CNS Guidelines for Practice
Membership in the Colorado Neuropsychological Society (CNS) commits members to conform to the American Psychological Association’s (APA) ethical guidelines and code of conduct and to the Colorado Psychological Association’s (CPA) guidelines. Psychologists involved in neuropsychological practice, whether or not they are members of APA, CPA or CNS, are required to abide by these codes and guidelines. These ethical principles provide guidelines pertaining to such areas as: welfare of the public, patient and consumer; representation of professional competencies; protection of testing materials; clinical supervision; confidentiality and privacy; marketing of professional skills; public statements; research guidelines; and forensic activities.
In the process of making decisions regarding professional behavior, neuropsychologists must be knowledgeable and should consult the various sources of information about standards of practice and ethical behavior. Several documents are provided by the APA that are of educative value to neuropsychologists, courts and other professional bodies. These documents include Ape’s Ethical Principles and Code of Conduct (2002); General Guidelines for Providers of Psychological Services (1987); Specialty Guidelines for the Delivery of Services by Clinical Psychologists, Counseling Psychologists, Industrial/Organizational Psychologists and School Psychologists (1981); Guidelines for Computer Based Tests and Interpretations (1987); Standards For Educational and Psychological Testing (1985); Guidelines for Providers of Psychological Services to Ethnic, Linguistic and Culturally Diverse Populations (1990); and American Psychology – Law Society Specialty Guidelines for Forensic Psychologists (1991). Other materials include general publications of APA Division 41 (Forensic Psychology) and APA Division 40 (Division of Neuropsychology).
When neither law nor codes of ethics help to resolve an issue, the neuropsychologist should consider other professional materials, the dictates of his/her own conscience, and seek consultation with others within his/her own professional field. These Guidelines for Practice, as revised by CNS (2003), were born out of the spirit of ethical concern for our profession and for assisting fellow psychologists in applying ethical principles to the complexities of the practice of neuropsychology.
This paper is intended to define, clarify and guide resolution of issues germane to the practice of neuropsychology in the state of Colorado.
Definition of a Neuropsychologist
Our definition of a neuropsychologist derives from the definition developed by the Joint Task Force of APA Division 40 and the National Academy of Neuropsychology on current procedural terminology in neuropsychology. This definition has been approved by the American Medical Association (AMA) Panel for Physicians; Current Procedural Terminology. The approved definition requires a neuropsychologist to meet the minimal criteria for eligibility to apply for diplomate status from either the American Board of Clinical Neuropsychology (ABCN) or the American Board of Professional Neuropsychology (ABPN). For the accepted definition of a clinical neuropsychologist, see Appendix A.
Beyond the education and training to meet the definition of a neuropsychologist, continuing education is highly recommended in order to update and maintain one’s previously established competency in the areas of neuropsychological assessment, psychopathology and the neurosciences. CEUs do not, however, take the place of university training in the basics of neuropsychology, but rather are intended to broaden the scope of established skills and competencies.
Neuropsychological assessments may include, entirely or in part, a clinical interview, neuropsychological testing and evaluation, psychological testing and evaluation, and examination of relevant available records and historical documents. Assessments may be requested by various parties including: other health care providers; the judicial system; and/or third party payors such as private insurers, attorneys, employers, and governmental agencies such as the Department of Social Services, Workers’ Compensation, Medicare and Medicaid. Assessments performed upon the request of third party payors are referred to as ‘third party assessments’ or ‘independent medical examinations’ (IME’s). The neuropsychologist takes appropriate action to ensure adherence to the guidelines set forth below irrespective of the nature of the assessment or the referral source. In cases of conflicting demands, the neurpsychologist makes known his/her commitment to the above noted ethical codes and resolves the conflict in a responsible manner.
The neuropsychologist accepts referrals for assessments only in areas in which the neuropsychologist is competent to practice independently.
The neuropsychologist’s role is diagnostic, consultative, therapeutic and educative in nature. The application of these roles should depend upon the specific circumstances of each case.
The neuropsychologist should have no vested interest in the outcome of an assessment. His/her ultimate responsibility is to provide an objective assessment that is free of bias from outside interests or pressures.
The neuropsychologist has a duty of care towards the client or patient and recognizes part of that duty is to perform in a competent and professional manner at all times and to protect the interests and well being of the patient. (For continuity of care, it is advisable that the treating neuropsychologist provide for ongoing assessments to monitor the patient’s response to rehabilitation efforts. The treating neuropsychologist should also consider consultation with another qualified neuropsychologist when appropriate.)
The neuropsychologist makes explicit to the patient the neuropsychologist’s role, relationship to the referral source, and the purposes of the evaluation. He/she has the responsibility to inform the patient of the limits and bounds of confidentiality.
Independent neuropsychologist examiners avoid providing treatment to the patient during the assessment.
The neuropsychologist reviews available records and historical documents that pertain to the patient’s past and present functioning when feasible. The neuropsychologist accurately reports collateral information and incorporates relevant historical facts into the evaluation.
If a neuropsychologist suspects misuse or misrepresentation of his or her work, he/she takes action to correct the situation and to inform appropriate parties.
The neuropsychologist must be sensitive to test-retest practice effects and plan his/her evaluation accordingly. As deemed appropriate by the evaluating neuropsychologist, this planning might include such activities as consultation with the treating caregiver(s) regarding prior testing procedures employed with the patient, the use of standardized alternate test forms, obtaining original raw test data, or postponing testing until a later date. The neuropsychologist is sensitive to the effect that exposure to certain test materials may have on the patient’s treatment plan or subsequent evaluation.
The neuropsychologist takes appropriate precautions not to compromise the welfare of the patient or the security of test procedures with regard to allowing the observation or recording of neuropsychological assessments. Except when clinically indicated (i.e., need for an interpreter, acute/emergency conditions that require the presence of a significant other in order to ensure the patient’s welfare, etc.), allowing observation by outside parties, or recording of any protected test items and procedures is to be avoided.
Opinions regarding diagnosis and treatment (i.e., appropriateness, duration, intensity, etc.) are offered only in areas in which the neuropsychologist has specific expertise by virtue of training and/or experience. The neuropsychologist has an obligation to disclose to the referral source the limits and areas of his/her clinical expertise. Expertise is demonstrated by documentable evidence of training and/or experience.
Except in instances in which it is expressly prohibited by contract or agreement with the referral source or otherwise prohibited, the neuropsychologist makes available explanations of results to the patient and/or authorized representative. Written and/or oral reports should present information germane to the purpose of the inquiry and should be in descriptive language that is reasonably understandable to the recipient(s).
The neuropsychologist takes appropriate steps and measures to maintain the integrity and security of tests and assessment procedures. The release of neuropsychological test data and/or test protocols should be limited to a licensed psychologist. Except in instances in which it is expressly prohibited by contract or agreement with the referral source, the examining neuropsychologist should provide summary reports to treating professionals upon request and with proper authorization.
Use of Nondoctoral Personnel
CNS supports the Division 40 ‘Guidelines Regarding the Use of Nondoctoral Personnel in Clinical Neuropsychological Assessment’ (The Clinical Neuropsychologist, 1989, Vol.3, No. 1, pp. 23-24). The use of nondoctoral personnel (technicians, psychometrists, psychometricians, psychological assistants, etc.) is a common and accepted practice when the supervising neuropsychologist maintains and monitors high standards of quality assurance.
Third Party Payment Issues
When a neuropsychologist agrees to provide services to a patient where a third party payor is involved, the roles and responsibilities of the neuropsychologist, the patient and the third party payor should be clarified with the patient prior to beginning any evaluation or treatment. The neuropsychologist clarifies to the patient and to the third party payor his/her roles and responsibilities regarding payment for services, billing procedures and collection procedures in case of delinquent payment.
The neuropsychologist should set his/her fees on the basis of a consistent and coherent system reflective of both local and industry-wide standards for usual and customary fees. For identification of neuropsychological services in billing procedures, the neuropsychologist should use the physician’s Current Procedural Terminology, (CPT) and guidance from CNS.
Neuropsychologists who provide opinions regarding the reasonableness and necessity of another neuropsychologist’s services, and/or the appropriateness of usual and customary fees, should do so only in areas consistent with their knowledge, training and/or experience, as well as appropriate utilization review criteria and relevant fee schedule surveys.
Managed Health Care Issues
The ultimate responsibility of the neuropsychologist contracting with a managed health care organization is to provide appropriate treatment services to the patient consistent with community and national standards of care. The neuropsychologist should practice in accordance with APA’s Ethical Principles and Code of Conduct (2002); General Guidelines for Providers of Psychological Serves (1987); Specialty Guidelines for the Delivery of Services by Clinical Psychologists, Counseling Psychologists, Industrial/Organizational Psychologists and School Psychologists (1981); Guidelines for Computer Based Tests and Interpretations (1987); Standards For Educational and Psychological Testing (1985); Guidelines for Providers of Psychological Services to Ethnic, Linguistic and Culturally Diverse Populations (1990); and American Psychology-Law Society Specialty Guidelines for Forensic Psychologists (1991). Other materials include general publications of APA Division 41 (Forensic Psychology) and APA Division 40 (Division of Neuropsychology). This should assist in ensuring a unique and interdependent relationship between standards of reasonable and necessary care and quality of care provided to patients. The test of an appropriate balance among competing influences should be an appropriate level of clinical efficiency and efficacy that does not sacrifice qualities of necessary and reasonable treatment to arbitrary cost ceilings or cost containment objectives.
The neuropsychologist should be sensitive to special managed health care concerns regarding supervisory responsibility for services provided by employees and other staff members. The neuropsychologist should delegate only those responsibilities that supervisees or employees can perform competently.
The neuropsychologist should accurately document professional work and report to third party payors or case managers relevant information regarding findings, diagnosis and recommendations. Evaluation results are explained to patients, case managers and third party payors in language that is reasonably understandable to all recipients.
The neuropsychologist should maintain the integrity and the security of tests and assessment procedures. Because of the sensitive nature of raw test data and original test protocols, these documents are shared only with other qualified licensed psychologists despite demands for access by third party payors unless court ordered.
Revised by the Colorado Neuropsychological Society May 30, 2003.
Appendix A – Definition of a Neuropsychologist
(This 2001 definition, which is the official statement of the National Academy of Neuropsychology, expands upon and modifies the 1989 definition by Division 40 of the APA, which was used as the foundation for this updated document.)
A clinical neuropsychologist is a professional within the field of psychology with special expertise in the applied science of brain-behavior relationships. Clinical neuropsychologists use this knowledge in the assessment, diagnosis, treatment, and/or rehabilitation of patients across the lifespan with neurological, medical, neurodevelopmental and psychiatric conditions, as well as other cognitive and learning disorders. The clinical neuropsychologist uses psychological, neurological, cognitive, behavioral, and physiological principles, techniques and tests to evaluate patients’ neurocognitive, behavioral, and emotional strengths and weaknesses and their relationship to normal and abnormal central nervous system functioning. The clinical neuropsychologist uses this information and information provided by other medical/healthcare providers to identify and diagnose neurobehavioral disorders, and plan and implement intervention strategies. The specialty of clinical neuropsychology is recognized by the American Psychological Association and the Canadian Psychological Association. Clinical neuropsychologists are independent practitioners (healthcare providers) of clinical neuropsychology and psychology. The clinical neuropsychologist (minimal criteria) has:
A doctoral degree in psychololgy from an accredited university training program.
An internship, or its equivalent, in a clinically relevant area of professional psychology.
The equivalent of two (fulltime) years of experience and specialized training, at least one of which is at the post-doctoral level, in the study and practice of clinical neuropsychology and related neurosciences. These two years include supervision by a clinical neuropsychologist.
A license in his or her state or province to practice psychology and/or clinical neuropsychology independently, or is employed as a neuropsychologist by an exempt agency.
At present, board certification is not required for practice in clinical neurpsychology. Board certification (through formal credential verification, written and oral examination, and peer review) in the specialty of clinical neuropsychology is further evidence of the above advanced training, supervision, and applied fund of knowledge in clinical neuropsychology.
(Individuals receiving training in clinical neuropsychology prior to this (2001) definition should be subject to the educational and experiential guidelines published by Division 40 of the American Psychological Association (APA, 1984; 1989). The current definition should not be interpreted as negating the credentials of individuals whose education and experience predates the Division 40-APA definitions. Individuals meeting these prior criteria are and continue to be clinical neuropsychologists under this current definition.
Report of the Division 40/INS Joint Task Force on Education, Accreditation and Credentialing (1984). Division 40 Newsletter, 2(2), pp. 3-8.
Definition of a Clinical Neuropsychologist, 1989. The Clinical Neuropsychologist 3(1), pp. 22.