One of the benefits of using the T.O.V.A.™ is direct, free access to on-staff PhDs and MDs that can help you understand and contextualize T.O.V.A. results. You can contact our clinical support staff by:
- Phone: We're available Monday - Friday, 8:30am - 5:00pm PST at 800.PAY.ATTN (800.729.2886 or 562.594.7700) extension 14.
- Email: support@tovatest.com
Manuals and Guides
- Clinical Manual (PDF format, 2.4 MB) - the guide to using the T.O.V.A. in a clinical setting
- Screening Manual (PDF format, 2.0 MB) - the guide to using the T.O.V.A. in a non-clinical setting
- T.O.V.A. Professional Manual (PDF format, 2.1 MB) - the neuropsychological details of the T.O.V.A. test
- A Guide to Clinical Interpretation of the Test of Variables of Attention (T.O.V.A.) is available for download.
Medical Billing Codes and the T.O.V.A.
Medical billing has not gotten easier in recent years, and some T.O.V.A. users have questions about how they can ensure third-party reimbursement for using the T.O.V.A. Billing practices vary widely from region to region in the US, and even across third party payers. While there is no substitute for a consultation with a competent coding expert, here are some guidelines that you might find useful.
Billing Time: When calculating how much time is spent using the T.O.V.A., we recommend that you report time as accurately as possible by tracking the amount of time spent for each component of a visit. This includes patient and/or caregiver interview, test administration, test interpretation, and report writing. Psychological testing codes normally require rounding up or down at the 30 minute mark. That is, testing of less than 30 minutes duration may not be separately reimbursable, but may be “bundled” into other services provided during a visit. Testing that requires greater than 30 minutes should be rounded to the next full unit (hour).
The T.O.V.A. typically requires about 40-50 minutes for administration, interpretation to patients and/or caregivers, and documentation, and most T.O.V.A. users bill one unit of time (one hour) for these services.
Billing Codes: For psychological and neuropsychological testing, medical providers utilize the same billing codes that are used by psychologists. In addition, physicians are able to utilize E/M codes. If you cannot work out reimbursement for the T.O.V.A. from a specific third party payer, you should be able to subsume T.O.V.A. administration and interpretation in an E/M code for an office visit. However, in general, you should be able to utilize any one of several common CPT codes.
What to know more? Click here for additional information and possible billing codes that may work for you.
Frequently Asked Questions (F.A.Q.)
The ADHD Score
There are two summary statements in the T.O.V.A. Interpretation Report, Form 1:
The first summary statement is the Interpretation results and is derived by comparing results to to a sample of age and gender matched individuals without ADHD. It states whether the subject’s performance is “within normal limits” or is “significantly deviant from the norm and compatible with an attention disorder, including ADHD.”
The second summary statement is the ADHD Score result and is derived by comparing results to a sample of age and gender matched individuals with ADHD. It states whether the ADHD Score is “significantly deviant1 from the norm” or is “inconclusive.” A “significantly deviant” ADHD Score is compatible with an attention disorder. An “inconclusive” ADHD Score is not clinically significant and is disregarded.
A significantly deviant ADHD Score is -1.80 or more negative. Thus, -1.80 and -1.89 would be labeled “deviant”, and -1.78 would not be labeled “deviant”.
If both the Interpretation and the ADHD Score are “deviant from the norm”, the protocol is considered abnormal and compatible with an attention disorder.
If either one is “deviant from the norm”, and the other is within normal limits, the protocol is considered abnormal and compatible with an attention disorder.
If neither one is “deviant from the norm”, the protocol is considered within normal limits and not compatible with an attention disorder. That doesn’t mean that the person doesn’t have an attention disorder- it only means that the T.O.V.A. protocol was normal.
Anticipatory Responses
An AR occurs whenever a response (button press) is made between 150 milliseconds (ms) before and 150 ms after any stimulus (target or nontarget) appears or, in the case of T.O.V.A.-A, any stimulus is heard.
We know from the norming studies that most teenagers and adults need more than 150 ms after a stimulus appears or is heard to distinguish between a target and a nontarget . Any response before then would be a guess or an attempt to "kill" the stimulus as soon as possible.
Parenthetically, in T.O.V.A. versions before the 7.1, we allowed 200 ms for ARs, but found that processing speeds are actually decreasing over the past few years, perhaps as a result of CNS stimulation by playing computer games. (This is a good example of the value of continued norming studies and upgrading the T.O.V.A.s as new information becomes available.)
When a person makes many random ARs, all of the T.O.V.A. variables are affected and can be significantly changed. Omissions Errors (inattention) tend to decrease, Commissions Errors (impulsivity) increase, Response Times shorten (become faster), and Response Time Variability can increase or decrease. The more frequent the ARs, the greater the four variables change. When ARs become too frequent, the four variables change so much that they become unreliable and can become invalid. (This also true when there are excessive Commission Errors.)
We've had cases in which even though the person had ADHD, the excessive ARs affected the four variables so much that they fell into normal limits, and the test would have been incorrectly interpreted as normal. If a person with ADHD could inhibit "quick trigger" responses during a subsequent test, the excessive ARs drop out, and the other variables usually become abnormal.
We also have had non ADHD cases in which the reverse happened- the excessive ARs affected the variables enough to make the results abnormal which would have been incorrectly interpreted as suggestive of ADHD.
To minimize what would be incorrect interpretations, the T.O.V.A. Interpretation Report labels the variables in any quarter with excessive ARs as “invalid” even though all of the variables are scored and recorded. That's why the variables are encased in brackets ([ ]) in Form 3 to indicate that they must be interpreted cautiously since they may be invalid when the ARs equal or exceed 10% in any quarter of the test. When this happens, the variables in that quarter are not included in the Interpretation (Form 1).
Excessive ARs are usually but not always abnormal (see the next paragraph) and are often a symptom of ADHD. They are thought to be the result of two conditions: 1) Some individuals are oppositional and convert the instructions (to balance speed and accuracy) to a game strategy in which they try to "kill" the stimulus as soon as possible, sometimes even before it occurs; and 2) some individuals just can't restrain ("inhibit") themselves, and speed takes precedence over accuracy. Often the observer can determine which condition explains a particular result. Having someone who can't control their responses take the test again often doesn't change the situation. They can't do it correctly until they're being treated.
While I don't want to confuse you (any further), it now turns out that there is a third reason why some people have excessive ARs. Some people are much, much faster than the norm. They are so fast that they can accurately respond to the targets in less than the usual 150 ms, avoiding the nontargets. Thus, when you examine the ratio of target to nontarget ARs in Form 5, you'll find that these people have very few nontarget ARs. Most if not all of their ARs are with targets. Since the presentation of stimuli is randomized, they can't be guessing. They are really processing the information and responding significantly faster than the norm.
As you might guess, experienced computer game players and athletes can perform so well that their correct responses can fall into the AR range, and their test results are labeled as invalid by the current interpretation program because of the excessive ARs. Similarly, musicians, including drummers, can "beat" the auditory T.O.V.A. (We assume that there are others, as well.)
Recognizing that some tests with excessive ARs should not be invalidated, we recommend that when there are excessive ARs that the clinician examine the target : nontarget ratio for ARs, and not invalidate those quarters in which the ratio is equal to or better than 1 target : 3.5 nontargets in quarters 1 and 2 or equal to or better than 3.5 targets : 1 nontarget in quarters 3 and 4.
Let's look at the performance of a 49 year old man to illustrate how to handle excessive ARs. Please note that this is the auditory version, T.O.V.A.-A.
Because of the excessive Anticipatory Responses (>10%/quarter) in quarters 3 (10.49%) and 4 (22.22%), all of the variables in these quarters would be labeled as invalid. However, we can disregard the [ ] when the AR target : nontarget ratio >1:3.5 in quarters 1 and 2 and >3.5:1 in quarters 3 and 4. The AR ratios in this illustration are 16:1, and 35:1 in quarters 3 and 4, respectively. Since the AR ratios are larger than the guidelines in both quarters, we consider them as valid.
Fortunately, the T.O.V.A. Interpretation Report for version 8 is being written to identify only the abnormal quarters as “invalid”.
The AR correction factor is a good example of how we are learning more and more about the T.O.V.A. and incorporating the new information in subsequent versions of the test. Call us for information on the latest version available.