Transcript Neurocognitive Testing in the Metabolic Clinic …moving

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
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
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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
•
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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 ADULTS
(3-17 YRS) (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
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–
–
–
–
–
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History
Examination
Medical decision making
Counseling
Coordination of care
Nature of presenting problem
Time
Three codes available for billing services provided during patient visits
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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:
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History
•
Examination
•
Medical decision making
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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, 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.
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–
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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, which
requires at least 2 of these 3 key components:
– A detailed history;
– A detailed examination;
– Medical decision making of moderate complexity.
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–
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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, which
requires at least 2 of these 3 key components:
– A comprehensive history;
– A comprehensive examination;
– Medical decision making of high complexity.
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–
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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
HISTORY
HPI (History of Present Illness)
Brief (1 – 3 elements)
ROS (Review of Systems)
N/A
PFSH (Past, Family, Social, History)
N/A
Type of History
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
Location
Quality
Severity
Duration
Timing
Context
Modifying factors
Associated signs and symptoms
ROS Elements
Constitutional Symptoms (e.g., fever, weight loss)
Eyes
Ears, Nose, Mouth, Throat
Cardiovascular
Respiratory
Gastrointestinal
Genitourinary
Musculoskeletal
Integumentary (skin and/or breast)
Neurological
Psychiatric
Endocrine
Hematologic/Lymphatic
Allergic/Immunologic
PFSH Elements
Past 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)
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Components of Selecting an E&M Code
EXAMINATION
BODY AREAS
Head, including face
Neck
Chest, including breasts and axilla
Abdomen
Genitalia, groin, buttocks
Back
Each extremity
ORGAN SYSTEMS
Eyes
Ears, Nose, Mouth, and Throat
Cardiovascular
Respiratory
Gastrointestinal
Genitourinary
Musculoskeletal
Skin
Neurologic
Hematologic/Lymphatic/Immunolo
gic
Psychiatric
Multi-System Exam
1 – 5 elements in 1 or more organ
systems
At least 6 elements in 1 or more
organ system
2 elements in at least 6 organ
systems OR at least 12 elements in 2
or more organ systems
At least 2 elements in at least 9
organ systems
Single Organ Exam
1 – 5 elements for the single organ
Type of Exam
Problem Focused
At least 6 elements
Expanded Problem Focused
At least 12 elements
Detailed
All elements
Comprehensive
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Components of Selecting an E&M Code
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
Minimal (<=1)
Limited (= 2)
Multiple (= 3)
Extensive ( >=4)
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Amount & complexity
of data
Minimal or None
Limited (= 2)
Moderate (= 3)
Extensive ( >=4)
Assessment of risk
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Minimal
Low
Moderate
High
Type of Decision
Making
Straightforward
Low Complexity
Moderate Complexity
High Complexity
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