Developmental ScreeningDevelopmental ScreeningAn OverviewAn OverviewAn OverviewAn Overview

Virginia Keane, MDVirginia Keane, MDAssociate Professor of Pediatrics Associate Professor of Pediatrics

University of Maryland School of MedicineUniversity of Maryland School of MedicinePresident, Maryland Chapter, American Academy of PediatricsPresident, Maryland Chapter, American Academy of Pediatrics

Jamie Perry, MD, Office of Genetics and Special Health Care Needs, Jamie Perry, MD, Office of Genetics and Special Health Care Needs, Marti Grant, RN, MA, Chief, Division Healthy KidsMarti Grant, RN, MA, Chief, Division Healthy Kids

Paul Lipkin, MD, Kennedy Kreiger InstitutePaul Lipkin, MD, Kennedy Kreiger InstituteTracey King,MD, Johns Hopkins Department of PediatricsTracey King,MD, Johns Hopkins Department of Pediatrics

P thfi d f A tiP thfi d f A tiPathfinders for AutismPathfinders for AutismParents Place of MarylandParents Place of Maryland

With Support from the Maryland Office of Maternal Child HealthWith Support from the Maryland Office of Maternal Child Healthand the Federal Bureau of Maternal Child Healthand the Federal Bureau of Maternal Child Health

Learning ObjectivesLearning ObjectivesLearning ObjectivesLearning Objectives

AAP Guidelines on general developmentalAAP Guidelines on general developmentalAAP Guidelines on general developmental AAP Guidelines on general developmental and autism screeningand autism screeningEvidence supporting screeningEvidence supporting screeningEvidence supporting screeningEvidence supporting screeningMaryland Recommended toolsMaryland Recommended toolsSteps in office based implementationSteps in office based implementationReferral and follow upReferral and follow upppHow to billHow to bill

Importance of early intervention:Importance of early intervention:First three years of life are critical to brain developmentFirst three years of life are critical to brain developmentFirst three years of life are critical to brain developmentFirst three years of life are critical to brain development

ModelModelModelModel

Early Identification

Early ActionEarly ActionAssessment and Treatment

Improved OutcomesDevelopment Behavior School Readiness School completionDevelopment, Behavior, School Readiness, School completion

What is Developmental Screening?What is Developmental Screening?What is Developmental Screening?What is Developmental Screening?

Surveillance:Surveillance: Flexible, longitudinal, continuous Flexible, longitudinal, continuous and cumulative process whereby knowledgeable and cumulative process whereby knowledgeable h l h f i l id if hild hh l h f i l id if hild hhealth care professional identify children who health care professional identify children who may have developmental problems. (AAP 2006)may have developmental problems. (AAP 2006)

Screening:Screening: Administration of a brief Administration of a brief standardizedstandardized screening tool aiding the screening tool aiding the sta da d edsta da d ed sc ee g too a d g t esc ee g too a d g t eidentification of children at risk of a identification of children at risk of a developmental disorder. (AAP 2006)developmental disorder. (AAP 2006)

Why Do Developmental Why Do Developmental S ?S ?Screening?Screening?

Developmental delays /disabilities affect up to 10% of all Developmental delays /disabilities affect up to 10% of all p y pp y pchildrenchildrenMany delays are subtle and may not be picked up by Many delays are subtle and may not be picked up by surveillancesurveillancesurveillancesurveillance–– Speech and Language delay: 5Speech and Language delay: 5--10/10010/100–– Global delay 2Global delay 2--3/1003/100–– Autism 1/150Autism 1/150–– Autism 1/150Autism 1/150–– Intellectual disability (MR) 2Intellectual disability (MR) 2--3/1003/100

Many parents report having their developmental Many parents report having their developmental concerns disregarded by their child health providerconcerns disregarded by their child health providerconcerns disregarded by their child health providerconcerns disregarded by their child health providerEarly intervention can make a difference, especially with Early intervention can make a difference, especially with the subtle delays.the subtle delays.

Developmental ScreeningDevelopmental ScreeningDevelopmental ScreeningDevelopmental ScreeningA little Maryland historyA little Maryland history–– Until 1997 Medicaid/Healthy Kids/EPSDT required screening Until 1997 Medicaid/Healthy Kids/EPSDT required screening

using the DDST (Denver) for all well child visits 6 months to 6 using the DDST (Denver) for all well child visits 6 months to 6 yearsyears

–– Maryland did away with this requirement when MedicaidMaryland did away with this requirement when MedicaidMaryland did away with this requirement when Medicaid Maryland did away with this requirement when Medicaid Managed Care was implemented in 1997Managed Care was implemented in 1997

–– A 2005 focus group study revealed that Maryland pediatricians A 2005 focus group study revealed that Maryland pediatricians were evaluating development but were evaluating development but not not using a standardized using a standardized screening toolscreening toolscreening tool screening tool

Personal judgmentPersonal judgmentMilestones on the EPSDT formsMilestones on the EPSDT formsParents did not perceive that development had been assessedParents did not perceive that development had been assessed

National studies support the Maryland findings: few child National studies support the Maryland findings: few child health providers do standardized developmental health providers do standardized developmental screening.screening.

What is the Data on developmental What is the Data on developmental SS ??ScreeningScreening??

Less than 50% of pediatricians use standardized Less than 50% of pediatricians use standardized % p% pscreening toolsscreening toolsAmong those who do most Among those who do most –– use it selectivelyuse it selectively–– Use the DDSTII, even though better tols are now Use the DDSTII, even though better tols are now

availableavailableavailableavailableParents report significant lag between when they Parents report significant lag between when they raise a concern and when evaluation occurs.raise a concern and when evaluation occurs.While 10%of children have delays, only 2.3% While 10%of children have delays, only 2.3% particpate in early intervention programsparticpate in early intervention programs

Sices et al 2003; Sand et al 2005Sices et al 2003; Sand et al 2005Sices et al, 2003; Sand et al 2005Sices et al, 2003; Sand et al 2005

Using Standardized Screening Tools Using Standardized Screening Tools Improves Early Identification andImproves Early Identification andImproves Early Identification and Improves Early Identification and

ReferralReferral

North Carolina: Clinician education and reimbursement North Carolina: Clinician education and reimbursement increased screening from 15increased screening from 15--70%, referrals to Early 70%, referrals to Early gg , y, yintervention increased form 2.6intervention increased form 2.6--77--8%, only 2% did not 8%, only 2% did not qualify for services (Earls, Pediatrics, 2006)qualify for services (Earls, Pediatrics, 2006)T f ld i i f l tT f ld i i f l tTennessee: saw a seven fold increase in referrals to Tennessee: saw a seven fold increase in referrals to Early InterventionEarly InterventionConnecticut: Saw 2Connecticut: Saw 2--3X increase in referrals, almost no 3X increase in referrals, almost no Co ect cut SaCo ect cut Sa 3 c ease e e a s, a ost o3 c ease e e a s, a ost ounnecessary referralsunnecessary referrals

The 2006 AAP Policy Statement on The 2006 AAP Policy Statement on S i d S ill G lS i d S ill G lScreening and Surveillance GoalsScreening and Surveillance Goals

Increase identification of children with Increase identification of children with developmental disorders by child health developmental disorders by child health professionalsprofessionalsprofessionalsprofessionals–– Improve methods of surveillance and screening Improve methods of surveillance and screening

Greater consideration of motor and communication Greater consideration of motor and communication disordersdisordersdisordersdisorders

–– Provide concrete guidelines (algorithm)Provide concrete guidelines (algorithm)AgeAge--targeted screeningtargeted screening

Eliminate barriers e g reimbursementEliminate barriers e g reimbursement–– Eliminate barriers, e.g. reimbursementEliminate barriers, e.g. reimbursement

Improve medical assessmentImprove medical assessment

The 2006 AAP Policy Statement on The 2006 AAP Policy Statement on Developmental Surveillance and ScreeningDevelopmental Surveillance and Screening::Developmental Surveillance and ScreeningDevelopmental Surveillance and Screening::

Working definitions: Working definitions: –– SurveillanceSurveillance-- continuouscontinuous–– ScreeningScreening-- periodicperiodic–– EvaluationEvaluation (vs. assessment)(vs. assessment)-- diagnosis and treatmentdiagnosis and treatment

E h i th id tifi ti f d l t lE h i th id tifi ti f d l t lEmphasis on the identification of developmental Emphasis on the identification of developmental disabilitiesdisabilitiesRole of the Medical HomeRole of the Medical HomePractice challenges Practice challenges Reimbursement issuesReimbursement issuesMedical evaluationMedical evaluationMedical evaluation Medical evaluation Subspecialist role, community linkagesSubspecialist role, community linkages

Identifying Infants and Young Children with Identifying Infants and Young Children with Developmental Disorders in the Medical Home: An Developmental Disorders in the Medical Home: An pp

Algorithm for Developmental Surveillance and Algorithm for Developmental Surveillance and ScreeningScreening

Perform developmental Perform developmental surveillancesurveillance at every at every wellwell--child visitchild visitP f d l t lP f d l t l ii iiPerform developmental Perform developmental screeningscreening using a using a standardized screening toolstandardized screening tool at select age at select age intervals( intervals( 9,18,30* months9,18,30* months) or when ) or when concernconcern is is

d (d ( b d t 24b d t 24 3636 ))expressed ( expressed ( may be done at 24may be done at 24--36 mos36 mos))If screening results are concerning, refer to If screening results are concerning, refer to developmental and medical evaluations anddevelopmental and medical evaluations anddevelopmental and medical evaluations and developmental and medical evaluations and early intervention servicesearly intervention servicesFollow up on referrals made and continually Follow up on referrals made and continually track child’s developmental statustrack child’s developmental statustrack child s developmental statustrack child s developmental status

Developmental SurveillanceDevelopmental Surveillancepp

Developmental ScreeningDevelopmental Screening

9 18 24-36

What to Do with the ResultsWhat to Do with the Results(AAP 2006)(AAP 2006)

When the results are normal:When the results are normal:When the results are normal:When the results are normal:–– Inform the parents and continue with other aspects of the Inform the parents and continue with other aspects of the

preventive visit.preventive visit.Provide an opportunity to focus on developmental promotionProvide an opportunity to focus on developmental promotion–– Provide an opportunity to focus on developmental promotion.Provide an opportunity to focus on developmental promotion.

When administered When administered due to concernsdue to concerns EVEN IF NORMALEVEN IF NORMAL–– Schedule early return visit for additional surveillance, even if the Schedule early return visit for additional surveillance, even if the

screening tool results do not indicate a risk of delayscreening tool results do not indicate a risk of delayscreening tool results do not indicate a risk of delay.screening tool results do not indicate a risk of delay.–– Consider referral to Infants and ToddlersConsider referral to Infants and Toddlers

When results are concerning:When results are concerning:–– Schedule developmental evaluations.Schedule developmental evaluations.–– Schedule medical evaluations at the discretion of the clinicianSchedule medical evaluations at the discretion of the clinician–– Refer to Infants and ToddlersRefer to Infants and Toddlers

So, what’s Implementation!next?

Implementation!

Integrating Screening Into Your Integrating Screening Into Your PracticePractice

Which tool will you use?Which tool will you use?Which tool will you use?Which tool will you use?Who will administer it? Who will administer it? Who will score it?Who will score it?Who will score it? Who will score it? How will it get to the clinician to assess How will it get to the clinician to assess and act?and act?and act?and act?Where will you file it in the chart?Where will you file it in the chart?H ill i l t billi ?H ill i l t billi ?How will you implement billing?How will you implement billing?How will you track referrals and follow up?How will you track referrals and follow up?

CQI: Continuous Quality CQI: Continuous Quality ImprovementImprovement

A set of principles and methods that allowA set of principles and methods that allowA set of principles and methods that allow A set of principles and methods that allow people to improve the processes and people to improve the processes and systems in which they worksystems in which they worksystems in which they work systems in which they work Based on evidence allowing you to plan a Based on evidence allowing you to plan a change implement assess results andchange implement assess results andchange, implement, assess results and change, implement, assess results and plan further change.plan further change.Y t t ith l d l d b thY t t ith l d l d b thYou start with a a plan, developed by the You start with a a plan, developed by the team of people who will create this changeteam of people who will create this change

The Core QuestionsThe Core Questionsfor Planningfor Planning

Langley, Nolan and NolanLangley, Nolan and Nolan

What are we trying to accomplish?What are we trying to accomplish?–– Define aimDefine aim

How will we know that change is an How will we know that change is an improvement?improvement?–– Define measuresDefine measures

What changes can we make that will result in What changes can we make that will result in improvement?improvement?–– Identify methodsIdentify methods

PDSA Cycles: a model for the PDSA Cycles: a model for the work of improvementwork of improvement

Little steps will get you thereLittle steps will get you thereLittle steps will get you thereLittle steps will get you theregoalg

PDSA

PDSA

PDSA

PDSA

Week four, parent advised by nurse to ask doctor

PDSAWeek three,desk staff gives questionnaire, nurse collect,80% done and scored, doctor interprets 50%

the results of the screening, 80% interpreted

PDSA

PDSAWeek two, desk staff has parent fill out questionnaire and collect it,nurses score, 80% done, 25% scored

PDSAstart Week one, doctors do screening, 20% eligiibles

get screened

Ch iCh iChoosing Choosing DevelopmentalDevelopmentalDevelopmental Developmental

Screening ToolsScreening ToolsggWhat’s best for your practice?What’s best for your practice?

Some Issues to Consider in Some Issues to Consider in Selecting a ToolSelecting a Tool

Psychometrics: sensitivity/specificity Psychometrics: sensitivity/specificity should be at least 70should be at least 70--80%80%Time/staffing requiredTime/staffing requiredCost and reimbursementCost and reimbursementParentParent--completed versus directly completed versus directly administeredadministeredCultural and linguistic sensitivityCultural and linguistic sensitivity

What About the DenverWhat About the Denver--II II S ?S ?Developmental Screen?Developmental Screen?

C b t l ifi itC b t l ifi itConcerns about low specificityConcerns about low specificity–– Study of 104 children age 3Study of 104 children age 3--72 months, over half of 72 months, over half of

the children with normal development received the children with normal development received ppabnormal, questionable, or untestable scores abnormal, questionable, or untestable scores (specificity = 43%)(specificity = 43%)

–– Leads to unacceptably high overLeads to unacceptably high over--referral ratereferral rateLeads to unacceptably high overLeads to unacceptably high over--referral ratereferral rateLacks certain other validity studiesLacks certain other validity studiesFailed to meet the review criteria for inclusionFailed to meet the review criteria for inclusionFailed to meet the review criteria for inclusion Failed to meet the review criteria for inclusion in list of approved screening tools for Maryland in list of approved screening tools for Maryland EPSDTEPSDT

Pediatrics 1992;89: 1221-1225

Time/Staffing/CostTime/Staffing/CostTime/Staffing/CostTime/Staffing/Cost

How much time to complete and/or How much time to complete and/or score tool?score tool?Who can administer and/or score tool?Who can administer and/or score tool?How much will it cost to screen with theHow much will it cost to screen with theHow much will it cost to screen with the How much will it cost to screen with the tool?tool?Can practice get adequatelyCan practice get adequatelyCan practice get adequately Can practice get adequately reimbursed for screening with tool?reimbursed for screening with tool?

ParentParent--Completed Screens: Completed Screens: AdvantagesAdvantages

As accurate as screens using other As accurate as screens using other ggmeasurement methodsmeasurement methodsTake less physician time (which may translate Take less physician time (which may translate i l )i l )into less cost)into less cost)Don’t depend upon cooperation of child during Don’t depend upon cooperation of child during office visitoffice visitoffice visitoffice visitBring parents more fully into screening processBring parents more fully into screening process

Cultural and Linguistic Cultural and Linguistic SensitivitySensitivity

Parent literacy: reading level of parentParent literacy: reading level of parent--Parent literacy: reading level of parentParent literacy: reading level of parentcompleted toolscompleted toolsLanguage: availability of tool in otherLanguage: availability of tool in otherLanguage: availability of tool in other Language: availability of tool in other languages represented in your populationlanguages represented in your population

ApprovedApproved General Developmental General Developmental S i T l f M l d EPSDTS i T l f M l d EPSDTScreening Tools for Maryland EPSDTScreening Tools for Maryland EPSDT

A d St Q ti i (ASQ)A d St Q ti i (ASQ)Ages and Stages Questionnaire (ASQ)Ages and Stages Questionnaire (ASQ)Parents’ Evaluation of Developmental Parents’ Evaluation of Developmental St t (PEDS) /St t (PEDS) / PEDS DMPEDS DMStatus (PEDS) +/Status (PEDS) +/-- PEDS: DMPEDS: DMBattelle Developmental Inventory Battelle Developmental Inventory S i T l 2S i T l 2ndnd ddScreening Tool, 2Screening Tool, 2ndnd ededBrigance ScreensBrigance Screens--IIIIEarly Screening Inventory Early Screening Inventory –– RevisedRevisedFirstSTEP Preschool Screening ToolFirstSTEP Preschool Screening Tool

RecommendedRecommended General Developmental General Developmental S i T l f M l d EPSDTS i T l f M l d EPSDTScreening Tools for Maryland EPSDTScreening Tools for Maryland EPSDTAges and Stages Questionnaire (ASQ)Ages and Stages Questionnaire (ASQ)Ages and Stages Questionnaire (ASQ)Ages and Stages Questionnaire (ASQ)Parents’ Evaluation of Developmental Parents’ Evaluation of Developmental Status (PEDS)Status (PEDS)Status (PEDS)Status (PEDS)Additional information on these tools, and Additional information on these tools, and h t h th b f d ih t h th b f d ihow to purchase them can be found in how to purchase them can be found in your packetsyour packets

Screening Tool Comparison: Screening Tool Comparison: SQ SSQ SASQ vs. PEDSASQ vs. PEDS

InstrumentInstrument DescriptionDescription CostCost Admin TimeAdmin Time PsychometricsPsychometrics Literacy/Literacy/Language Language issuesissues

ASQASQ Use 4Use 4--60 60 $199 per $199 per 1010--15 15 Sens: .Sens: .7070--.90.90 55thth grade grade monthsmonths19 age19 age--based based formsforms

$ p$ planguagelanguageUnlimited Unlimited copiescopies

minutesminutesparentparent

(mod(mod--high)high)Spec:Spec: .76.76--.91.91(mod(mod--high)high)

gglevellevelEnglish, English, Spanish, Spanish, FrenchFrenchformsforms

30 items 30 items per ageper age

French, French, and Koreanand Korean

PEDSPEDS Use Use 00--8 8 $30 per$30 per 22--10 10 minutesminutes Sens: .74Sens: .74--.79.79 55thth grade grade yearsyearsSingle Single response response form for all form for all

50 survey 50 survey forms and forms and 50 score 50 score sheetssheets

parentparent (moderate)(moderate)Spec: .70Spec: .70--.80.80(moderate)(moderate)

levellevelEnglish, English, Spanish, Spanish, French, French,

agesages10 items10 items

$70 $70 manualmanual

Chinese, Chinese, Arabic, Arabic, SomaliSomali, etc, etc

Autism ScreeningAutism ScreeningAutism ScreeningAutism ScreeningNovember 2007 AAP published Guidelines on Autism November 2007 AAP published Guidelines on Autism ppscreeningscreeningAutism spectrum disorders affect about 1/150 children:Autism spectrum disorders affect about 1/150 children:–– Autistic disorderAutistic disorderAutistic disorderAutistic disorder–– Asberger syndromeAsberger syndrome–– Pervasive developmental disorder NOSPervasive developmental disorder NOS

Survey results show that 44% of pediatricians care forSurvey results show that 44% of pediatricians care for >>Survey results show that 44% of pediatricians care for Survey results show that 44% of pediatricians care for >>ASD children, but only 8% screenASD children, but only 8% screenRecent research shows that early identification and Recent research shows that early identification and th i tth i ttherapy can improve outcomestherapy can improve outcomesScreening is recommended at Screening is recommended at 18 and 2418 and 24 monthsmonths

Examples of ParentExamples of Parent-- Completed Completed ToolsTools

Modified Checklist for Autism in Toddlers (MModified Checklist for Autism in Toddlers (M--((CHAT)CHAT)–– Currently most commonly used screen in primary Currently most commonly used screen in primary

carecare–– www.firstsigns.comwww.firstsigns.com

Pervasive Developmental Disorders ScreeningPervasive Developmental Disorders ScreeningPervasive Developmental Disorders Screening Pervasive Developmental Disorders Screening TestTest--II, Primary Care Screener (PDDSTII, Primary Care Screener (PDDST--II PSC)II PSC)–– www.harcourtassessment.comwww.harcourtassessment.com

Screening Tool Comparison: MScreening Tool Comparison: M--C SC S SCSCCHAT vs. PDDSTCHAT vs. PDDST--II PSCII PSC

InstrumentInstrument DescriptionDescription CostCost Admin TimeAdmin Time PsychometricsPsychometrics Literacy/Literacy/InstrumentInstrument DescriptionDescription CostCost Admin TimeAdmin Time PsychometricsPsychometrics Literacy/Literacy/Language Language issuesissues

MM--CHATCHAT Use 16Use 16--48 48 Free Free 55--10 10 Sens: .85Sens: .85--.87.87 ? reading ? reading monthsmonths23 items23 items

(in public (in public domain)domain)

minutes minutes parentparent

(moderate)(moderate)Spec: .93Spec: .93--.99.99(high)(high)

levellevelEnglish, English, Spanish, Spanish, Turkish, Turkish, Chinese, Chinese, JapaneseJapanese

PDDSTPDDST--II II PSCPSC

Use 18Use 18--48 48 monthsmonths

$149/kit$149/kit$39/25$39/25

1010--15 15 minutesminutes

Sens: .85Sens: .85--.92.92(mod(mod high)high)

? reading ? reading levellevelPSCPSC monthsmonths

22 items22 items$39/25 $39/25 Response Response formsforms

minutesminutesparentparent

(mod(mod--high)high)Spec: .71Spec: .71--.91.91(mod(mod--high)high)

levellevelEnglish English

Developmental Screening:Developmental Screening:Normal Results Normal Results (AAP 2006)(AAP 2006)

When the results are When the results are normal:normal:normal:normal:–– Inform parents and continue Inform parents and continue

with other aspects of the with other aspects of the pppreventive visitpreventive visit

–– Provides an opportunity to Provides an opportunity to pp ypp yfocus on developmental focus on developmental promotionpromotion

Developmental Screening:Developmental Screening:Concerns Concerns (AAP 2006)(AAP 2006)

When administered When administered due to concerns:due to concerns:–– Schedule early return visit for additional Schedule early return visit for additional

ill if th i t l ltill if th i t l ltsurveillance, even if the screening tool results surveillance, even if the screening tool results do not indicate a risk of delaydo not indicate a risk of delay

WhenWhen results concerningresults concerning refer for:refer for:When When results concerningresults concerning, refer for:, refer for:–– Developmental evaluations Developmental evaluations

Infants and ToddlersInfants and ToddlersInfants and ToddlersInfants and ToddlersDevelopmental specialistsDevelopmental specialists

–– Medical evaluationsMedical evaluations–– Early developmental intervention/early Early developmental intervention/early

childhood services:Infants and Toddlerschildhood services:Infants and Toddlers

Developmental Screening: What Developmental Screening: What Constitutes “Concerning” ResultsConstitutes “Concerning” Results??Constitutes Concerning ResultsConstitutes Concerning Results??

Failed/abnormal/positive screenFailed/abnormal/positive screen –– Yes!Yes!Failed/abnormal/positive screen Failed/abnormal/positive screen Yes! Yes! Refer immediately to Early Intervention, Refer immediately to Early Intervention, Decide if further medical and Decide if further medical and developmental workup is neededdevelopmental workup is needed“Borderline” screen? “Borderline” screen? -- MaybeMaybeyy–– Use clinical judgment based on screening Use clinical judgment based on screening

results and knowledge of child, family, risk results and knowledge of child, family, risk f t t d t i if f l d df t t d t i if f l d dfactors to determine if referrals neededfactors to determine if referrals needed

–– At minimum, should schedule early return visit At minimum, should schedule early return visit for additional surveillance/screeningfor additional surveillance/screeningfor additional surveillance/screeningfor additional surveillance/screening

Developmental Diagnostic Developmental Diagnostic Evaluation Evaluation (AAP 2006)(AAP 2006)

P f d h ill i id ifi hildP f d h ill i id ifi hildPerformed when surveillance or screening identifies a child as Performed when surveillance or screening identifies a child as being at high risk of a developmental disorderbeing at high risk of a developmental disorderPerformed by a developmentalist, neurologist, or early intervention Performed by a developmentalist, neurologist, or early intervention specialist, or a specially trained generalistspecialist, or a specially trained generalistp , p y gp , p y gAimed atAimed at–– identifying the specific developmental disorder or disorders (and identifying the specific developmental disorder or disorders (and

possible associated developmental and behavioral disorders)possible associated developmental and behavioral disorders)P idi f th ti i f tiP idi f th ti i f ti–– Providing further prognostic informationProviding further prognostic information

–– Allowing prompt initiation of specific and appropriate early Allowing prompt initiation of specific and appropriate early childhood therapeutic interventionschildhood therapeutic interventions

Medical Diagnostic Evaluation:Medical Diagnostic Evaluation:AimAim

To identify an underlying etiologyTo identify an underlying etiologyTo identify an underlying etiologyTo identify an underlying etiology–– May provide parents with a greater depth of May provide parents with a greater depth of

understanding of their child’s disabilityunderstanding of their child’s disability–– Can affect various aspects of treatment Can affect various aspects of treatment

planningplanningS ifi ti i f tiS ifi ti i f tiSpecific prognostic informationSpecific prognostic informationGenetic counseling around recurrence risk and Genetic counseling around recurrence risk and family planningfamily planningy p gy p gSpecific medical treatments for improved health Specific medical treatments for improved health and function of the childand function of the childTherapeutic intervention programmingTherapeutic intervention programmingTherapeutic intervention programmingTherapeutic intervention programming

Medical Diagnostic EvaluationMedical Diagnostic EvaluationMedical Diagnostic EvaluationMedical Diagnostic EvaluationMay be performed by any of the following:May be performed by any of the following:y p y y gy p y y g–– Trained and skilled general pediatricianTrained and skilled general pediatrician–– Pediatric subspecialistPediatric subspecialistpp

Neurodevelopmental pediatricians, developmental and Neurodevelopmental pediatricians, developmental and behavioral pediatricians, child neurologists, pediatric behavioral pediatricians, child neurologists, pediatric physiatrists, or pediatric geneticistsphysiatrists, or pediatric geneticists

Additional medical evaluation based on risk Additional medical evaluation based on risk factors and findings and particular factors and findings and particular developmental disorder of interestdevelopmental disorder of interestdevelopmental disorder of interestdevelopmental disorder of interest–– Brain imaging, electroencephalogram (EEG), genetic Brain imaging, electroencephalogram (EEG), genetic

testing, and/or metabolic testing testing, and/or metabolic testing

Early Developmental Intervention/Early Developmental Intervention/E l Childh d S iE l Childh d S iEarly Childhood ServicesEarly Childhood Services

Often provide evaluation andOften provide evaluation andOften provide evaluation and Often provide evaluation and other services:other services:–– Developmental therapiesDevelopmental therapies–– Service coordinationService coordination–– Social work servicesSocial work services–– Assistance with transportation andAssistance with transportation andAssistance with transportation and Assistance with transportation and

related costsrelated costs–– Family trainingFamily training

CounselingCounseling–– CounselingCounseling–– Home visitsHome visits

Diagnosis not necessary for Diagnosis not necessary for referralreferral

Documentation andDocumentation andDocumentation and Documentation and Billing “101Billing “101Billing 101Billing 101

””Marti Grant, R. N., M.A.Marti Grant, R. N., M.A.a t G a t, ,a t G a t, ,

Chief, Division of Healthy KidsChief, Division of Healthy KidsAugust 17, 2007August 17, 2007

Developmental Screening Developmental Screening CPT 96110CPT 96110CPT 96110CPT 96110

Definition:Definition:Developmental testing; Developmental testing; limitedlimited, with , with interpretation and reportinterpretation and reportp pp pMust use a Must use a Standardized Screening ToolStandardized Screening Tool[ie. Ages and Stages Questionnaire (ASQ) or Parent’s Evaluation [ie. Ages and Stages Questionnaire (ASQ) or Parent’s Evaluation f S ( S)f S ( S)of Developmental Status (PEDS)]of Developmental Status (PEDS)]

Code Code does notdoes not include “physician work” include “physician work” [ie can be completed by parent or office staff with physician[ie can be completed by parent or office staff with physician[ie. can be completed by parent or office staff, with physician [ie. can be completed by parent or office staff, with physician interpreting results]interpreting results]

Documentation CPT 96110Documentation CPT 96110I t t ti d R tI t t ti d R tInterpretation and Report:Interpretation and Report:

Document score and/or designation of Document score and/or designation of screening test as normal or abnormalscreening test as normal or abnormal–– ““PEDS normal/no concerns” or “Abnormal PEDS PEDS normal/no concerns” or “Abnormal PEDS –– concerns in concerns in

expressive language, socialexpressive language, social--emotional”emotional”p g g ,p g g ,–– “Failed ASQ “Failed ASQ –– communication and problemcommunication and problem--solving”solving”

Document directly on the screening forms or Document directly on the screening forms or i ti tin progress notesin progress notesKeep screen score sheets in chartKeep screen score sheets in chartDocument counseling and referrals forDocument counseling and referrals for

abnormal screening results abnormal screening results gg[[ie. Early Intervention, subspecialty evaluationie. Early Intervention, subspecialty evaluation] ]

Billing CPT 96110Billing CPT 96110How to bill MD Medicaid:How to bill MD Medicaid:

Bill in conjunction with preventive care code, Bill in conjunction with preventive care code, no modifierno modifierno modifierno modifierWhen indicated, may also use in conjunction When indicated, may also use in conjunction with other appropriate outpatient E&M code with other appropriate outpatient E&M code [ie. [ie. pp p ppp p pchild brought back specifically for rechild brought back specifically for re--screen, or take advantage of screen, or take advantage of missed opportunity by screening at sick visit]missed opportunity by screening at sick visit]New this year: New this year: two units of 96110 allowed two units of 96110 allowed

i it d b MD M di idi it d b MD M di id( dd( ddper visit per day by MD Medicaidper visit per day by MD Medicaid( may add ( may add mental health, psychosocial or autism screen)mental health, psychosocial or autism screen)Current reimbursement from MD Medicaid =Current reimbursement from MD Medicaid =Current reimbursement from MD Medicaid Current reimbursement from MD Medicaid $12.50 per unit of 96110$12.50 per unit of 96110

Billing CPT 96110Billing CPT 96110

How to bill private insurers:How to bill private insurers:Some will separately reimburse, some Some will separately reimburse, some will notwill notMay need to use modifier May need to use modifier --25 along 25 along with E&M service codewith E&M service codeWill need to consider a charge to Will need to consider a charge to familiesfamilies [recommend not greater than $15][recommend not greater than $15]families families [recommend not greater than $15][recommend not greater than $15]

ConclusionConclusionConclusionConclusionDevelopmental screening using a standardized tool Developmental screening using a standardized tool i id tifi ti f hild h b fit fi id tifi ti f hild h b fit fincreases identification of children who may benefit from increases identification of children who may benefit from early interventionearly interventionUse a standardized, Md. Medicaid approved screening Use a standardized, Md. Medicaid approved screening t l t 9 18 d 24t l t 9 18 d 24 36 th d h36 th d htool at 9. 18 and 24tool at 9. 18 and 24--36 months, and when concerns are 36 months, and when concerns are raisedraisedUse Autism screening tools at 18 and 24 monthsUse Autism screening tools at 18 and 24 monthsC QC QConsider using Quality Improvement techniques to Consider using Quality Improvement techniques to integrate screening into your practiceintegrate screening into your practiceRefer for further assessment and early intervention all Refer for further assessment and early intervention all hild h f il th d l l f ll fhild h f il th d l l f ll fchildren who fail the screen, and closely follow or refer children who fail the screen, and closely follow or refer

those who are of concernthose who are of concernDocument your assessment and plan according to Document your assessment and plan according to

di id d ti d bill 96110di id d ti d bill 96110medicaid recommendations, and bill 96110medicaid recommendations, and bill 96110Private insurance payment varies plan to planPrivate insurance payment varies plan to plan