McKay Moore Sohlberg , PhD, CCC-SLP University of Oregon Laurie Ehlhardt Powell, PhD, CCC-SLP

1. Cognitive Rehabilitation:Using research evidence and careful documentation to strengthen the case for insurance funding McKay Moore Sohlberg, PhD, CCC-SLP University of Oregon Laurie Ehlhardt Powell, PhD, CCC-SLP Center on Brain Injury Research and Training Kathy de Domingo, MS, CCC-SLP Progressive Rehabilitation Associates

2. Agenda Introduction Research Evidence BREAK (10:30-10:45) Insurance/Documentation Nuts ‘n Bolts Question and Answer

3. Introduction What is cognitive rehabilitation? Who provides cognitive rehabilitation services? What are different types of cognitive rehabilitation?

4. 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…

5. 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…

6. 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

7. 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)

8. 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)

9. 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

10. Research evidence

11. 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)

12. What is evidence-based practice? “…the conscientious, explicit and judicious use of current best evidence in making decisions about the care of individual patients.” Sackett et al. (1996) “...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)

13. Making Clinical Decisions Best Available Evidence Clinician Expertise Client’s Values and Preferences

14. Best Available Evidence • Theoretical knowledge • Client-generated data • Empirical evidence (EBP)

15. 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 the American Academy of Neurology (1999)

16. 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)

17. 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 judgments Montgomery & Turkstra, 2003 Ylvisaker et al., 2002

18. 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?

19. 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

20. 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

21. 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

22. 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

23. 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

24. Standardized AssessmentTurkstra, 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)

25. 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

26. Non-standardized AssessmentCoelho, 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

27. 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

28. Direct Attention TrainingSohlberg, 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

29. Direct Attention TrainingPractice Guidelines • Treatment gains beyond the clinic were observed only in studies with • individualized attention exercises • treatment sessions that were 1 hr (vs. 2 hr) in duration • at least weekly treatment sessions • outcome measures that included a range of different tests sensitive to attention and working memory • outcome measures that included activity-based measures using client self-report data.

30. 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

31. 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.

32. 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 problems i.e., self-awareness, self-monitoring, self-regulation

33. 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

34. 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)

35. Social & Behavioral ProblemsYlvisaker, 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)

36. Social & Behavioral ProblemsPractice 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

37. 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

38. 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

39. What types of cognitive rehab did she receive? [McKay) • Direct attention training (APT) • External memory aid training (Day planner) • Executive functions- Problem solving strategy training (when cooking) • Functional communication training (work-related role play) • Task specific training (writing thoughts ahead of time) • Environmental modifications (reduce distractions)

40. 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!

41. Insurance Documentation Nuts ‘n Bolts

42. 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

43. 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

44. ICD-9 Components Composed 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)

45. 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

46. 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

47. Correct Coding Initiative • 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

48. Correct Coding Initiative • 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.

49. 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)

50. Important Insurance Concepts Skilled care/medically necessary Prognosis Goal Writing Progress/Functional gains Compensatory training Acquired versus congenital/developmental