Relatively undervalued: comparing the work relative value units of neuropsychological evaluation to other services.

Objective: We examined work relative value units (wRVUs) and associated revenue of current procedural terminology (CPT) codes for evaluation and management (E&M) services, neuropsychological evaluation (NPE), psychological evaluation (PE), and psychotherapy. Method: CPT code wRVUs were aggregated for E&M (99202-99215), NPE (96116, 96132, 96133, 96136, and 96137), PE (90791, 96130, 96131, 96136, and 96137), and psychotherapy (90791 and 90832-90837 with and without the complexity modifier, 90785). Per minute wRVUs were calculated for each CPT code. The Centers for Medicare and Medicaid Services 2023 conversion factor ($33.8872) was multiplied by wRVUs to examine reimbursement per hour and per prototypical four-hour clinic slot. Results: The wRVUs per minute showed the following ranges: 0.032-0.07 for E&M services, 0.015-0.063 for NPE, 0.015-0.124 for PE, and 0.043-0.135 for psychotherapy. Average hourly revenue ranged from $72 for NPE to $132 for psychotherapy with the complexity modifier. Revenue for prototypical four-hour clinics ranged from $283 for NPE to $493 for psychotherapy with the complexity modifier. PE and psychotherapy services were valued at 124-184% of NPE. Conclusions: E&M code wRVUs increase with case complexity reflecting greater work intensity, and a modifier to PE and psychotherapy captures additional effort needed in complex cases. In contrast, NPE codes lack a complexity modifier, and NPE wRVUs are lower than those of PE and psychotherapy, the latter of which can be billed by master's level providers. NPE is undervalued compared to PE and psychotherapy based on wRVUs currently assigned to the CPT codes used for the respective services.

Intra-individual variability in cognitive performance predicts functional decline in Parkinson's disease.

BACKGROUND: Cognitive deficits contribute to disability in Parkinson's disease (PD). Cognitive intra-individual variability (IIV) is associated with cognitive decline in age-related disorders, but IIV has not been related to functional ability in PD. We examined IIV in predicting functional ability in participants with PD. METHODS: De-identified National Alzheimer's Coordinating Center data (N = 1,228) from baseline and follow-up visits included participants with PD propensity score matched to control participants at baseline on age (M = 72), education (M = 15), and gender (28% female). PD symptom duration averaged 6 years. Outcome measures included the Functional Ability Questionnaire (FAQ), overall test battery mean (OTBM) of ten cognitive variables, IIV calculated as the standard deviation of cognitive data for each participant, Geriatric Depression Scale (GDS), and Unified PD Rating Scale gait and posture items. Baseline FAQ status in the PD group was predicted using logistic regression with age, education, cognition, GDS, and motor function as predictors. We compared baseline characteristics of PD participants with and without functional impairment at follow up. RESULTS: PD participants showed lower OTBM and greater IIV, GDS, and motor dysfunction than controls (p < .0001). Education, OTBM, IIV, GDS, and gait predicted functional status (77% overall classification; AUC = .84). PD participants with functional impairment at follow up showed significantly lower OTBM and greater IIV, GDS, and motor dysfunction at baseline (p < .001). CONCLUSION: IIV independently predicts functional status in participants with PD while controlling for other variables. PD participants with functional impairment at follow up showed greater IIV than those without functional impairment at follow up.

Racial differences in positive findings on embedded performance validity tests.

INTRODUCTION: Embedded performance validity tests (PVTs) may show increased positive findings in racially diverse examinees. This study examined positive findings in an older adult sample of African American (AA) and European American (EA) individuals recruited as part of a study on aging and cognition. METHOD: The project involved secondary analysis of deidentified National Alzheimer's Coordinating Center data (N = 22,688). Exclusion criteria included diagnosis of dementia (n = 5,550), mild cognitive impairment (MCI; n = 5,160), impaired but not MCI (n = 1,126), other race (n = 864), and abnormal Mini Mental State Examination (MMSE < 25; n = 135). The initial sample included 9,853 participants (16.4% AA). Propensity score matching matched AA and EA participants on age, education, sex, and MMSE score. The final sample included 3,024 individuals with 50% of participants identifying as AA. Premorbid ability estimates were calculated based on demographics. Failure rates on five raw score and six age-adjusted scaled score PVTs were examined by race. RESULTS: Age, education, sex, MMSE, and premorbid ability estimate were not significantly different by race. Thirteen percent of AA and 3.8% of EA participants failed two or more raw score PVTs (p < .0001). On age-adjusted PVTs, 20.6% of AA and 5.9% of EA participants failed two or more (p < .0001). CONCLUSIONS: PVT failure rates were significantly higher among AA participants. Findings indicate a need for cautious interpretation of embedded PVTs with underrepresented groups. Adjustments to embedded PVT cutoffs may need to be considered to improve diagnostic accuracy.

Rehabilitation Strategies for Cognitive and Neuropsychiatric Manifestations of COVID-19.

Purpose of Review: Extrapulmonary manifestations of COVID-19 are abundant, including after recovery of acute SARS-CoV-2 infection. This review seeks to explore the cognitive and neuropsychiatric manifestations of COVID-19 and post-acute sequelae of SARS-CoV-2 (PASC), including Long COVID syndromes. Furthermore, the review will discuss rehabilitation strategies for the emerging neurological consequences of COVID-19 to help those experiencing long-term effects of COVID-19. Recent Findings: There is emerging evidence depicting the neural involvement of COVID-19. Health priorities have shifted from understanding pathogenesis and treatment of pulmonary symptoms to targeting the acute and chronic sequelae of COVID-19, including cognitive and neuropsychiatric symptoms. The sequelae of COVID-19 often co-occur with other medical problems and is best managed by assessment and care across multiple disciplines. Symptoms following infection are similar to those found by other syndromes and disorders that disrupt the central nervous system. Summary: The acute and chronic sequelae of COVID-19 have become major targets of current health care providers given its significant public health impact, inclusive of cognitive and neuropsychiatric sequelae. Assessment and referral to rehabilitation based on each individual's needs and symptoms can decrease morbidity and improve quality of life.

Comparing Boston naming test short forms in a rehabilitation sample.

The Boston Naming Test (BNT) has multiple short forms that do not include the noose item that have been primarily examined in dementia populations. This study compared BNT short forms with standard administration (BNT-S) in physical medicine and rehabilitation patients who underwent outpatient evaluation. The sample (N = 480) was 34% female and 91% white with average age of 46 years (SD = 15) and average education of 14 years (SD = 3). Five 15-item short forms were calculated: Consortium to Establish a Registry for Alzheimer's disease (CERAD-15); Lansing; and Mack 1, 2, and 4 (Mack-15.1, -15.2). Three 30-item short forms were calculated: Mack A, Saxon A, and BNT odd items. BNT-S and short forms were compared with Spearman correlations. Cronbach's alpha was calculated for all BNT forms. Impaired BNT scores were determined with norm-referenced scores (T < 36 and T < 40). Area under the curve (AUC) values were compared across short forms with impaired BNT as criterion. BNT-S showed strong correlations with 30-item (rho = 0.92-0.93) and 15-item short forms (rho = 0.80-0.87) except for CERAD-15 (rho = 0.69). Internal consistency was acceptable for all short forms (alpha = 0.72-0.86). BNT-S was impaired in 17% and 33% of participants at 35 T and 39 T cutoffs, respectively. BNT short forms showed excellent to outstanding classification accuracy predicting impairment using both cutoffs. BNT short forms warrant further study in rehabilitation settings.

Psychometric Equivalence of Standard and Prorated Boston Naming Test Scores.

This study compared prorated Boston Naming Test (BNT-P; omitting the noose item) and standard administration (BNT-S) scores in physical medicine and rehabilitation patients (N = 480). The sample was 34% female and 91% White with average age and education of 46 (SD = 15) and 14 (SD = 3) years, respectively. BNT-P was calculated by summing correct responses excluding item 48 and estimating the 60-item score with cross multiplication and division. BNT-P and BNT-S scores were compared via concordance correlation (CC) coefficients; reflected and log transformed data were examined with equivalence tests. BNT-P and BNT-S scores showed almost perfect agreement (CC = .99). Transformed scores demonstrated equivalence (±1.1 points). Raw and scaled score differences were 0 in 88% and 96% of cases, respectively. Race and ethnicity accounted for item 48 outcomes while controlling for age and education. Findings support the utility of prorated BNT scores in rehabilitation patients.

Estimating Premorbid Ability in Rehabilitation Patients Using the Test of Premorbid Functioning and Wide Range Achievement Test-Fourth Edition.

Objective: This study examined premorbid ability estimate concordance using Test of Premorbid Functioning predicted Full Scale Intelligent Quotient (TOPF-IQ) and Wide Range Achievement Test-Fourth Edition Word Reading (WRAT4-WR). Method: The sample (N = 145) was 28% female with average age and education of 40.6 and 13.2 years, respectively. Outpatient neuropsychological evaluations were conducted in a rehabilitation setting. Measures included the TOPF, WRAT4-WR, Wechsler Adult Intelligence Scale-Fourth Edition, and other neuropsychological tests. Non-WAIS measures defined impairment groups. Analyses included t tests, pairwise correlations, concordance correlation coefficients, and root mean square differences. Results: TOPF-IQ, WRAT4-WR, and Full Scale Intelligent Quotient scores were not significantly different but were lower than normative mean. TOPF-IQ and WRAT4-WR showed acceptable agreement (concordance correlation coefficient = .92; root mean square difference = 5.9). Greater premorbid-current ability differences were observed in the impaired group. TOPF-IQ and WRAT4-WR showed lower but similar agreement with Full Scale Intelligence Quotient in the unimpaired group. Conclusions: Findings support the WRAT4-WR in predicting premorbid ability in rehabilitation settings.

Examining the Cognitive Proficiency Index in rehabilitation patients.

This study examined the Wechsler Adult Intelligence Scale-Fourth Edition (WAIS-IV) Cognitive Proficiency Index (CPI) in relation to other WAIS-IV indices, overall test battery mean (OTBM), and impairment (IMP) in an outpatient rehabilitation setting. Participants (N = 329) were 35% female and 88% Caucasian with average age and education of 42.9 (SD = 13.5) and 13.6 (SD = 2.4) years, respectively. Participants were grouped by diagnosis and validity: traumatic brain injury (TBI; n = 176; 39% mild), cerebrovascular accident (CVA; n = 52), other neurologic and psychiatric conditions (OTH; n = 49), and questionable performance validity (QPV; n = 52). OTBM was calculated from non-WAIS-IV tests; IMP was dichotomously defined as four or more non-WAIS-IV scores below cutoff (≤35 T). Significant group differences were observed on CPI, WAIS-IV indices, OTBM, and IMP. CPI significantly contributed (ß = .51) to a linear regression model predicting OTBM (R2 = .63) with education and GAI as covariates. A logistic regression model with IMP as the outcome and education, GAI, and CPI as predictors correctly classified 80% of cases with area under the curve of .86. A previously identified cutoff (CPI < 84) correctly classified 65-78% of clinical groups categorized by IMP. A novel cutoff (CPI ≤ 80) differentiated clinical participants with history of mild TBI from the QPV group with sensitivity of 44.2% and specificity of 89.7%. CPI showed incremental validity in predicting OTBM and IMP and warrants further study as a useful clinical addition to other WAIS-IV indices.

Finger Tapping: Why Can't We Alternate Hands?

The purpose of this research was to determine if there is any need, as per the Halstead-Reitan instructions, to test each hand uninterruptedly on the Finger Oscillation Test (FoT). To the authors' knowledge, there is no widely available research addressing this issue. Enabling administration of the FoT using alternate hands would theoretically make the administration of the assessment more efficient. In this study, participants consisted of 49 graduate students. All were administered the FoT with standard instructions and using an alternating-hands method. The order of administration was counterbalanced to avoid practice effects, and subjects completed distractor tasks between administrations. Results indicated there was a difference between the two administration methods for both dominant, t(47) = -4.09, p < .001, and nondominant, t(48) = -4.17, p < .001, hands. Surprisingly, mean T-scores were significantly higher for both the dominant and nondominant hands in the alternative administration group when compared with the standard method score (50 vs. 44 and 51 vs. 44, respectively). The standard deviations for both hands were also lower using the alternative method. This study highlights the need for neuropsychologists to be aware of the established administration protocols for tests and to carefully consider how deviations from these methods could affect test scores.