CNS Vital Signs Advancing Substance Abuse Care

CNS Vital Signs Advancing Substance Abuse Care Adding Value to Your Practice by Providing Solutions for Measuring, Monitoring and www.cnsvs.com

Contents Why CNS Vital Signs?... Why CNS Vital Signs in Substance Abuse?... Addiction and Cognition... CNS Vital Signs Substance Abuse Research CNS Vital Signs Substance Abuse Toolbox.... About CNS Vital Signs... CNS Vital Signs Brief Interpretation... CNS Vital Signs Practice Benefit and Billing Next Steps.. 3 4 5 9 14 21 24 27 30 The following pages have been assembled from various sources and publications and is meant to be a reference or roadmap guide to assist and inform how CNS Vital Signs can be used to improve clinical insight and care management, enable current guidelines, be integrated into a clinic or practice, and help improved practice revenues and performance. 2

Why CNS Vital Signs? CNS Vital Signs valid, reliable, and affordable research quality NEUROCOGNITIVE & BEHAVIORAL HEALTH assessment platform can be easily configured and deployed depending on each practices or researchers needs and goals. The CNS Vital Signs assessment platforms helps to support a practices comprehensive, state of the art clinical assessment, and evidence based treatment services for children, adolescents, and adults across the lifespan by: Enhanced Brain & Behavior Evaluation and Care Management OBJECTIVE, PRECISE, and STANDARDIZED Customizable Toolboxes or Test Panels Supporting many Neurological, Psychiatric, & Psychological Clinical Guidelines Accurately measuring and characterizing a patient s neurocognitive function based on his or her status or effort Facilitating the thinking about the patient s condition (50+ well known medical and health rating scales)and helping to explain the patient s current difficulties Optimizing serial administration which helps to monitor and guide effective intervention. Systematically collecting brain function, behavioral, symptom, and comorbidity data enabling outcomes and evidence based medicine Extend Practice Efficiency Objective and Evidence Based Assessments, Auto Scored and Systematically Documented. (HIPAA Enabled) $ Enhanced Revenue Streams Expanded Services with Well Established Billing Codes to Improve Practice Referrals and Performance 3

Why CNS Vital Signs in Substance Abuse? Benefits for Substance Abuse Clinics VA/DoD Clinical Practice Guideline For Management of Substance Use Disorders Assessment and Management of Cognitive Impairment in Substance Abuse Assessment is the beginning of the therapeutic process. A comprehensive biopsychosocial assessment covers physical, cognitive, behavioral, emotional, and environmental domains. The guidelines do not exclusively endorse the use of any particular instrument as the basis for a comprehensive assessment. American Psychiatric Association (APA) Treating Substance Use Disorders: A Quick Reference Guide Address factors that may be more likely to influence treatment adherence in individuals with co occurring disorders (e.g., concern about medication interactions, cognitive impairment, limited motivation, lack of peer and social support). http://psychiatryonline.org/content.aspx?bookid=28&sectionid=1663538 Substance Abuse and Mental Health Services Administration (SAMHSA) Elements of a Comprehensive Patient Assessment: Mental Status: Cognition (e.g., attentional capacity, memory), Mood, Suicidal ideation and behavior, Medication focused, Somatic preoccupation Co Occurring Conditions and Disorders: Psychological conditions (e.g., depression, anxiety, post traumatic stress disorder [PTSD], Medical conditions, Cognitive impairments; Function: Activities of daily living/ability to care for oneself, Sleep, Mood, Sex. Heavy drinking can cause psychiatric symptoms such as depression, anxiety, insomnia, cognitive dysfunction Enhanced Substance Abuse Evaluation, Management & Tracking Strategies Free SBIRT Screening Tools e.g. AUDIT and DAST Auto Scored Remote Testing CNS Vital Signs provides a valid, reliable and granular view of neurocognitive status Efficient: Reports are Auto Scored in seconds and Screens for possible in valid tests e.g. malingering Multi Modal Assessment platform allowing for improved Comorbid Symptom identification and management e.g. Mood, Depression, Sleep, Suicidal Ideation, Quality of Life / Outcomes, Etc. Longitudinal reports auto generated to monitor and measure e.g. treatment outcomes Telemedicine Enabled 4

Addiction and Cognition http://www.ncbi.nlm.nih.gov/pmc/articles/pmc3120118/pdf/ascp 05 2 4.pdf ADDICTION SCIENCE & CLINICAL Practice December 2010 The brain regions and neural processes that underlie addiction overlap extensively with those that support cognitive functions, including learning, memory, and reasoning. Drug activity in these regions and processes during early stages of abuse foster strong maladaptive associations between drug use and environmental stimuli that may underlie future cravings and drugseeking behaviors. With continued drug use, cognitive deficits ensue that exacerbate the difficulty of establishing sustained abstinence. The developing brain is particularly susceptible to the effects of drugs of abuse; prenatal, childhood, and adolescent exposures produce long lasting changes in cognition. Patients with mental illness are at high risk for substance abuse, and the adverse impact on cognition may be particularly deleterious in combination with cognitive problems related to their mental disorders. Thomas J. Gould, Ph.D. Department of Psychology and Center for Substance Abuse Research Temple University; Philadelphia, Pennsylvania 5

Addiction and Cognition http://www.ncbi.nlm.nih.gov/pmc/articles/pmc3120118/pdf/ascp 05 2 4.pdf ADDICTION SCIENCE & CLINICAL Practice December 2010 Cognition Deficits In Chronic Drug Abuse Drug abusers who progress to the second stage of addiction are subject to withdrawal when they initiate abstinence. Many drugs produce cognition related withdrawal symptoms that may make abstinence more difficult. These include: cocaine deficits in cognitive flexibility (Kelley et al., 2005); amphetamine deficits in attention and impulse control (Dalley et al., 2005); opioids deficits in cognitive flexibility (Lyvers and Yakimoff, 2003); alcohol deficits in working memory and attention (Moriyama et al., 2006); cannabis deficits in cognitive flexibility and attention (Pope, Gruber, and Yurgelun Todd, 2001); and nicotine deficits in working memory ADDICTION SCIENCE & CLINICAL Practice December 2010 6

Addiction and Cognition http://www.ncbi.nlm.nih.gov/pmc/articles/pmc3120118/pdf/ascp 05 2 4.pdf ADDICTION SCIENCE & CLINICAL Practice December 2010 Clinical Implications The literature reviewed here highlights the importance of considering past and present cognitive function when treating patients for addiction, as drug related cognitive changes may bias patients toward responses and actions that contribute to the cycle of addiction. Clinicians face the challenge of helping patients master adaptive strategies to overcome the strong associations that contribute to relapse when patients return to environments associated with their prior substance use. In addition, cognitive deficits may hinder patients ability to benefit from counseling, and more sessions and/or reminders may be necessary to aid these patients in incorporating abstinence sustaining strategies into their daily routines. Research into the changes in cognition that accompany addiction and the neural substrates of learning and addiction is still in its infancy but has potential to reshape views on addiction. For example, a recent discovery that has generated excitement in the addiction field is that smokers who suffered damage to the insula often lost their desire to smoke (Naqvi et al., 2007). The authors of this finding proposed that the insula is involved in the conscious urge to smoke and that therapies that modulate insula function may facilitate smoking cessation. It may also be that damage to the insula will have a similar effect on the desire to use other drugs of abuse (for a review see Goldstein et al., 2009). A better understanding of how substances of abuse change cognitive processes is needed to develop new therapeutic agents to treat addiction and ameliorate cognitive deficits. This is a complex issue, however, as different drugs of abuse appear to alter different cognitive processes and cell signaling pathways. Even among users of the same drug, cognitive impacts will differ depending on variations in environmental factors and genetics. Understanding the influence of an individual s genetic background on the manifestation of symptoms is a critical area for future research, holding the promise of informing more effective treatments that can be tailored to the individual s genotype. Finally, understanding how prenatal exposure to drugs of abuse changes neural development should be a high priority, as prenatal exposure increases the new generation s susceptibility to addiction and other problems. 7

Cognitive Function as an Emerging Treatment Target for Marijuana Addiction Mehmet Sofuoglu, M.D., Dawn E. Sugarman, Ph.D., and Kathleen M. Carroll, Ph.D.; Yale University, School of Medicine, Department of Psychiatry and VA Connecticut Healthcare System, West Haven, CT Cannabis is the most widely used illicit substance in the world and demand for effective treatment is increasing. However, abstinence rates following behavioral therapies have been modest, and there are no effective pharmacotherapies for the treatment of cannabis addiction. We propose a novel research agenda and a potential treatment strategy, based on observations that both acute and chronic exposure to cannabis are associated with dose related cognitive impairments, most consistently in attention, working memory, verbal learning, and memory functions. These impairments are not completely reversible upon cessation of marijuana use and moreover may interfere with the treatment of marijuana addiction. Therefore, targeting cognitive impairment associated with chronic marijuana use may be a promising novel strategy for the treatment of marijuana addiction. Preclinical studies suggest that medications enhancing the cholinergic transmission may attenuate cannabis induced cognitive impairments, but these cognitive enhancing medications have not been examined in controlled human studies. Preliminary evidence from individuals addicted to other drugs suggests that computerized cognitive rehabilitation may also have utility to improve cognitive function in marijuana users. Future clinical studies optimally designed to measure cognitive function as well as drug use behavior would be needed to test the efficacy of these treatments for marijuana addiction. 8

Sensitive to Measuring the Effects of a Mild Sedative Top Poster Award ISCTM 2011 9

CNS Vital Signs in Substance Abuse Research 10

CNS Vital Signs in Substance Abuse Research Poster ISCTM 2012 11

CNS Vital Signs in Substance Abuse Research Poster ISCTM 2012 12

CNS Vital Signs in Substance Abuse Research Poster NCDUE 2012 13

Advancing SA Care Management CNS Vital Signs Substance Abuse Toolbox Clinician Expertise Brain Function: Processing Speed, Memory, Attentional, Executive, Psychomotor Speed & more Computerized Neurocognitive Testing Nine Neurocognitive Domains Measured Frontal Lobe / Executive & Attentional Tests Recognition Memory immediate and delayed recall Processing and Psychomotor Speed Immediate Auto Scored Reports Rapid Assessment 30 45 Minute initial Assessment/Baseline, 15 45 Minute for monitoring Easy to interpret and longitudinally graph Systematic & Standardized Documentation for Patient Registry/Research HIPAA Compliant Behaviors, Symptoms, and Comorbidities Computerized Medical and Health Rating Scales* AUDIT Alcohol Use Disorders Identification Test DAST Drug Use Questionnaire SF 36 Medical Outcomes Zung Self Rating Anxiety and Depression Scales NeuroPsych Questionnaire NPQ 207 & NPQ 45 both Child & Adult Adult and Vanderbilt AD/HD Rating Scales Epworth Sleepiness Pittsburgh Sleep Quality Index Over 50 Rating Scales available * Used with permission Free use of rating scales 14

Risk Factors? Adapted From: NIH Pub No. 10 5605 Where the CNS Vital Signs Assessment Platform can add efficiency, validity, and standardization to the assessment of brain functions, behaviors, symptoms, and treatment effects. Etiology of Substance Abuse Genes Environment Genetics Gender Mental disorders Route of administration Effect of drug itself DRUG Early use Availability Cost Chaotic home and abuse Parent s use and attitudes Peer influences Community attitudes Poor school achievement BRAIN Mechanisms Addiction BEHAVIOR Scientists estimate that genetic factors account for between 40 and 60 percent of a person s vulnerability to addiction, including the effects of environment on gene expression and function. Adolescents and individuals with mental disorders are at greater risk of drug abuse and addiction than the general population. 15

SBIRT Screening: A Systems Based Approach Neurocognitive Tests CNS Vital Signs is a computerized neurocognitive health assessment platform that enables the OBJECTIVE EVALUATION of COGNITION WEB & COMPUTER Based Testing Sleep Rating Scales identifying symptoms, possible comorbidities, behavioral issues, and other important clinical information. Patient In Take / Early Detection Multi Modal Professional Assessment Measure Progress and Performance Screening Evidence Based Rating Scales Neurocognitive Testing Follow up and Outcomes Identify FREE SBIRT Screening Possible Behavioral or Comorbid Issues Cognitive Status Baseline NeuroPsych, Mental, and Behavioral Health Issues (symptoms that can effect educational or vocational productivity and performance) Behavioral Neuropsychiatric Symptoms & Comorbidities Attentional Issues Internalizing (anxiety depression PTSD) Issues Externalizing (behavioral conduct) issues and many more. Brain Memory Attentional Executive Control Processing Speed Cognitive Flexibility Social Acuity Reasoning Working Memory and many more SOPHISTICATED yet SIMPLE Systems Based approach to Screening, Assessment, & Surveillance Monitor Assess Medication Effect Measure Progress or Changes Document for Outcomes and/or Research Conduct Web Based Mental and Behavioral Health Surveillance Improve Compliance 16

AUDIT - Alcohol Use Disorders Identification Test Example Alcohol Use Disorders Identification Test (AUDIT) SF-10 Subject Reference/ID: substanceabuse Test Date: March 06 2012 13:04:26 To Learn More: Age: 22 Administrator: administrator Total Test Time: 2:01 (min:secs) for all tests Language: English (United States) in this report This scale was administered using CNS Vital Signs Questions 1 8 are scored 0, 1, 2, 3 or 4. Questions 9 and 10 are scored 0, 2 or 4 only. The minimum score (for nondrinkers) is 0 and the maximum possible score is 40. A score of 8 or more indicates a strong likelihood of hazardous or harmful alcohol consumption. 1 How often do you have a drink containing alcohol? 3 - Two to three times per week 3 2 How many drinks containing alcohol do you have on a typical day when you are drinking? 3-7 to 9 3 3 How often do you have six or more drinks on one occasion? 3 - Weekly 3 4 5 How often during the last year have you found that you were not able to stop drinking once you had started? How often during the last year have you failed to do what was normally expected from you because of drinking? 3 - Weekly 3 3 - Weekly 3 6 7 8 9 10 How often during the last year have you needed a first drink in the morning to get yourself going after a heavy drinking session? How often during the last year have you had a feeling of guilt or remorse after drinking? How often during the last year have you been unable to remember what happened the night before because you had been drinking? Have you or someone else been injured as a result of your drinking? Has a relative or friend, or a doctor or other health worker been concerned about your drinking or suggested you cut down? 4 - Daily or almost Daily 4 2 - Monthly 2 4 - Daily or almost Daily 4 2 - Yes, but not in the last year 2 2 - Yes, but not in the last year 2 http://whqlibdoc.who.int/hq/2001/who_msd_msb_01.6a.pdf AUDIT Score 29 REFERENCE: Saunders, J. B., Aasland, O. G., Babor, F., et al. (1993). Development of the alcohol use disorders screening test (AUDIT). WHO collaborative project on early detection of persons with harmful alcohol consumption, II. Addiction,88,791 804. 17

DAST - Drug Use Questionnaire A factor analysis of the 20 items has indicated that the DAST is essentially a uni dimensional scale. Accordingly, it is planned to yield only one total or summary score ranging from 0 to 20, which is computed by summing all items that are endorsed in the direction of increased drug problems. Only two items, 4 and 5 are keyed for a "No" response. A score of five or less points indicates a Normal Score. A score of six or more points indicates a Drug Problem. A DAST score of six or above is suggested for case finding purposes, since most of the clients in the normative sample scored six or greater. It is also suggested that a score of 16 or greater be considered to indicate a very severe abuse or a dependency condition. Used with permission: Author Dr. Harvey A. Skinner (York University, Toronto, Canada) Drug Use Questionnaire (DAST) SF-20 Subject Reference/ID: substanceabuse Test Date: March 06 2012 13:14:59 Age: 22 Total Test Time: 3:38 (min:secs) for all tests in this report Administrator: administrator Language: English (United States) 1 Have you used drugs other than those required for medical reasons? 1 - Yes 2 Have you abused prescription drugs? 1 - Yes 3 Do you abuse more than one drug at a time? 1 - Yes 4 Can you get through the week without using drugs? 1 - Yes 5 Are you always able to stop using drugs when you want to? 1 - Yes 6 Have you had "blackouts" or "flashbacks" as a result of drug use? 1 - Yes 7 Do you ever feel bad or guilty about your drug use? 1 - Yes 8 Does your spouse (or parents) ever complain about your involvement with drugs? 1 - Yes 9 Has drug abuse created problems between you and your spouse or your parents? 0 - No 10 Have you lost friends because of your use of drugs? 1 - Yes 11 Have you neglected your family because of your use of drugs? 0 - No 12 Have you ever been in trouble at work because of drug abuse? 0 - No 13 Have you lost a job because of drug abuse? 1 - Yes 14 Have you gotten into fights when under the influence of drugs? 0 - No 15 Have you engaged in illegal activities in order to obtain drugs? 1 - Yes 16 Have you been arrested for possession of illegal drugs? 0 - No 17 Have you ever experienced withdrawal symptoms (felt sick) when you stopped taking drugs? 1 - Yes 18 Have you had medical problems as a result of your drug use (e.g. memory loss, hepatitis, convulsions, bleeding, etc.)? 0 - No 19 Have you gone to anyone for help for a drug problem? 1 - Yes 20 Have you been involved in a treatment program specifically related to drug use? 0 - No DAST Score 11 References: 1. Skinner, Harvey A. The Drug Abuse Screening Test. Addictive Behavior, 1982, 7, 363-371. 2. Yudko E., Lozhkina O. & Fouts A. A comprehensive review of the psychometric properties of the Drug Abuse Screening Test. Journal of Substance Abuse Treatment, 2007, 32, 189-198. 18

Tools to Help Assess Symptoms and Comorbidities NPQ 45 Rapid In take or Re test to Assess the Neuro Psych Status of a Patient NPQ 45 (Adult Patient & Informant Version) Rapid In take or Re test to Assess the Neuro Psych Status of a Patient Symptoms Brain Function Behaviors Key Symptoms Comorbidities The Neuropsych Questionnaire (NPQ) Short Form (SF 45) provides a subjective measure of 13 neuropsych symptoms. The symptoms are Attention, Impulsive, Memory, Anxiety, Panic, Depression, Mood Stability, Oppositional (child adolescent), Aggression, Fatigue, Sleep, Suicide, and Pain. The shorter NPQ version is used to monitor or follow up with the patient before or during their visit. The NPQ 45 can be used when the longer version is either impractical or inappropriate e.g. the physician wants a quick view of their patients core symptoms. Both versions are automatically scored and the data stored. 19

Optimized for SA Evaluation & Management Epilepsy & Behavior 25 (2012) 329 333 CNS Vital Signs Neurocognitive Battery in Measuring Medication Effects Patient Evaluation and Management Brain Behavior Objective Neurocognitive Assessment Health Outcomes Evidence - Based Health Rating Scales Care Management Reports Brain Function Symptoms Comorbidities Standardized and Secure Data Care Team Caregiver & Informants e.g. Spouse, Family, etc. Easy Export to EMR and Spreadsheet for Analysis 1600+ Norms from Age s 8 to 90 Systematic Documentation Acute Lorazepam Effects on Neurocognitive Performance In conclusion, this study demonstrates comparable sensitivity of CNS Vital Signs to traditional neuropsychological testing after acute administration of LOR (2 mg orally) that occurs largely independent of plasma concentrations for the range of levels reported here. Acute benzodiazepine administration is frequently the initial choice for treating either convulsive status epilepticus [24] or clusters of repetitive seizures [25] and remains the preferred treatment choice in managing seizure emergencies. Adapted from: Epilepsy & Behavior 25 (2012) 329 333; David W. Loring a,b,, Susan E. Marino c, David Parfitt d, Glen R. Finney d, Kimford J. Meador a,b a Department of Neurology, Emory University, Atlanta, GA, USA b Department of Pediatrics, Emory University, Atlanta, GA, USA c Center for Clinical and Cognitive Neuropharmacology, Experimental and Clinical Pharmacology, University of Minnesota, Minneapolis, MN, USA d Department of Neurology, University of Florida, Gainesville, FL, USA The CNS Vital Signs Sleep Toolbox helps clinicians systematically collect brain function, symptoms, and comorbidities data, automatically scoring and systematically documenting the resulting clinical endpoints. 20

About CNS Vital Signs? Assessing Brain Function: CNS Vital Signs is a clinical testing procedure used by clinicians to evaluate and manage the neurocognitive state of a patient. Across the lifetime, serial testing allows ongoing assessments of a patient s condition, disease progression, or clinical outcome. About CNS Vital Signs Clinician Benefits Both Valid & Reliable Neurocognitive Testing and Evidence-Based Symptom & Functional Ratings Scales in one Platform Optimized for MULTI-MODAL Assessment enabling the efficient collection and systematic documentation of important brain function and behavioral, symptom and comorbid clinical endpoints Lifespan Testing Rapid Neurocognitive Testing from ages 8 to 90 Longitudinal View CNS Vital Signs contains an Auto Randomization Algorithm Ideal for Serial Neurocognitive Testing with an almost unlimited number of alternate forms (others use a pseudo randomization or limited number of alternate forms) Flexible Deployment Easy Integration via Local Computer Software and Web Based Testing Solutions Ideal for busy clinics, hospitals, or academic research RAPID INSIGHT computerized neurocognitive testing helps clinicians evaluate and describe the health of the cognitive or higher functions of the brain in a more granular and standardized fashion. DASHBOARD VIEW Neurocognitive domain functions and functional status is presented in a summary view that is easy to interpret. LONGITUDINAL VIEW Repeated testing allows clinicians to track disease progress and treatment/rehabilitation effects DETAILED VIEW Each report presents the testing data in a detailed view. All results can be easily exported to EMR s or spreadsheets for clinical or research purposes. VALID ACROSS the LIFE SPAN Peer reviewed normative data allows clinicians to examine patients from age 8 to 90. 21

About: CNS Vital Signs in Substance Abuse CNS Vital Signs provides clinicians and researchers with leading edge neurocognitive and behavioral health assessment technologies that efficiently collects valid and reliable brain & behavioral clinical endpoints for a more objective view of a patient s functional status, disease progression, and outcomes. The CNS Vital Signs Assessment platform supports a lifespan chronic care model and helps enable productive interactions between the family, caregivers, and a specialist practice team. CNS Vital Signs is a clinical procedure that utilizes scientifically validated objective tests to evaluate the neurocognitive status of patients and covers a range of mental processes from simple motor performance, attention and memory, to executive functions. The CNS Vital Signs tests are computerized versions of well established neuropsychological tests. Medical professionals and researchers know that good health has many dimensions, one of the most important and yet least measured is the health of a person's brain. Outcomes based medicine seeks a quantitative estimate of the effect of impairment or disease and the effectiveness and efficiency of treatment. CNS Vital Signs provides a standardized and quantitative view of your patient s CORE COGNITIVE FUNCTION. CNS Vital Signs computerized neuropsychological tests can enhance efficiency and insight in assessing cognitive status and the difference between normal performance and a patients current status and provides the clinician with a normative comparison that can be paired with an interview, exam, and other valid test(s) or rating scales to help add validity to the evaluation and management of Substance Abuse. Reevaluation or serial testing with CNS Vital Signs supports the effective management and tailoring of treatments e.g., medications and assessment of outcomes. A very detailed assessment of abilities is auto scored, and the pattern of strengths and weaknesses can be used in treatment planning and measuring progress. One of the most robust features of the CNS Vital Signs assessment is its randomization algorithm allowing for an almost infinite number of alternate forms. This allows for retesting patients and minimal practice effects. Clinicians establish a baseline and upon re test, compare the results to assist in decision making regarding the observed change in the patient s condition, monitor disease or recovery progress, measure treatment results, compliance, and outcomes e.g., Therapy Management, Medication Optimization, Etc. Often Patients and families benefit from seeing testing results allowing the understanding of the status and nature of their or a loved one s neurocognitive function. CNS Vital Signs is one of many tools clinicians use in evaluating changes in a patient s condition. If you have question or would like to register for a free in service webinar go to www.cnsvs.com or email support@cnsvs.com or call 1.888.750.6941. 22

Why Use CNS Vital Signs to Assess SA? The CNS Vital Signs VSX Assessment Platform represents a legacy of innovation and a commitment to advancing neurocognitive and behavioral clinical assessment tools. Clinical Pathology Measure and Monitor Comorbid Status Measure and Monitor Serial Assessment Longitudinal View Assess BRAIN FUNCTION and Determine the Existence or Level of IMPAIRMENT CNS Vital Signs computerized neurocognitive testing allows clinicians to assess abnormal neurocognitive impairment by comparing patients to a PEER REVIEWED normative data set from ages 8 to 90 across the lifespan Provides a broad spectrum of clinical domains and the sensitivity to assess neurocognitive function to reveal abnormal cognitive function. Assess symptoms or COMORBID conditions Evidence based rating scales and neurocognitive testing can help clinicians sort out symptom, behavioral, and comorbid issues and help better understand possible brain and behavior relationships. 50+ Free Rating Scales: Audit Dast SF 36 Medical Outcomes Zung Self Rating Anxiety and Depression Scales NeuroPsych Questionnaire NPQ 207 & NPQ 45 both Child & Adult KEY ADVANTAGE contains an auto randomization algorithm Ideal for serial testing with an almost unlimited number of alternate forms (other systems use a pseudo randomization or limited number of alternate forms). This allows practices to shift toward new assessment approaches that allow for monitoring of change and the reinforcement of treatment compliance. 23

HOW? CNS Vital Signs begins with A B C Conduct Neurocognitive Testing Procedure Evaluate Neurocognitive Testing Results Re-test Neurocognitive Testing Procedure Is the Validity Indicator (VI) suggestive of an invalid test? Is the Pattern suggestive of a condition or pathology? 1 Evaluate Pattern Evaluate Effort 3 2 Evaluate Severity Are the Scores suggestive of a deficit or impairment? A: Conducting a Valid Assessment (Refer to the Test Administration Guide.) To begin the staff should collect information about the CHIEF or REFERRAL COMPLAINT. This will be a primary driver for the selection of tests and rating scales. For initial evaluations or in complex presentations, a broad spectrum battery is always an appropriate starting point. 1 2 B: Review the immediately auto scored report to validate testing effort, evaluate the Domain Dashboard to quickly assess the level of impairment or grade the deficit, and 3 Evaluate the Domain Pattern to help rule in, ruleout, or confirm certain clinical conditions. Feedback to the patient on the testing results may be presented at the clinical encounter or at a subsequent patient visit. C: If invalid test results were noted then consider re testing the patient to confirm clinical results. If the test results were valid, then, as part a continuum of care, reschedule testing to track disease progression and measure ongoing status or outcomes. NOTE: The Validity Indicator denotes a guideline for representing the possibility of an invalid test or domain score. No means a clinician should evaluate whether or not the test subject understood the test, put forth their best effort, or has a clinical condition requiring further evaluation. 24

Evaluate Severity Impairment Status CNS Vital Signs grades severity of impairment based on an age matched normative comparison database mtbi Example Psychometric and Normative Comparison Mean + Standard Deviations Percentiles Standard Scores Z Scores T Scores -4σ -3σ -2σ -1σ 0 +1σ +2σ +3σ +4σ 1 5 10 20 30 40 50 60 70 80 90 95 99 55 70 85 100 115 130 145-4.0-3.0-2.0-1.0 0 +1.0 +2.0 +3.0 +4.0 20 30 40 50 60 70 80 Above: Average: Low Average: Low: Very Low: > 110 90 110 80 90 70 79 < 70 Standard Scores High Function and High Capacity Normal Function and Normal Capacity Slight Deficit and Slight Impairment Moderate Deficit and Impairment Possible Deficit and Impairment Likely 25

Neurocognitive Domain Dashboard CNS Vital Signs presents testing results in Subject (raw), Standard Scores, and Percentile Ranks. NOTE: See the CNS Vital Signs Interpretation Guide for more information. >115 100 85 70 +1SD 1SD 2SD 3SD Above: Above Expected Level Average: At Expected Level Low Average: Borderline Low: Below Expected Level Very Low: Well Below Expected Level <55 SD = Standard Deviation from the MEAN 26

HOW can CNS Vital Signs Benefit My Practice? Ask about our NO COST Practice Evaluation! CNS Vital Signs Benefits Enhanced Patient Insight and Care Management CNS Vital Signs Mobile Test Station ULTRA Series Enables Evidence-Based Medicine and Outcomes Improved Practice Efficiencies and Documentation Solution Example $1,400.00 Testing Station with 40 test sessions. $ Improved Practice Revenues and Performance Potential Return On Investment Based on Established Billing Codes* 40 Patient Test Sessions ROI: $2,400 to $10,000+ Possible Yearly IMPACT $80K to $160K depending on patient volumes *Based on a survey of Payers. Contact support@cnsvs.com for billing information. Popular with Clinics and Hospitals: Engineered with BUSY PRACTICES in mind (roll into exam rooms), the Ultra Series combines the ultimate in practical functionality, ergonomic ease ofuse, and remarkable durability. 27

Billing Codes: Neurocognitive Testing 96101 Testing & Interpretation 96101 Additional Professional 96102 Testing & Interpretation 96103 Testing & Interpretation 90791 Formerly 90801 90792 Formerly 90801 96111 Testing & Interpretation Psychological and Psychiatric Conditions Psychological testing (includes psych assessment of emotionality, intellectual abilities, cognition, personality and psychopathology, e.g., MMPI, Rorschach, WAIS, CNS Vital Signs), per hour of the qualified healthcare professional time, both face-to-face time administering tests to the patient and time interpreting these test results and preparing the report. 96101 is also used in those circumstances when additional time is necessary to integrate other sources of clinical data, including previously completed and reported technician and computer administered tests (Do not report 96101 for the interpretation and report of 95102, 96103) Psychological testing (includes psych assessment of emotionality, intellectual abilities, cognition, personality and psychopathology. e.g., MMPI, CNS Vital Signs, and WAISI), with qualified health care professional interpretation and report, administered by technician, per hour of technician time, face-to-face. Psychological testing (includes psych assessment of emotionality, intellectual abilities, personality and psychopathology, e.g., MMPI, CNS Vital Signs), administered by a computer, with qualified health care professional interpretation and report. Psychiatric evaluation exam (no medical services) for the elicitation of a complete medical and psychiatric history, a mental status examination, Integrated biopsychosocial assessment, and an evaluation of the patient's ability and capacity to respond to treatment on an initial plan of treatment. Non-Prescriber. Psychiatric evaluation exam (with medical services) for the elicitation of a complete medical and psychiatric history, a mental status examination, Integrated biopsychosocial assessment, and an evaluation of the patient's ability and capacity to respond to treatment on an initial plan of treatment. Prescriber. Developmental Testing Developmental testing extended (includes assessment of motor, language, social, adaptive and/or cognitive functioning by standardized developmental instruments (including CNS Vital Signs) with interpretation and report. http://www.cdc.gov/ncbddd/autism/documents/aap-coding-fact-sheet-for-primary-care.pdf http://pediatrics.aappublications.org/content/118/1/405.full Estimated Reimbursement Rate* $92 $112 $89 $174 $137 $142 28

Billing Codes: SBIRT and Others SBIRT Substance Abuse Screening Estimated Reimbursement Rate* Payer Code Description Fee Commercial Insurance Medicare Medicaid CPT 99408 CPT 99409 G0396 G0397 H0049 H0050 Alcohol and/or substance abuse structured screening and brief intervention services; 15 to 30 minutes Alcohol and/or substance abuse structured screening and brief intervention services; greater than 30 minutes Alcohol and/or substance abuse structured screening and brief intervention services; 15 to 30 minutes Alcohol and/or substance abuse structured screening and brief intervention services; greater than 30 minutes Alcohol and/or substance abuse structured screening and brief intervention services; 15 to 30 minutes Alcohol and/or substance abuse structured screening and brief intervention services; greater than 30 minutes Medical, Developmental, and Mental Health Rating Scales 96150 Health and behavior assessment (e.g., health-focused clinical interview, behavioral observations, psychophysiological monitoring, health-oriented questionnaires), each 15 minutes face-to-face with the patient; Initial Assessment. $33 $66 $29 $58 $24 $48 $24 per 15 min. 96151 Health and behavior assessment (e.g., health-focused clinical interview, behavioral observations, psychophysiological monitoring, health-oriented questionnaires), each 15 minutes face-to-face with the patient; Re-Assessment. Developmental Screening 96110 Developmental testing; limited (e.g., Pediatric Symptom Checklist, Vanderbilt AD/HD, Developmental Screening Test II, Early Language Milestone Screen), with interpretation and report. Code 96110 is often reported when performed in the context of preventive medicine services, but may also be reported when screening is performed with other evaluation and management (E/M) services such as acute illness or followup office visits. http://brightfutures.aap.org/pdfs/coding%20pr%20f0809.pdf http://pediatrics.aappublications.org/content/118/1/405.full http://www.alcoholcostcalculator.org/sub/payment/ $14 29

NEXT STEPS: Contact Us Getting Started Learn More Step One: Register at www.cnsvs.com After registering download the VSX Brief Core Assessment Software with 5 FREE Test Sessions Take it for a test drive. Step Two: Schedule a FREE One on One In Service Webinar Contact CNS Vital Signs Support support@cnsvs.com with dates and times that you will be available. After the webinar the total CNS Vital Signs Assessment platform (Web & Local) can be configured to meet your practice needs. Contact me to receive report examples, case studies, administration guides etc. Website: www.cnsvs.com Phone: 888.750.6941 Email: support@cnsvs.com Address: 598 Airport Blvd. Suite 1400 Morrisville, NC 27560 The webinar training was terrific it covered the Validity & Reliability of the platform, the interpretation of results, billing and coding, testing protocol, and the integration of the CNS Vital Signs platform into our practice. Practice Administrator 30