2. Neurocognitive Testing in the Metabolic Clinic …moving from concept to practice
Presented at the New England Consortium of Metabolic Programs Annual Meeting
Susan Waisbren
Sheryn Honest
October 21, 2011

3. 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
Susan slide
October 21, 2011
NE Consortium

4. 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?
Susan slide
October 21, 2011
NE Consortium

5. 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
Executive Functioning --
BRIEF
Social/Emotional Functioning
BASC-II
BDI-II & BDI-II
Susan Slide: Non-psychologists might consider administering a set of parent (or self-report) questionnaires when a psychologist is not available. A group of 10 psychologists and a psychiatrist with expertise in neuropsychological assessment and in PKU selected these questionnaires that reliably detect deficits in Adaptive Behavior, Executive Functioning, and Emotional Well-being. They are available in Spanish and English, include forms for infants through adulthood, and can be administered in under an hour. Computerized scoring that provides basic interpretation of the results is also available. If a child is determined by these assessments to be having difficulties, further evaluation by a psychologist should take place. Moreover, a physician or psychologist needs to be consulted if responses indicate that a patient may be at risk for harming him/herself or others.
These questionnaires can be administered every time the child or adult with PKU attends clinic and can be used to assess changes in functioning that may be related to changes in treatment strategies or blood levels. There are no practice effects and the age of the child is taken into consideration because standard scores (not raw scores) are used.
All children and adults should receive the Adaptive Behavior Assessment System-Second Edition (ABAS-II) as a baseline description of their functioning. The General Adaptive Composite (GAC) from the ABAS-II correlates reasonably well with IQ. The ABAS-II may also be particularly useful for adults, since it includes scales related to the ability to work, live independently and maintain relationships. The Behavior Rating Inventory of Executive Function (BRIEF) provides scores related to Executive Functioning, including subscales for memory, attention, organization and planning abilities. The BASC-II also provides scores related to attention deficit disorders, anxiety and depression. The Beck Anxiety Inventory (BAI) and Beck Depression Inventory, Second Edition (BDI-II) can be used as self-report measures for adults with PKU or can be completed by an “informant” who knows the individual.
October 21, 2011
NE Consortium

6. 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)
Susan slide
October 21, 2011
NE Consortium

7. 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?
Susan slide
October 21, 2011
NE Consortium

8. 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
Sheryn slide
October 21, 2011
NE Consortium

9. 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
Sheryn slide
October 21, 2011
NE Consortium

10. 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?
Susan and Sheryn slide
October 21, 2011
NE Consortium

11. Thank You

12. Appendix: More on Reimbursement and Coding
October 21, 2011
NE Consortium

13. 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:
Office or other outpatient visit for the evaluation and management of an established patient, which
requires 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
October 21, 2011
NE Consortium

14. Evaluation & Management Codes (Established Patient Visits 99213 – 99215)
Criteria for an Established Patient – Level 4 and 5 Visit:
Office or other outpatient visit for the evaluation and management of an established patient, which
requires 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
Office or other outpatient visit for the evaluation and management of an established patient, which
A comprehensive history;
A comprehensive examination;
Medical decision making of high complexity.
Physicians typically spend 40 minutes face-to-face with the patient and/or family
October 21, 2011
NE Consortium

15. Components of Selecting an E&M Code
October 21, 2011
NE Consortium

16. Components of Selecting an E&M Code
October 21, 2011
NE Consortium

17. Components of Selecting an E&M Code
October 21, 2011
NE Consortium