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Point-of-care tests in behavioral health

April 1, 2006
by William M. Glazer, MD
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Glucose monitoring and a new lithium test can provide instant results to patients and clinicians

Lithium is underused for at least two reasons: (1) Because lithium is not a brand-name drug, it does not generate high revenues for pharmaceutical companies and is consequently downplayed in educational programs sponsored by industry, and (2) it has the monitoring burden mentioned above. Lithium levels are monitored for three reasons: first, to prevent or recognize side effects, such as tremor, nausea, diarrhea, and confusion, all signs of lithium toxicity; second, to ensure ongoing efficacy and effectiveness, including the prevention of suicidal behavior; and, third, to help ensure patient adherence to the prescribed regimen.

Not only does the burden of lithium monitoring probably contribute to underuse of lithium, it also explains the observed underuse of therapeutic monitoring of patients taking lithium in clinical settings. One study of more than 700 patients from a Medicaid database revealed that a substantial proportion of bipolar patients prescribed lithium (36.5%), valproate (42.4%), and carbamazepine (42.2%) did not receive therapeutic drug-level testing during the 12-month study.11 Product labeling for lithium products indicates that stable patients should have their lithium levels checked every two months.

Recently, the FDA approved an instant POC test for lithium blood levels.12–14 The test requires a finger-stick blood sample, which is placed in a reader that reports the blood level in less than two minutes. This new technology offers a benefit to clinicians and patients—instant feedback. By eliminating the need for laboratory testing, clinicians will be able to balance the patient's therapeutic response with possible toxicity at the time of contact. During the visit, the clinician will be able to manage a patient's response to therapy and make adjustments to the patient's dosage level, according to his/her metabolism. Such an individualized response raises the bar for quality of care.


Table 1. The burden of lithium monitoring

To the patient

  • Travel and waiting time

  • Expense

  • Anxiety while waiting for results

To the prescriber

  • Ordering

  • Ensuring patient follow-through for venipuncture

  • Uncertainty of sample timing

  • Communicating with the central laboratory

  • Experiencing errors related to lag time

  • Charting the results


Table 2. Codes used when seeking reimbursement for lithium testing

Code type

Code

Description

ICD-9

296.00

Manic Disorder

CPT

90862

E&M of established patient

CPT

80178QW

Lithium assay

CPT

36416

Collection of capillary blood specimen

Removing the lag time between blood sampling and test results leads to fewer lost results and, consequently, reduced risk for error. It is worth recalling at this point that the Institute of Medicine reported 98,000 deaths occurring annually in U.S. hospitals as a result of preventable medical errors.15 Moreover, a recent international survey supported by The Commonwealth Fund found that one-third of U.S. patients with health problems reported experiencing medical mistakes, medication errors, or inaccurate or delayed lab results, the highest rate of any of the six nations surveyed.16

With in-office lithium testing clinicians can proactively confirm patient adherence to therapy. Problems with lithium adherence are no different than with any other drug, which means that a substantial number of patients are not following the prescription as written.5 Discussing adherence with patients can be awkward because it can mean confronting them about their choice to not follow the prescribers’ recommendations, but when the numbers are right in front of the clinician and the patient, it is easier to initiate a productive dialogue that empowers the therapeutic alliance. More importantly, with instant feedback, an opportunity exists to offer the patient positive reinforcement—a distinct advance in the practice of behavioral healthcare.

Reimbursement

The sale of CLIA-waived devices to the practitioner alters the traditional reimbursement pattern for monitoring blood sugar or lithium levels: That is, it shifts the payment from the laboratory to the practitioner or the consumer. In the case of the lithium test, plans and insurance companies need to understand that behavioral healthcare providers will submit CPT code 80178QW for reimbursement for measuring lithium levels. Note that the “QW” modifier after this CPT code indicates that the test has been CLIA-waived. Practitioners also will be able to bill CPT code 36416 for the collection of capillary blood. This shift in the reimbursement pattern means that certain plans (e.g., in capitated systems) will have to reorganize their reimbursement procedures if they have designated a line of funds to go to laboratories, not prescribers.

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