ system

At least 6 elements Expanded Problem Focused

2 elements in at least 6 organ systems OR at least 12 elements in 2

or more organ systems

At least 12 elements Detailed

At least 2 elements in at least 9 organ systems

All elements Comprehensive

Components of Selecting an E&M Code

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MEDICAL DECISION MAKING

Is determined by: The number of diagnosis and management options The amount and complexity of data reviewed The assessment of risk (complications, morbidity, and/or mortality, etc…) based on Presenting Problem(s), Diagnostic

Procedure(s) and Possible Management Options

# of diagnosis & mgt options

Amount & complexity of data

Assessment of risk Type of Decision Making

Minimal (<=1) Minimal or None Minimal Straightforward Limited (= 2) Limited (= 2) Low Low Complexity Multiple (= 3) Moderate (= 3) Moderate Moderate Complexity

Extensive ( >=4) Extensive ( >=4) High High Complexity