Implementing Developmental-Behavioral Screening, Surveillance, and Promotion in Primary Care
Probably the most challenging aspect of adopting quality approaches to surveillance/screening is figuring out how to make it work in our practices. There are many considerations but there are also many effective models. Chapter 16 provides numerous case examples of how clinics implemented tools and organized developmental-behavioral promotion materials, referral resource lists, how they learned to bill and code for optimal reimbursement.
On this web page we include:
A downloadable implementation worksheet (in Word) showing considerations for use with paper charts as well as electronic records. The worksheet allows you to personalize the sequence of steps, assign tasks to various staff, and establish time frames for getting things done.
Downloadable workflow diagrams (in Powerpoint) that can be modified to reflect what works in your clinic. You can use these to plan an optimal process and then modify the sequence as needed –after trialing the approach most likely to be effective.
Live links to resources for the many considerations in implementation planning.
Information on billing/coding for reimbursement.
Resources for Implementation
Below are several sites with guidance for initiating careful developmental-behavioral care. Adding early detection and intervention services often leads to training demands and so we encourage you to also read Chapters 14 and 15 where in there are extensive lists of training/self-training resources for providers. Improved early detection also leads to a need for developmental-behavioral promotion and so be sure to capture links and information from Chapter 7.
Created by Dr. Alison Schonwald at Harvard University, this site focuses on the challenges of implementing early detection in primary care. There’s a compelling video about the process—challenges and solutions, strategies for encouraging colleagues and clinic staff, selecting tools, etc. The site also has helpful information on how to help reluctant clinic staff and providers, how to select among several tool options, etc.
The site for PEDS Tools houses rousing slide shows and videos for encouraging interest in early detection and intervention including the “how-to’s” of implementation in health care settings.
The site for ASQ Tools houses case examples, tutorials and a webcast for print and/or online applications of the ASQ and ASQ:SE.
This American Academy of Pediatrics' site includes information on practice management, billing/coding, webinars, suggestions for efficient and effective care, and also workshops.
The American Academy of Pediatrics’ Medical Home Initiative website is designed to help establish for children with special health care needs, health care that is “accessible, family-centered, continuous, comprehensive, coordinated, compassionate, and culturally-competent.” The site has training materials, rating scales, an e-mail announcement list for providers, how-tos, etc. Medical Home also sponsors several conferences each year.
Guidance on Billing and Coding
Because the information below is subject to change, we will endeavor to update the guidance provided in light of new information (e.g., from the Affordable Care Act, new decisions about coding from the Centers for Medicaid and Medicaid, etc.). Current recommendations are below but we recommend that clinic supervisors’ check with each payer regarding preferred procedures. Also note that the American Academy of Pediatrics actively fights for reimbursement beyond 24 – 30 months. Note that some States and certain types of practices (e.g., Federally Qualified Health Centers) are not able to receive separate reimbursement for screening, but rather enhanced reimbursement for the preventive visit if screening tools are used. Discussed below is guidance on how to value the reductions in practice time/expense when screening tools are used.
Select the appropriate code for the preventive service, such as:
99402: Preventive medicine counseling and/or risk factor reduction intervention(s) provided to an individual (separate procedure); approximately 30 minutes (Problem Counseling) 99429: Unlisted preventive medicine service (Initial Patient Education/Counseling) 99205: New patient of high complexity 99204: New patient with moderate complexity (or use the appropriate sick or return visit codes if screening during such visits)
Add a modifier to your visit code denoting a stand-alone service deserving separate reimbursement. For Medicaid (in most States) the modifier is -25 but in some States it is -59 (which is often the case for private payers and sometimes used only when appealing denied claims). But it is best to check with each payer.
List separately the screening procedure code:
The 96110 code seems to work best whether screening is psychosocial or developmental-behavioral. However, the AAP has endorsed 99420 as a reimbursable code for children in at-risk environments (e.g., when parents are depressed, there are other psychosocial risk factors, absence of resilience factors). We don’t know how well this one actually works. So for the sake of your patients’ financial health, if 99420 doesn’t work, resubmit with 96110. In general, 96110 garners an average of $8.00 per screen (although some States, e.g., North Carolina, and increasingly California) have opted for an overall higher reimbursement for the preventive visit codes instead. Bottom line, know your payers and their preferred billing procedures.
List the number of screens administered:
For example, if you’ve used two screens (e.g., PEDS and ASQ), write 96110 X 2 to indicate the number of screens administered, or X 3 if you’ve also given the M-CHAT.
A diagnosis code is rarely needed but if required by a payer, use codes sufficiently vague so as not to interfere with future, more specific diagnoses made by those to whom you refer for additional evaluations. Examples are:
783.4 Developmental Delay 309.23 Academic Inhibition (school problems) 315.4 Developmental Coordination Disorder 318.104.22.168 Hyperkinetic syndrome NOS 784.5 Other Speech Disturbance 309.3 Disturbance of Conduct 799.9 Unknown unspeciﬁed cause 799.89 Other ill-deﬁned conditions 309 Adjustment Reaction 315.10 Unspeciﬁed adjustment reaction 300.00 Anxiety state, unspeciﬁed 312.9 Disruptive behavior, NOS 315.9 Unspeciﬁed delays in development
If rule-out codes are needed to code a patient as typically developing, the following may help (although payers vary on their tendency to financially recognize V codes):
V20.2 (Encounter for routine child health examination without abnormal findings)
For coding parent education and follow-up:
Routine parent education is considered part of any well-visit and so unlikely to be reimbursable. However, if your clinic has a case coordinator (e.g., via deployment of the Medical Home model), case-management may well be reimbursed. If so, these procedure codes may help:
99339: Care Plan Oversight (15 - 29 minutes per month) 99340: Care Plan Oversight (30 or more minutes per month) 99401: Preventive medicine counseling and/or risk factor reduction intervention(s) provided to an individual (separate procedure); approximately 15 minutes (Method Speciﬁc Education) T1017 Targeted Case Management
Review Denied Claims. Although parents must participate in appealing these, it is wise to follow-up with payers on any systematic errors in billing/coding that your clinic can and should correct.
Report Systematic Denials of Valid Claims. If payers refuse to pay for screening (and you are not in a State with higher coverage for preventive service visits), let your State AAP Chapter know (whether you are a FAAP or not) and seek their advice about what to do. Your State AAP Chapter works with the national AAP where you can check for updates. In addition to checking the AAP website and contacting your State AAP Chapter you can also email: firstname.lastname@example.org.
Be prepared to advise parents on how to appeal. It may be wise to prepare a fact sheet to send or read to parents over the phone. They will need to know exactly what to say to insurers and exactly what number to call. See Chapter 6 for additional information for preparing parents and its web page for a downloadable copy.
When reimbursement for screening is not available. In some States and for some types of practices (e.g., Federally Qualified Healthcare Centers), clinics are paid a rate “per medical encounter”. When developmental screening is provided, a specified “visit code” (typically a pre-defined preventive service code) is used to trigger enhanced reimbursement. The 96110 screening code is not reimbursed separately even when States have a specified list of tools required for Early Periodic Screening, Diagnosis and Treatment (EPSDT) visits.
In such clinics, adoption of quality screens is best evaluated in terms of time saved and thus reductions in practice expense. Consider these self-evaluation questions, especially in light of the advantages afforded by online screening services:
How much time do clinicians spend eliciting informal milestones such as those on age-specific encounter forms? (Published research on this topic does not yet exist but informal time/motion studies suggest that providers spend ~ 1 – 2 minutes on these activities—time that could be saved if parents complete quality skills-focused tools on their own. Accurate parent-report tools are also known to vastly improve detection rates).
How much time is spent eliciting parents’ concerns with informal questions? What percent of visits incur "oh by the way" concerns and how much time is required to address these? (Research shows that informal questions do not work well and result in "door knob" concerns in about 20% of visits. In contrast, accurate measures eliciting parents’ concerns, preferably by self-report in advance of the visit, shave about 3 minutes from average visit length and make encounters far more relevant. Also families are more likely to return for subsequent visits when their specific concerns are elicited and addressed.
If using quality tools in print how much time is spent hand-scoring or administering screens by interview? Would shorter screens with online scoring save time? (Chapter 4 shows the scoring time per tool, cost of various administration methods and associated practice expense).
How much time is spent dictating/proofing referral letters and parent summary reports? (Published research on this issue does not yet exist but we can anticipate that for about 20% of patients, referrals and thus report dictation/proofing will be needed. These activities require at least 5 – 10 minutes of professional time. To this expense must be added requisite staff time for transcribing dictations). Would not much of this time/expense be eliminated if using an online screening service that automatically generates reports?
Informal measures, whether focused on parents’ concerns or children’s milestones incur costs to practices; but these approaches are, unfortunately, without much benefit to patients. Quality screening tools are not without costs but these expenses are minimal and the benefits to children parents and society are enormous. Practice time/expense is greatly reduced if parents self-administer measures. Practice time/expense is reduced even further when using online screening services wherein scoring is automated and referral letters and parent summary reports are automatically generated.