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 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

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

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

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

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

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

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

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

Thank You

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

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 October 21, 2011 NE Consortium

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 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

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

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

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