Implementing the AAP's new policy on developmental and behavioral screening

How you can implement the AAP's new policy on developmental and behavioral screening By Frances Page Glascoe, PhD, and Michelle M. Macias, MD The American Academy of Pediatrics has recommended giving a developmental screening test at each well-child visit. Is this a realistic expectation? Yes, say the authors. Here's how to meet it. In July 2001, the American Academy of Pediatrics' Committee on Children with Disabilities issued an updated policy statement that recommended routine administration of a validated, accurate developmental screening test at each well-child visit. Can this recommendation actually work in a busy practice? Yes! In this article, we explain how developmental screening can be done within the time constraints of primary practice and why such screening improves the care you give. We also describe methods for ensuring adequate reimbursement. Why routine screening? Accurate, early detection of developmental problems is necessary for a number of reasons: Research on early brain development has revealed the limited window of malleability of the developing brain, highlighting the need to identify and address emerging problems during preschool years.1 Reauthorization of the Individuals with Disabilities Education Act (IDEA) mandates and expands intervention services for young children and their families. For further information and links to services, see the National Early Childhood Technical Assistance Center Web site: http://www.nectas.unc.edu . Studies of early intervention reveal immediate and long-term benefit to patients, including better intellectual, social, and adaptive behavior; increased high school graduation and employment rates; and decreased criminality and teen pregnancy.2,3 A recent national survey of parents with young children, conducted by the Commonwealth Fund, showed that fewer than half of families receive developmental screening, promotion, and counseling from their primary care provider. Not only do parents want these services, they are willing to pay extra for them.4 Families who receive developmental services from their pediatrician are more satisfied with care and more likely to demonstrate positive parenting practices, including appropriate disciplinary techniques.5 Despite pediatricians' enthusiasm for early intervention, most use either informal methods (such as checklists or clinical observation), which have unproven sensitivity and specificity, or screening tests that are too long for primary care. The latter result in screening the symptomatic rather than the asymptomatic child (which is especially troubling given the subtleties of early developmental and behavioral problems) and administering screens selectively instead of to all patients.6 Well-normed and validated parent questionnaires are more accurate than directly administered screening tests given in a nonstandardized manner. As a consequence of prevailing screening practices, fewer than 30% of children with a developmental or behavioral problem are detected and referred before they enter kindergarteneliminating all hope for early intervention and contributing significantly to school failure and disenfranchisement.7,8 Twenty-eight states have been the targets of class-action lawsuits against Medicaid's Early Periodic Screening Diagnosis and Treatment (EPSDT), largely for failures in the delivery of developmental/behavioral screening and referral. Many states (including North Carolina, Tennessee, and Louisiana) have responded with physician training, prescribed menus of acceptable tools, mandated screening in primary care, and improved Medicaid reimbursement for screening and referral services. For more information on the lawsuits, see the following Web site: http://www.nhelp.org/pubs/child1999EPSDTdocket.html Parental report: An effective tool for primary care In addition to embracing the issues listed above, the AAP's new statement on developmental screening includes this comment: The science of developmental testing has improved in the last 10 years, making it easier for the pediatrician to accurately and efficiently screen development. Parental report of skills and concern had been considered too inaccurate to be used as a screening tool alone. However, several studies have shown that parental report of current skills is predictive of developmental delay. This has led to the development of parental report instruments that have been well tested in economically and culturally diverse populations and provide accurate information about development.9 This article focuses on parental report screening tools for developmental and behavioral issues (primary level screening) because they are easier than other measures for pediatricians to use. They can be administered to parents in the waiting room, sent home with appointment reminders, or conducted by telephone or during an in-office interview (thus circumventing obstacles such as behavioral noncompliance, illness, and sleepiness). Using a parental report tool reduces the time the physician and staff would otherwise spend administering a screening test or getting children to demonstrate skills, thereby ensuring that all children can be screened. The time saved also frees the physician to concentrate on more important tasks of developmental promotion, anticipatory guidance, and marshaling community resources. In this age of time constraints and cost containment, parental report tools can be the most accurate and the most time- and cost-efficient method of developmental and behavioral screening. Quality parental report screens Several parental report tools are known to be workable in primary care. All meet standards for screening test accuracy, with sensitivity and specificity of at least 70% to 80%. The following descriptions consider the pros and cons of each tool and material and administrative costs, which are based on the reading level of the tool, the expected percentage of patients who may not be able to read and respond independently, and the costs of professional time required for interviewing and scoring. We have excluded tools such as the Denver Prescreening Developmental Questionnaire (PDQ), a parent report screen drawn from the Denver-II assessment tool, because such screens lack validation and proof of accuracy.10 Parents' Evaluations of Developmental Status (PEDS). (1997; Ellsworth & Vandermeer Press, Ltd., PO Box 68164, Nashville, TN 37206; Phone: 615-226-4460; fax: 615-227-0411; http://www.pedstest.com ) Designed to screen children from birth through 8 years of age, PEDS comprises 10 questions that elicit parents' concerns about development and behavior. It assigns risk levels and determines when to refer, provide a second screen, and provide patient education, reassurance, or vigilant monitoring of development, behavior and mental health, and academic progress. The PEDS is written at the fifth-grade level and is available in English, Spanish, and Vietnamese. Parents can complete the tool in about five minutes; scoring takes one or two minutes. A longitudinal score and interpretation form remains in each patient's chart to ensure adequate documentation for billing. Material costs are $30 for two pads (50 sheets each), one with test forms and one with scoring forms; the per-visit material cost is less than 25 cents. Costs for scoring the test and administering 8% of the screens by interview brings the total expense to about $1.19 per patient. One of the benefits of PEDS is that it elicits parents' concerns rather than requiring them to note which skills a child has or doesn't have. This simplifies interpretation of results because parents' concerns are easily affirmed. PEDS reduces "Oh, by the way" concerns and strengthens physician confidence in decision-making because decision support is built into the tool. Some providers worry that parents with limited education or parenting experience will have difficulty describing their concerns, perhaps because such parents are known to be less likely to raise concerns spontaneously. Considerable research shows that PEDS assesses the concerns of these parents as accurately as those of parents with higher socioeconomic status and that PEDS helps all parents not only express concerns but also recognize that developmental topics are a part of primary care (for a list of published research, see www.pedstest.com ). Another concern about PEDS is that its emphasis on parents' concerns rather than developmental milestones will dissuade parents (and residents) from learning about child development. In fact, PEDS helps parents and professionals think about development as a range of domains because the questions probe all aspects of growth and learning. Even so, physicians also may want to disseminate copies of the AAP's brochure, "Your Child's Growth: Developmental Milestones." Child Development Inventories (CDIs) (1992; Behavior Science Systems, Box 580274, Minneapolis, MN 55458; phone: 612-929-6220) Formerly known as the Minnesota Child Development Inventories, the CDIs are three separate instruments that measure development in children from 3 months to6 years of age (one instrument is for 3 months to 18 months, one for 18 months to 3 years, and one for3 to 6 years). Each comprises 60 yes-no descriptions. The screen for 3 months to 18 months provides cutoff scores for each developmental domain. The other two screens provide a single pass-fail score and cutoff result. Available in English and Spanish, the CDIs are written at the sixth-to-eighth-grade level. Parents can complete them in about 10 minutes; scoring takes about two minutes. The cost of all three CDIs is $65 dollars, and the per-patient materials cost is about 40 cents. The total per-patient cost, including scoring and administering 10% of the screens by interview, is about $3.80. Although the CDIs were initially standardized only in Minnesota, subsequent research supports their use in other parts of the country and with different populations. The manual does not contain information about the instruments' accuracy, but a text by the author (which must be ordered separately) illustrates their applicability, sensitivity, and specificity. The lack of scoring criteria for the items assessing behavioral and mental health issues necessitates using clinical judgment to decide whether referral for behavioral-emotional intervention is needed. Thus it is preferable to use a separate behavioral screen with clear cutoffs for referral in addition to the CDIs. Parents may have to arrive at the office early to complete the form, depending on typical wait times. Ages and Stages Questionnaire (ASQ). (1994; Paul H. Brookes Publishing Co., Inc., PO Box 10624, Baltimore, MD 21285; phone 800-638-3775; http://www.pbrookes.com ). For children 4 months to 6 years of age, the ASQ presents parents with 35 descriptions and clear drawings of developmental tasks to endorse by checking a box to indicate "yes," "sometimes," or "no." Totals are compared to a single cutoff, revealing the presence or absence of developmental delay. A different three- to four-page form is used for each well visit according to the child's age. For children tested between ages specified by the well-visit schedule, two forms are administered: the one below and the one above the child's age. Available in English, Spanish, and French, the ASQ is written at the sixth-to-eighth-grade level. Parents can complete the screen in 10 to 15 minutes, and scoring takes about two minutes. Material costs are $190. Once purchased, the forms can be photocopied, making the material cost per patient 30 to 40 cents (excluding the costs of labor and time away from billing or patient care). Scoring and administering 10% to 15% of screens by interview brings the total per-patient cost to about $4.60. The recently published ASQ-Social Emotional (SE) works the same way as the ASQ and screens for behavioral and emotional problems. Both the ASQ and the ASQ-SE are needed to screen for developmental and behavioral-mental health problems, which essentially doubles the cost and administration time. This suggests that the ASQs may best be used when more detailed information is needed. The use of multiple forms (a different one for each visit) requires administrative organization to ensure the correct version is given to parents. Although the overall reading level is relatively easy, individual items vary from fourth to 12th grade level. This means that more items will need to be administered by interview, increasing professional time devoted to screening. Having parents arrive well in advance of the appointment addresses some of these issues. Pediatric Symptom Checklist. (Jellinek MS, Murphy JM, Robinson J, et al: Pediatric Symptom Checklist: Screening school-age children for academic and psychosocial dysfunction. J Pediatr 1988;112:201; the test is included in the article and can also be downloaded free of charge at http://www.psc.partners.org .) The PSC presents parents of children 4 to 16 years of age with 35 short statements about problem behaviors, including both externalizing (conduct) and internalizing (depression, anxiety, adjustment) behaviors. Ratings of "never," "sometimes," or "often" are assigned a value of 0, 1, or 2 and compared to cutoffs. Factor scores identify attentional, internalizing, externalizing, and academic problems. The PSC is available in English, Spanish, and Chinese and is written at the sixth-to-eighth-grade level. Parents can complete it in about seven minutes. A youth self-report version is also available. Scoring takes two to five minutes. The PSC can be photocopied, making the per-patient cost of materials about 10 cents (excluding labor and time away from billing or patient care). Scoring and administering 10% of the screens by interview brings the total per-patient cost to about $2.48. Recent research on the PSC reveals three distinct factors that assess various aspects of mental health and behavior: internalizing problems (symptoms of depression, anxiety, withdrawal), externalizing problems (conduct, oppositional defiance), and attention problems (symptoms of ADHD). Other studies show that academic and global dysfunction can be predicted by problematic performance on the PSC. Although separate scoring exists for children 4 to 5 years of age (academic items are dropped, and a lower cutoff is used to compensate), some remaining items may not adequately reflect development in young children4- and 5-year-olds do not always understand the concept of stealing, for example. For this reason, the PSC appears best suited to children 6 years to 18 years of age. Guidelines for scoring the three factors can be downloaded at www.pedstest.com . Other options The Web site of the AAP's Section on Developmental Behavioral Pediatrics includes a lengthy article on tools other than those described here that may be useful, depending on variables such as the availability of a nurse practitioner or in-office developmental specialist who can offer more in-depth screening or assessment if needed. The article contains information on measures that are useful for academic screening of older children and includes a measure that assesses family psychosocial issues, such as parental depression, substance abuse, and risk factors. To read the article, go to www.dbpeds.org . What else is needed? To effectively use a screening tool in pediatric practice, physicians must be aware of what community resources are available. Too often, clinicians believe "there is nothing out there." This is rarely the case. Rather, medical providers are not always familiar with local services or how to find them. At the same time, nonmedical providers do not always know how best to work with pediatricians. For example, they may not respond to inquiries and referrals in the same way that subspecialists do (calling with or mailing results, collaborating in decision-making). Following the links listed in the "Where to look for local services and parent education materials" box and, preferably, having someone on your staff get to know local nonmedical providers is advisable. Posting a list of telephone numbers and contacts in each exam room is also helpful. Screening also raises patient education issues. Gather parent handouts and brochures about available resources and programs. Well-organized education materials and referral information help expedite interpretation of results to patients and parents and the referral process. In addition, clinicians need to think carefully about implementing screening. Office staff should inquire routinely whether parents would like to fill out screens on their own or have someone go through the tool with them (to ensure that literacy limitations are not a barrier to screening). Office staff may need background information on the value of screening and will need to maintain supplies and, in some cases, help with scoring. Assistance with implementation issues will be available soon from the AAP at www.dbpeds.org . Coding and billing Quality screening tests cost money, and screening instruments take professional time to implement, score, and interpret, even when they are completed by parents. Billing for developmental or behavioral screening requires both a diagnosis and a procedure code. The procedure code states what was done, and the diagnosis code states why it was done.11 Use of appropriate codes is essential to receive optimal reimbursement and avoid later claim denials arising from incorrect diagnostic codes (when screening results are confirmed by other professionals, for example). First, appropriate diagnostic classification(s) must be made, generally using the International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM).12 By definition, developmental or behavioral screening does not result in a diagnosis but rather a risk category. Accurate diagnoses based on developmental-behavioral screening can be made, however. The Diagnostic and Statistical Manual for Primary Care (DSM-PC)13 was developed to help code developmental and behavioral problems in primary care. The DSM-PC uses pertinent diagnoses consistent with DSM-IV and ICD-9-CM. Table 1 lists some common diagnosis codes. Diagnoses must be as accurate as possible, given the results of screening; so-called up-coding (increasing the severity of the diagnosis) and down-coding (substituting broader symptoms) are considered fraudulent. TABLE 1 Common developmental and behavioral diagnosis codes* *From the International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9R-CM) V codes are symptoms, signs, ill-defined conditions, and supplementary classifications of factors influencing health status. Second, appropriate procedure codes need to be applied, using the American Medical Association's Current Procedural Terminology (CPT), which contains the currently accepted procedure codes used for billing. Developmental screening can be billed using CPT code 96110. Extended developmental screening or assessment is billed under code 96111. Because developmental-behavioral screening is usually completed at an office visit, evaluation and management codes can be used in conjunction with the screening code (Table 2). TABLE 2 CPT codes for developmental screening 96110 Developmental screening 96111 Extended developmental screening 99202-99205 Evaluation and management, office procedural codes, new patient 99212-99215 Evaluation and management, office procedural codes, return patient The physician must be sure to fully document time spent because it can be used for billing when more than 50% of the visit consists of counseling and coordination of care. Time documentation directly relates to the Resource Based Relative Value Scale (RBRVS), recently adapted by the AAP from the Medicare reimbursement system to identify "relative work effort" using relative value units (RVUs) reflective of a particular CPT code. The RBRVS was originally designed by the Health Care Financing Administration to calculate Medicare reimbursement. Private payers often use it to determine reimbursement for pediatric services. The RVU assigned to each CPT code is a calculated value reflecting physician work effort, inherent practice costs, and malpractice premiums. Dobrez and colleagues, in a 2001 article in Pediatrics, provide an example of a scalable cost model that estimates work effort for various combinations of developmental-behavioral screening based on the RBRVS.14 This model does not include the initial cost of the screening tool or the cost of the protocols if they cannot be photocopied. Details about CPT coding can be found on the AMA Web site ( www.ama-assn.org ). Not surprisingly, the rate of coverage by Medicaid and private third-party payer systems varies widely for developmental and behavioral screening. Reimbursement is inconsistent for claims applying pertinent codes and diagnoses used in such screening. The health-care provider's primary obligation, however, is to the patientto provide the most accurate diagnosis and reflect the appropriate amount of work effort involved in the screening process. Work is continuing to develop uniform guidelines for billing, coding, and reimbursement for developmental and behavioral problems screened by primary care physicians. Pediatricians can challenge denied claims by writing letters of medical necessity.15 Introducing screeningto your practice As previously noted, implementing quality developmental and behavioral screening in pediatric practice requires some thought and planning. It also requires a committed leader who believes in the value of such screening and intervention and can convey enthusiasm to staff. Office staff will need to participate in nuts-and-bolts decisions about how screening tools will be disseminated and scored. Table 3 on page 100 of the print edition (Adapted from North Carolina?s ABCD project materials and Ploof D, Hamel SC: Developmental screening is an important part of well care: How can we really make it happen? Basic principles for practice change in the real word. Newsletter of the American Academy of Pediatrics Section on Developmental and Behavioral Pediatrics, June 2002) includes a series of questions to consider when implementing developmental and behavioral screening in your practice. The Web site of the AAP's Section on Developmental and Behavioral Pediatrics www.dbpeds.org is a gold mine of information. It includes articles on disabilities and common developmental and behavioral issues. Developmental-behavioral pediatricians and general practitioners can participate in online discussions that cover topics of interest to participants, such as bilingualism, adoption of Eastern European children, management of ADHD, and complementary and alternative therapies. The Section on Developmental and Behavioral Pediatrics also offers a range of continuing education activities and a newsletter. The Web site includes information on how to join the section. Parting thoughts The "flu model" does not apply to developmental and behavioral problems. Just as development develops, or unfolds over time, so do developmental and behavioral problems. Unlike viruses, these problems tend to get worse, not better, with time. Moreover, it is better to err in the direction of referral to a subspecialist than of deferral. Research shows that children who are over-referred on screens tend to have below-average performance and numerous psychosocial risk factors.16 Access by at-risk children and their families to intervention services or other kinds of monitoring and counseling helps ensure that even the mildest problems do not get worse. Our concluding message, therefore, is, "screen and screen again" and "refer, refer, refer."17 REFERENCES 1. Shonkoff JP, Phillips D (eds): From Neurons to Neighborhoods: The Science of Early Childhood Development. Washington, D.C., National Academies Press, 2000 http://www.nap.edu/books/0309069882/html/ 2. Reynolds AJ, Temple JA, Robertson DL, et al: Long-term effects of an early childhood intervention on educational achievement and juvenile arrest: A 15-year follow-up of low-income children in public schools. JAMA 2001;285:2339 http://jama.ama-assn.org/issues/ v285n18/abs/joc01444.html 3. Gomby DS, Larner MB, Stevenson CS, et al: Long-term outcomes of early childhood programs: Analysis and recommendations. Futures of Children 1995;5:6 http://www.futureofchildren.org/homepage2824/archive.htm 4. Halfon N, McLearn KT, Schuster MA (eds): Child Rearing in America: Challenges Facing Parents with Young Children. New York, Cambridge University Press, 2002 http://books.cambridge.org/0521012643.htm 5. Bethell C, Peck C, Schor E: Assessing health system provision of well-child care: The Promoting Healthy Development survey. Pediatrics 2001;107:1084 http://www.pediatrics.org/cgi/content/full/107/5/1084 6. Halfon N, Olson L, Inkelas M, et al: Summary statistics from the National Survey of Early Childhood Health, 2000. National Center for Health Statistics. Vital Health Stat 15(4), in press. http://www.cdc.gov/nchs/about/major/slaits/nsech.htm 7. Pelletier H: Assuring Better Child Health and Development (ABCD) Project, 2002. www.nashp.org 8. Rushton J, Bruckman D, Kelleher K: Primary care referral of children with psychosocial problems. Arch Pediatr Adolesc Med 2002;156:592 http://archpedi.ama-assn. org/issues/v156n6/rfull/poa10364.html 9. American Academy Of Pediatrics: Developmental surveillance and screening of infants and young children (RE0062). Pediatrics 2001;108:192 http://www.aap.org/policy/re0062.html 10. Glascoe FP, Byrne KE, Chang B, et al: The accuracy of the Denver-II in developmental screening. Pediatrics 1992; 89:1221 www.pediatrics.org 11. Rappo PD: Coding for mental health and behavioral problems: The arcane elevated to the ranks of the scientific. Pediatrics 2002;110;167 12. International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM). Los Angeles, Calif., Practice Management Information Corporation, 2003 13. Wolraich ML, Felice ME, Drotar D (eds): The Classification of Child and Adolescent Mental Diagnoses in Primary Care. Diagnostic and Statistical Manual for Primary Care (DSM-PC), Child and Adolescent Version. Elk Grove Village, Ill., American Academy of Pediatrics, 1996 14. Dobrez D, Lo Sasso A, Holl J, et al: Estimating the cost of developmental and behavioral screening of preschool children in general pediatric practice. Pediatrics 2001;108:913 15. Hagan JF, Jr: The new morbidity: Where the rubber hits the road, or the practitioner's guide to the new morbidity. Pediatrics 2001;108:1206 16. Glascoe FP: Are over-referrals on developmental screening tests really a problem? Arch Pediatr Adolesc Med 2001; 155:54 http://archpedi.ama-assn.org/issues/ v155n1/rfull/poa00202.html 17. Johnson C: Using Developmental and Behavioral Screening Tests. Pediatr Rev 2000;21:255 http:// pedsinreview.aapjournals.org/content/vol21/issue8/ index.shtml#ARTICLES DR. GLASCOE is adjunct professor of pediatrics, Vanderbilt University, Nashville, Tenn. She is a member of the executive committee of the American Academy of Pediatrics' Section on Developmental and Behavioral Pediatrics. She is the developer of the Parents' Evaluations of Developmental Status (PEDS) screening test and co-owner of the company that publishes it. DR. MACIAS is associate professor of pediatrics and medical director, developmental pediatrics, Medical University of South Carolina, Charleston. She is a member of the executive committee of the American Academy of Pediatrics' Section on Developmental and Behavioral Pediatrics. She has nothing to disclose in regard to affiliations with, or financial interests in, any organization that may have an interest in any part of this article. Where to look for local services and parent education materials Head Start and Early Head Start programs http://www.ehsnrc.org/ProgramLocator/ehssites.cfm Accredited day-care programs http://www.naeyc.org/accreditation/center_search.asp Parent training (using the Parents As Teachers Curriculum) http://www.patnc.org For other parent-training programs, check with your local United Way Mental health services http://www.mentalhealth.org/databases/default.asp Services and information about autistic spectrum disorders http://www.firstsigns.org/ Early intervention, for children 03 years of age http://www.nectas.unc.edu/ Intervention for older children Contact the special education department within your local school district Parent education http://www.aap.org See especially the most recent brochures on development and discipline http://www.pedstest.com Contains links to a number of quality parent education sites Frances Glascoe, Michelle Macias. Implementing the AAP's new policy on developmental and behavioral screening. Contemporary Pediatrics 2003;4:85.