Cognitive Rehabilitation:

Using research evidence and careful documentation to strengthen the

case for insurance funding

McKay Moore Sohlberg, PhD, CCC-SLPUniversity of Oregon

Laurie Ehlhardt Powell, PhD, CCC-SLPCenter on Brain Injury Research and Training

Kathy de Domingo, MS, CCC-SLPProgressive Rehabilitation Associates

Agenda Introduction Research Evidence

BREAK (10:30-10:45) Insurance/Documentation Nuts ‘n

Bolts Question and Answer

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Introduction

1. What is cognitive rehabilitation?

2. Who provides cognitive rehabilitation services?

3. What are different types of cognitive rehabilitation?

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What is Cognitive Rehabilitation?

Cognitive rehabilitation is a systematically applied set of medical and therapeutic services designed to improve cognitive functioning and participation in activities that may be affected by difficulties in one or more cognitive domains. (It) is often part of comprehensive interdisciplinary programs…based upon sound scientific theoretical constructs and strategic approaches… 4

Cog Rehab Definition (cont)

Treatment goals vary depending on the etiology, extent and severity of injury to the brain, the timing of treatment, individual differences, phase of recovery and prospects for restoration or compensation of a problem with remedial interventions. Treatments may be process specific…or skill-based, aimed at improving performance of particular activities…

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Cog Rehab Definition (cont)

…The overall goal may be restoring function in a cognitive domain or set of domains or teaching compensatory strategies to overcome domain specific problems, improving performance of a specific activity, or generalizing to multiple activities.”

“Cognitive Rehabilitation: The Evidence, Funding and Case for Advocacy in Brain Injury”, BIA, Nov. 2006

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Examples of Types of Cognitive Rehabilitation

(CR) Executive Functions: Problem-solving

& self-monitoring strategies Memory: Training use of external

memory aids (ex. diaries, notebooks or PDAs) & strategies (ex. imagery)

Attention: Attention process training; strategies training (ex. time management)

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Examples of Types of Cognitive Rehabilitation

(CR) Communication: Functional

communication training (ex. listening to directions; asking for help)

Task Specific Training (ex. filing tasks; dressing routines)

Environmental Modifications (ex. change lighting; decrease noise)

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Who provides CR services?

Certified speech-language pathologists, occupational therapists, vocational rehabilitation counselors, neuropsychologists

May work collectively with patients as part of a team or individually

CAUTION: Some service providers claim expertise in providing these services 9

Research evidence

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Rational Decision Making

Requires that clinicians provide an explicit rationale for clinical choices Treatment candidacy (who to treat) Treatment targets (what to treat) Treatment approaches (how to treat) Treatment progression and modifications

(measurement—how to measure whether client behavior is related to treatment)

Treatment schedules (when/how much to treat)

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What is evidence-based practice?

“...an approach to decision making in which the clinician uses the best evidence available, in consultation with the patient, to decide upon the option that suits that patient best.”

Muir Gray (1997)

“…the conscientious, explicit and judicious use of current best evidence in making decisions about the care of individual patients.”

Sackett et al. (1996)12

Making Clinical Decisions

BEST AVAILABLE EVIDENCE

CLIENT’S VALUES AND

PREFERENCES

CLINICIAN EXPERTISE

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Best Available Evidence

Theoretical knowledge Client-generated data Empirical evidence (EBP)

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Traditional Evidence Classifications

Class I: One or more well-designed randomized, controlled trials (RCTs)

Class II: One or more well-designed, observational clinical studies with concurrent controls (e.g., control or cohort studies), including single subject designs with multiple-baselines and 2 or more participants

Class III: Expert opinion, case series, case reports, studies with historical controls

Quality Standards Subcommittee of theAmerican Academy of Neurology (1999) 15

Classifying Practice Recommendations

Standard High degree of certainty based on Class I or

very strong Class II studies Guideline

Moderate degree of certainty based on Class II or strong consensus from Class III studies

Option Evidence is inconclusive (e.g., conflicting,

expert opinion)16

But keep in mind… As heterogeneity increases, RCT results

are less applicable Evidence from other populations has

relevance Clinically meaningful outcomes are

often personal and social judgmentsMontgomery & Turkstra, 2003

Ylvisaker et al., 2002

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To be a Critical Consumer: PROBE(www.asha.org)

Population: Is the information relevant to your patient population & circumstance?

Results: Do you believe the results? Are they positive and what aspects of the intervention do YOU believe are responsible for reported outcomes?

Objectivity & Bias: Any bias? Evidence: Is there scientific evidence to

support the report? 18

Types of evidence reviews & domains

Types: Broad reviews vs. reviews to generate Practice Guidelines (see below)

Practice Guidelines Topics (www.ancds.org) Assessment

Standardized Nonstandardized

Intervention Attention training Use of external memory aids Intervention for impaired executive function and

metacognition Intervention for social and behavioral disorders Instructional techniques

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Previous Broad ReviewsNIH Consensus report (1999), JAMA (1999)

Very broad review Epidemiological, ICD2 outcomes, underlying

mechanisms, treatment for behavioral and cognitive sequelae, general models of rehabilitations

Preferred large RCTs Source of individual recommendations not

discernable (e.g., expert opinion versus RCTs)

Written for physicians Identified future research needs

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Broad ReviewsCicerone et al. (200o, 2005)

Target areas: Attention Visual perception and construction Language and communication Memory Problem solving and executive functions Multi-modal intervention approaches Comprehensive/holistic approaches

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Cicerone et al., (2000, 2005)

Summary Substantial evidence for: cognitive rehabilitation following TBI,

including strategy training for memory and attention deficits and functional communication treatment

cognitive-linguistic treatment following left CVA

apraxia treatment following left CVA Visual-spatial treatment for left neglect

following right CVA 22

Practice Guideline Reviews

Assessment Standardized Nonstandardized

Intervention Instructional techniques Attention training Use of external memory aids Intervention for social and behavioral disorders Intervention for impaired executive function and

metacognition

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Standardized Assessment

Turkstra, Ylvisaker, Coelho, Kennedy, Sohlberg, & Avery (2005)

Test with good reliability/validity: ASHA-FACS Behavior Rating Inventory of Executive

Function Communication Activities of Daily Living -

Second Edition Repeatable Battery for the Assessment of

Neuropsychological Status Test of Language Competence-Extended Western Aphasia Battery (i.e., CQ) 24

Standardized AssessmentPractice Guidelines

Must clarify purposes of assessment and choose appropriate tools

Use caution in applying most standardized tests for persons with TBI

Consider standardized testing within broader framework that considers pre-injury characteristics, stage of development and recovery, life and communication context

Integrate cognitive-communication assessments with those of other professionals whose scope of practice includes cognitive assessment, particularly neuropsychology

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Non-standardized Assessment

Coelho, Ylvisaker, & Turkstra (2005).

Conversational discourse Measures of content and topic management

appeared to be most useful Appears to better discriminate individuals with TBI

from peers than does monologic discourse

Pragmatic rating scales appear useful but require training and are psychometrically weak

Interpretation of discourse analyses must consider context

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Non-standardized Assessment

Summary There is evidence to support the use of discourse

measures, particularly conversations, for discriminating individuals with TBI from peers

Impairments of social cognition are a source of long-term disability, and tools are needed

There is evidence that collaborative, contextualized hypothesis testing should be used for planning behavioural intervention and supports

There is limited research on the effect of partner competencies, and existing “checklists” are methodologically weak

Checklists for evaluating environmental demands need validation 27

Direct Attention Training

Sohlberg, Avery, Kennedy, Coelho, Turkstra, Ylvisaker, & Yorkston (2007)

Based on the premise that attentional abilities can be improved by activating particular aspects of attention through a stimulus drill approach Repeated stimulation of attentional systems via

graded attention exercises is hypothesized to facilitate changes in attentional functioning

Includes functions related to sustaining attention over time (vigilance), information processing capacity and speed, shifting attention, resisting distraction

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Direct Attention Training

Practice Guidelines Treatment gains beyond the clinic were

observed only in studies witha) individualized attention exercisesb) treatment sessions that were 1 hr (vs. 2 hr) in

durationc) at least weekly treatment sessionsd) outcome measures that included a range of

different tests sensitive to attention and working memory

e) outcome measures that included activity-based measures using client self-report data.

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External Memory AidsSohlberg, Kennedy, Avery, Coelho, Turkstra, Ylvisaker, & Yorkston

(2007)

Provide the user with a way to compensate for memory impairments by using a tool or device that either limits the demands on a person’s impaired ability, or transforms the task or environment such that it matches the client’s abilities

Other terms for external aids: cognitive orthoses, cognitive prostheses, assistive technology

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External Aids Practice Guidelines

Universal evidence that external aids helps people with memory problems and that they can use them effectively.

What is strikingly absent is information about how to train or introduce people with memory impairments to the use of aids.

NOTE: Internal memory aids (e.g., mnemonic strategies) were not considered, as there is good evidence that these are not effective for individuals with moderate-severe memory impairments.

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Executive FunctionsKennedy, Coelho, Ylvisaker, Sohlberg, Avery, Turkstra &

Yorkston (2007)

Definition: Processes required for the execution of goal-

directed behaviors over time Include ability awareness of performance and

ability to monitor and flexibly alter one’s own behavior to solve problemsi.e., self-awareness, self-monitoring, self-

regulation

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Executive FunctionsPractice Standards

Strong evidence for intervention for young and middle-aged

adults in the chronic stage post-injury training using step-by-step self-regulatory

or self-instruction techniques will improve problem solving in personally relevant activities or problem situations, in young or middle-aged adults Strong evidence that positive outcomes will be

maintained

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Executive FunctionsPractice Guidelines

The evidence supports self-awareness training for young and middle-aged adults in the

chronic stage post-injury to increase general awareness of injury and

knowledge about brain injury, when tailored to the individual and in large doses

that includes feedback, while fading and shaping behaviour, to improve self-awareness, self-monitoring, and self-control for disruptive behaviors in specific contexts or activities (no evidence of generalization)

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Social & Behavioral Problems

Ylvisaker, Turkstra, Coelho, Kennedy, Sohlberg, Avery, & Yorkston (2007)

Common challenges (often linked with challenges in executive functions, memory, etc)

Acting without thinking Socially inappropriate comments Reduced anger control

Types of Intervention Contingency-based (reward systems) Antecedent-based (Positive Behavioral

Supports)

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Social & Behavioral Problems

Practice Guidelines Behavioral intervention, both

traditional contingency management and PBS procedures, not otherwise specified, can be considered a treatment guideline for children and adults with behavior disorders after TBI

Literature has significant limitations, e.g., inconsistent reports of follow-up, lack of reports of failures, procedures that work only in some contexts 36

InstructionEhlhardt, Sohlberg et al, 2008

Many rehabilitation professionals receive little to no training in the design and delivery of effective teaching

Therapy involves teaching and learning; we need to understand the science of instruction

Instruction is critical to all the previously mentioned areas of cognitive rehabilitation

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InstructionRecommendations

Clearly specify intervention targets and/or use of task analyses when training multi-step procedures

Constrain errors and control client output when teaching new (or relearning) information and procedures

Provide sufficient practice Distribute practice Use of stimulus variation (e.g., multiple

exemplars) Use of strategies to promote more effortful

processing (e.g., verbal elaboration; imagery) Select and train ecologically valid targets 38

What types of cognitive rehab did

she receive? [McKay)1. Direct attention training (APT)2. External memory aid training (Day

planner)3. Executive functions- Problem solving

strategy training (when cooking)4. Functional communication training (work-

related role play)5. Task specific training (writing thoughts

ahead of time)6. Environmental modifications (reduce

distractions)39

Answers…For Sara, answers #4, 5, and 6 are

correct.

However, for other individuals 1, 2, and/or 3 might be the most appropriate.

Cognitive rehabilitation should be evidence-based AND individualized!

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Insurance Documentation Nuts

‘n Bolts

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The “Nuts ‘n Bolts” Objectives

Provide Overview of Billing and Coding for SLPs

Provide Overview of Insurance and Rehabilitation

Identify current issues in funding for Cognitive Rehabilitation

How to use research evidence to support funding

Identify future needs and opportunities 42

Coding for SLPs International Classification of Diseases –

9 or ICD-9 (indicates version in use) “Designed to promote international

comparability in the collection, processing, classification, and presentation of mortality statistics.”

“Used in assigning codes to diagnoses associated with inpatient, outpatient, and physician office utilization in the U.S.”

Center for Disease Control/National Center for Health Statistics

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ICD-9 ComponentsComposed of 3, 4 and 5 digits

3 digit codes are usually the heading of a category of codes that may be further subdivided to provide greater detail

Cerebrovascular disease (430 – 438) Late effects of cerebrovascular disease = 438

Speech & language deficits = 438.1 Aphasia = 438.11

Fracture of the skull (800 – 804) Fracture of vault of skull, includes frontal bone,

parietal bone = 800 Closed with other and unspecified intracranial

hemorrhage = 800.3 Symptoms, signs, and ill defined conditions

(796 – 799)44

Fresh off the press codes!

New Subcategory for 2011: 799.5 Signs and symptoms involving

cognition New 799.51 Attention or concentration deficit New 799.52 Cognitive communication deficit New 799.53 Visuospatial deficit New 799.54 Psychomotor deficit New 799.55 Frontal lobe and executive function deficit New 799.59 Other signs and symptoms involving cognition

http://www.asha.org/uploadedFiles/ICD-9-CM-Diagnosis-Codes.pdf

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Billing for Rehab Services

Current Procedural Terminology (CPT) Listing of descriptive terms and codes to

report medical and other health care services delivered by a practitioner.

Each procedure is associated with a 5 digit code. Example: 92506 = Evaluation of speech,

language, voice, communication, and/or auditory processing disorder

Codes can be timed or untimed. Example: 92507 = treatment of speech,

language…; individual 97532 = cognitive skills development, each

15 minutes

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Correct Coding Initiative

CPT Procedure

(one)

Paired With (one)

Modifier Used

92507, 92508, 92526

97032, 97110, 97112, 97150, 97530, 97532

-59

Correct Coding Initiative: Codes often have associated components that will restrict how and/or in what combination they are billed.

Table 2: Medicare Correct Coding Initiative (CCI) Edits and OCE Edits SLP Codes Paired With Physical Medicines Codes

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Correct Coding Initiative

CPT Procedure

(one)

Paired With (one)

Modifier Used

92507, 92508, 92526

97032, 97110, 97112, 97150, 97530, 97532

-59

Use of the-59 modifier is not intended to permit speech-language pathologists to bill for physical medicine procedures (97000 codes). The purpose of the modifier, in this case, is to allow billing of 97000 procedures performed by OTs and PTs on the same day that SLPs are billing 92507, 92508, or 92526.

Regarding 97532 (cognitive skills development), Medicare allows usage by speech-language pathologists, but not on the same day as 92507.

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Health Insurance Basics

Medicare provides the most comprehensive policy statements and descriptions of how codes can be applied. Medicare Benefit Policy Manual

Chapter 15, Sections 220 – 230 provide coverage information for PT, OT, SLP services

http://www.cms.gov/manuals/Downloads/bp102c15.pdf (not in handouts; will be posted)

 

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Important Insurance Concepts

Skilled care/medically necessary Prognosis Goal Writing Progress/Functional gains Compensatory training Acquired versus congenital/developmental

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Now the ugly words for rehab

Progressive illness Chronic condition Maintenance Co-treatment/duplication of services Experimental & Investigational Sample policy:

Regence Speech Therapy Utilization Policy

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Which goal statement is best?

Key difference?A. Client will perform memory drills

for 1 hour per day.

B. Client will independently use an external memory aid (personal digital assistant with repeated alarms) to recall when to take medications 4/5 days a week, per family member observation/report.

Which progress statement is best?

Key difference?

A. Having mastered use at home, client is now responding to PDA alarms to cue scheduled activities at work 80% of the time when provided with indirect questioning cues by his job coach.

B. Client is maintaining use of the PDA at home.

Your Responsibilities as a Licensed Professional

Provide competent care Know your client’s insurance policy limits

Remain within authorized visits/time period Know if you are “sharing benefits” with another discipline

Inform your client of your treatment plan and what may be a non-covered service Do not proceed without documented informed consent Plan for future needs Advocate Appeal

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Future of Cognitive Rehabilitation

Set back with Tri-Care/VA ruling and recent VA study

Current status in Oregon 2009 Senate bill passed requiring insurers to

accept medically necessary treatment for traumatic brain injury

2011 bills to be proposed to specify cognitive rehabilitation and to broaden access under OHP.

As of 11/10, Regence has “archived” the CR policy!

http://blue.regence.com/trgmedpol/um/um09.html

(not in handouts; will be posted)

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Resources http://www.asha.org/practice/ http://www.ncepmaps.org/TBI-Adults.php http://www.internationalbrain.org/?q=node/

144 http://www.ancds.org/ http://www.biausa.org/ http://www.cdc.gov/TraumaticBrainInjury/

index.html http://www.tbims.org/combi/list.html 56

Overview of Services Advocacy Toolkit

www.cbirt.org/resources/services-advocacy-toolkit

Sample items Power point presentations Links to Cicerone and ANCDS literature reviews Insurance documentation strategies Appeals process strategies

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Questions & Answersmckay@uoregon.eduehlhardtl@wou.edu

kathy@progrehab.com