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

1. 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

2. 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 NE Consortium

3. 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? NE Consortium

4. A group of psychologists has recommended a uniform assessment method for screening PKU patients NE Consortium

5. 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) NE Consortium

6. 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? NE Consortium

7. 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 NE Consortium

8. 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 NE Consortium

9. 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? NE Consortium

10. Thank You

11. Appendix:More on Reimbursement and Coding NE Consortium

12. 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, 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 NE Consortium

13. 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. • 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. • 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 NE Consortium

14. Components of Selecting an E&M Code NE Consortium

15. Components of Selecting an E&M Code NE Consortium

16. Components of Selecting an E&M Code NE Consortium