Developmental and Behavioral Health Screening in Pediatric

Primary Care

Kim Brownell, MDHUB Medical Director, ACCESS-MH CT,

Institute of Living/Hartford Hospital

Barbara Ward-Zimmerman, PhDConsultant, Child Health and Development Institute, Educating

Practices in the Community Program

Objectives of Webinar

• Underscore the value of screening for developmental and behavioral health concerns

• Identify common screening instruments to be used for early detection

• Review coding and billing procedures for screening

• Provide mechanisms for securing timely behavioral health referral resources

Remember, you are not alone in Connecticut!

Child Health and Development Institute (CHDI)

• The Educating Practices In The Community Program (EPIC) provides in-office trainings on a variety of topics, including screening and connecting children and families to behavioral health resources

• To Learn More About EPIC or to SCHEDULE A Training Session, Contact:

• Maggy Morales, EPIC Coordinator• mamorales@uchc.edu• 860-679-1527

Why is Screening Critical in Pediatric Primary Care?

Primary Care: ideal setting to identify developmental delays; de facto behavioral health system; PC providers often serve as gatekeepers to early intervention and behavioral health care 1

Decreases inappropriate referrals, facilitates early identification and early intervention to improve overall outcomes and cost savings 2,3

Behavioral health conditions are highly prevalent in PC 4

Majority of behavioral health conditions are undetected and/or untreated 5

Barriers to Screening in Primary Care

Anticipated Barrier Proven Experience

Lack of Time Screening can be completed quickly and efficiently

Lack of Staff No additional staff required

Lack of Training Minimal training is needed for screening

Lack of Patient and/or Parent Acceptance

Vast majority patients and parents accept and appreciate screening

Remaining Barrier

• Timely, Readily Available, and Collaborative behavioral health referral resources

• This barrier is being tackled in Connecticut and the expanding solutions will be addressed throughout today’s webinar

First-Stage ScreeningBrief standardized measures administered on a routine basis

Designed for asymptomatic, apparently “normal” patients

Does not provide a diagnosis but identifies those in need of further assessment

Results in further discussion, second-stage screening, or referral for a formal evaluation

Helps to formulate referral questions

Second-Stage ScreeningGenerally conducted when 1st stage screen identified a risk

Available to all patients but only administered after positive 1st stage screen

Determines if referral for extensive evaluation is needed/conserves full intensity services for those truly in need

Effectiveness relies on knowledge of resources to facilitate timely triage

Uses Single or Multi-Dimensional Scales dependent on need

Clinical Pearls for the Pediatric Health Care Provider to Introduce Screening in Primary Care

• Universal (First-Stage) Screening: “We ask all of our patients these questions because it helps us understand if you have concerns that we should discuss in our visit.”

• Selective (Second-Stage) Screening: “I see that you have concerns about your child’s development/your life and would like you to answer these questions so I can better understand what is happening and see if I can help.”

• Note: Parents are typically the informants on standardized screening in pediatric primary care until the child reaches adolescence

Establishing Screening Practices

WHO will administer and score the

screening instruments and how will they be trained?

WHAT are the concerns of the

practice which you wish to establish screening for?

WHEN will the screening occur?

WHERE will the screening occur and via what mechanism?

HOW will screens be scored and results be

made available to providers,

communicated to patients, and entered

in the record?

HOW much time will screening require?

Key Steps to Implementing a Screening Program

• Assess current office protocols• Identify a clinical champion and an administrative champion

to maintain the initiative as a priority• Select screening tool(s)• Map the workflow• Identify system supports (networking with community

partners is key)• Conduct staff orientations• Share process and outcome data at regular intervals with staff

and modify procedures as needed

Establishing a Protocol for Responding to Positive Screens

Interpretation of a Positive Screen and Follow-Up Activities

• Interpret score as child is “at risk”

• May schedule a separate appointment to fully discuss screening results

• Choose from a pre-established continuum of intervention options 1

• Primary care-delivered psychosocial interventions• Behavioral health/developmental specialist or team based in primary care• Linkage with specialty behavioral health/developmental services

• Referrals for further evaluation/treatment should take into consideration: settings in which behavioral health difficulty occurs; developmental status; health status; and family/cultural factors 2

• Provide assistance to ensure that recommended follow-up services are secured

Consider Developing a Patient Registry:It helps to recognize developmental and behavioral

health issues as chronic conditions• Maintain ongoing follow-up• PCP office should serve as the patient’s medical home• Use a chronic care model for treatment• This can involve a “Chronic Disease Registry” in your office which could

look like:• a cardex• an excel spread sheet• an electronic data bank

• Some offices will designate one person (medical assistant or nurse) to be in charge of all matters involving developmental and behavioral health issues, e.g., ADHD diagnosis and follow-up

• This person can help you with efficiency by making sure parents complete all relevant paperwork and that you have the results of screening (e.g., Vanderbilt) in a timely fashion. They can also obtain copies of any formal psycho-educational testing done by school or specialists

Patient Registries

• Facilitate clinical decision support approaches and evidence-based practice guidelines

• Sophisticated registries extract data directly from the electronic medical record and track outcomes overtime

Example Patient Registries

• FDA recommends follow up weekly times 4 weeks then every 2 weeks times 2 months and then at 12 weeks

• EHR registry extracts patients who recently started antidepressant medication

• Care manager schedules 2 phone follow-ups and an in-person visit within 84 days to monitor medication compliance and track PHQ9

Newly Identified

Patients with Depression Initiated on

Antidepressant Medication

Follow-UpFDA Statement: Ideally, such observation would include at least weekly, face-to-face contact with the patients or their family members or caregivers during the first 4 weeks, then biweekly x4 weeks, then at 12 weeks. Additional contact by telephone maybe appropriate between face-to-face visits.

*NOTE* There is no empirical evidence to support weekly face-to-face; evidence suggests telephone contact may be just as effective. AACAP recommends following FDA guidelines until more research findings available.

Follow Up Schedule

* Face- to- Face• After 12 weeks, visits every 1-2 months x 1year• Continue medications until 9 months after remission is achieved• REMEMBER: Start low, go slow, When stopping, small changes, go slow

1*

2*

3*

4*

6*

8*

12*

Example Patient Registries

• EHR registry extracts patients with A1C >9% • Care manager invites patient to a visit or

interdisciplinary group medical appointment; design individualized plans to address areas of need (e.g., nutrition, exercise, pharmacological, behavioral health)

Diabetic Patients

with Recent

Increase of A1C >9%

Sample First-Stage Screening for Children Measure Age Range Time Languages Source

Ages and Stages Questionnaires, 3rd Edition (ASQ3)

1-66 Months**Recommend: 9, 18 and 24/30

months

10-15 Minutes English, Spanish Purchased from: www.brookespublishing.com (sample form on website)

Parent Evaluation of Developmental Status (PEDS)

0-8 Years**Recommend: 9, 18 and 24/ 30

months

5 Minutes English, Spanish, Vietnamese

Purchased from:www.pedstest.com Online test found at: www.Forepath.org

Modified Checklist for Autism in Toddlers, Revised with Follow-Up (M-CHAT-R/F)

16-30 months**Recommend:

18 and 24 months

Initial screen:5 minutes

English, Spanish, French, Japanese,

Vietnamese +

Freely available: www.mchatscreen.com

Coming Soon:The Survey of Wellbeing of Young Children (SWYC)

2-60Months

<15 minutes

English, Spanish Freely available:www.THESWYC.org

Pediatric Symptom Checklist (PSC-17; parent completed)

4-16 Years 5 Minutes English, Spanish, Brazilian, Chinese +

Freely available:http://www.massgeneral.org/psychiatry/services/psc_home.aspx

Pediatric Symptom Checklist-Youth ReportComing Soon: Brief Pediatric Symptom Checklist-Youth Report

11-18Years

5-10 Minutes

English, Spanish Freely available:http://www.massgeneral.org/psychiatry/services/psc_home.aspx

Patient Health Questionnaire (PHQ-9): Modified for Teens (Depression)

12-18 Years <5 Minutes English, Spanish, Chinese, Italian +

www.phqscreeners.com

CRAFFT Test (Substance Abuse) 11-21 Years <5 Minutes English, Spanish + www.ceasar-boston.org/clinicians/crafft.php

ASQ3

22

PEDS

23

M-CHAT-R

PSC-17

25

PHQ-9: Modified for Teens

26

CRAFFT

Measure Age Range Time Languages Source

Edinburgh Postnatal Depression Scale (EPDS)

Mothers 1, 2, 4 and 6 months postpartum

<5 minutes 23, Including English & Spanish

Freely Available:www.brightfutures.org; andhttp://www.fresno.ucsf.edu/pediatrics/downloads/edinburghscale.pdf

New Recommendation in Connecticut:

• 10% to 20% of women giving birth each year experience mental health challenges that affect their ability to nurture their children 1

• Consequences of maternal postpartum mental health disorders are far-reaching and family-wide 2, 3 contributing to:

• Developmental delays; Learning difficulties; Lifelong behavioral health difficulties; Partner stress and depression

• Pediatric primary care, where infants receive services frequently in the first year of life, is an opportune site to identify mothers with Postpartum Mood and Anxiety Disorders and connect them to treatment 4

Screening for Postpartum Mood and Anxiety Disorders

Measure Domain Age Range Time Source

Screen for Child Anxiety Related Disorders- Brief (SCARED-Brief)

Anxiety 8-18Parents complete: 8-

11Child completes:

12-18

<5 minutes Freely Available:Birmaher, B., et al., (1999)J Am Acad Child Adolesc Psychiatry, 38(10), 1230-1236

Vanderbilt ADHD Screening Tool

ADHD and Comorbid Disorders

6-12 (parent and teacher forms)

10 minutes Freely Available:www.nichq.org

SNAP-IV Rating Scale - Revised (SNAP-IV-R)

ADHD and Comorbid Disorders

6-18 (parent and teacher forms)

**Recommended: 13-17

10 minutes Freely Available:http://www.adhd.net

Center for Epidemiological Studies – Depression Scale for Children & Adolescents (CES-DC)

Depression 6-17**Recommended: Children Under 12

5 minutes Freely Available:http://www.brightfutures.org/mentalhealth/pdf/tools.html

Post-Traumatic Stress Disorder Reaction Index – Abbreviated (UCLA PTSD RI)

Trauma Caregiver Report: 4+

Child Report: 8+5 – 10

minutes

© 2001 R.S. Pynoos, MD and A.M. Steinberg, PhD (Youth Version)© 2008 R.S. Pynoos, MD, A.M. Steinberg, PhD, and M.S. Scheeringa, MD.

Coming Soon:Connecticut Trauma Screen

Trauma Caregiver Report: 6+

Child Report: 7+

5 – 10 minutes

Lang, Cloud, Stover, & Connell. 2014.Permission is granted to use for non-

commercial purposes

Second-Stage Screening for Children

Measure Domain Age Range Time Source

Cardiac Health and Family History

Prior to Selecting

Psychotropic

Medication

Any Age <5 minutes Freely Available:CTAAP Developmental & Behavioral Screening Tool Kit, October 2014

Child and Family Mental Health History (CHDI)

Prior to Selecting

Psychotropic

Medication

Any Age <5 minutes Freely Available:CTAAP Developmental & Behavioral Screening Tool Kit, October 2014

Adult ADHD Self-Report Scale (ASRS-v1.1) Symptom Checklist

Adult ADHD 18+ 5 minutes Freely Available:www.help4adhd.org(under Rating Scales and Checklists)

Ask Suicide Screening Questions

Follow-up to Positive Suicidal Ideation

10-21 <5 minutes Freely Available:http://www.nimh.nih.gov/news/science-news/2013/file_143902.pdf

Targeted Screens To Consider:

Measure Domain Age Range

Time Source

STOPFIRES

Self Harming Adolescents

Adolescence

5 minutes

Freely Available:Non-suicidal Self-Injury; Kerr, P., et al. (2010). A review of current research for family medicine and primary care physicians. J Am Board Family Medicine, 23, 240-259.

Helpful Mnemonic for Evaluating Self Harm:

S T O P F I R E S

Tool SelectionUseful Resources for Selecting Measures Include:

• American Academy of Pediatrics’ Mental Health Toolkit (2010) http://www.aap.org/commpeds/dochs/mentalhealth/docs/MH-ScreeningChart.pdf

• Weitzman, C., & Wegner, L. (2015). Promoting optimal development: Screening for Behavioral and Emotional Problems. Pediatrics, 135(2), 384-395.

• Massachusetts General Hospital School Psychiatry Program & Madi Resource Center http://www2.massgeneral.org/schoolpsychiatry/screeningtools_table.asp

• Massachusetts Primary Care Behavioral Health Screening Toolkit http://www.mcpap.com/pdf/PCCScreeningToolkitUpdate04292010.pdf

Tool Selection: Consider the Role of Electronic

ScreeningElectronic Systems Administer, Score, and Analyze Online Measures with Potential Advantages:

• Conducted in either the patient’s home or in the office• Pre-visit data collection from the patient’s home allows increased time for

parent to consider responses and formulate questions• The increasing use of handheld tablets allows for flexibility and growing

possibilities in the office • Saves time for provider as tools are scored and interpreted

immediately• Information can be collected from multiple adults (parents and

teachers) with online consent to share data• Primary care clinician aware of problems and strengths prior to a

visit and can prepare• For adolescents: electronic screening is more likely to elicit

concerns and may be viewed as more confidential than interviews or paper-and-pencil measures 1

• Assists with overcoming language and literacy challenges• Measures are becoming available with audio tracks in a variety of

languages, customization is possible• Facilitates quality improvement activities

• Creates patient registries; tracking progress over time for individual children, sub-groups, and entire population

• Assists with program performance measurement

Sample Resources for Electronic Screening

• Multiple tools in one system• Child Health and Development Interactive System (CHADIS)

• Web-based diagnostic, management, and tracking tool www.childhealthcare.org/chadis

• Over 50 tools with linked decision support and resources (E-Textbook, handouts, imported local referral sources)

• Patient Tools System – pediatrics.patienttools.com • Integrates with office systems to automate screening in the practice and at

home• Assessment Library includes the most commonly used tools• Can be tailored to a particular practice’s needs

• Customized Tablet Systems (e.g., Phreesia – www.phreesia.com) • Electronically administers validated screening tools• Responses are automatically scored• Results immediately communicated to the clinician via a Patient Report

• Single tools available online (PEDS, ASQ3)

• Individualization of Electronic Medical Records Systems (e.g., Free access measures incorporated by a health system into their EMR, such as EPIC)

Reimbursement for Screening

CPT Codes: Overview

• 96110 (developmental screening, (e.g., developmental milestone survey, speech and language delay screen) with scoring and documentation, per standardized instrument), covers office overhead, i.e., the practice and malpractice expenses in the use of a screening instrument (nonphysician may give the instrument to the patient, score, and record but physician reviews)

• CT Medicaid requires specification of results: Positive or Negative (effective August 1, 2014)

• 96127 (brief emotional or behavioral assessment, with scoring and documentation, per standardized instrument)

• Code became effective nationally: January 1, 2015• CT Medicaid requires specification of results: Positive or Negative

• 99420 covers administration and interpretation of health risk assessment instruments, e.g., postpartum depression screening

Coding Resource• AAP Coding Hotline: aapcodinghotline@aap.org

AAP NewsflashMedicaid Uses New CPT Code 96127 for Billing Behavioral Health Assessments (BH screens)

• Connecticut's Department of Social Services loaded CPT code 96127 to the physician office and outpatient fee schedule to be used for behavioral health assessments. Providers will be required to bill with the appropriate modifier (U3 or U4) similar to when billing for developmental screens.

• Effective for dates of service January 1, 2015 and forward there will be a new CPT code for billing behavioral health screens (BH screens).

• 96127 is a new code for "Brief emotional/behavioral assessment (e.g., depression inventory, ADHD scale) with scoring and documentation, per standardized instrument. " CT DSS also requires the use of modifiers U3 (positive screen) and U4 (negative screen) when billing for screens for patients under age 18 with HUSKY.

• 96110 has been modified and now is defined as "Developmental screening (e.g., developmental milestone survey, speech and language delay screen) with scoring and documentation, per standardized instrument. CT DSS also requires the use of modifiers U3 (positive screen) and U4 (negative screen) when billing for screens for patients under age 18 with HUSKY.

• As communicated in PB 2014-43, the Department requires physicians (excluding psychiatrists), APRNs (excluding psychiatric APRNs), and physician assistants to use modifiers U3 (positive developmental / BH screen) and U4 (negative developmental / BH screen) when billing for developmental and behavioral health screens for HUSKY Health clients under the age of eighteen. This policy will continue to be required for developmental screens billed as CPT code 96110, and effective for dates of service January 1, 2015 and forward, will be required for BH screens billed as CPT code 96127. Please refer to PB 2014-43 and PB 2014-58 for more information regarding developmental and behavioral health screens, including how to locate validated tools.

Download the Provider Bulletin: PB 2014-91 2015 HIPPA Update.pdf

Nina Holmes, MPHNina.Holmes@ct.govDepartment of Social ServicesDivision of Health Services

Steps to Bill for Universal Developmental and Behavioral Health Screening

1. Code well child exam (99391 – 99395) with Z00.129 (Encounter for routine child health examination without abnormal findings) or Z00.121 (Encounter for routine child health exam with abnormal findings, e.g., ear infection, ADHD)

2. Designate Screening TypeDevelopmental Screening:

• Add 96110 with a modifier 25 appended to the preventative service code

Behavioral Health Screening (As of January 1, 2015): • Add 96127 with a modifier 25 appended to the preventative service code • OPTIONAL: add modifier 33 appended to the 96127 code

Notes:• CPT Codes 96110 and 96127 CAN be billed on the same date of service• Typically a maximum of 2 units will be reimbursed for a given visit, however, some companies will

pay for as many as 2 screens of each type conducted at the same visit (i.e., 2 developmental and 2 behavioral health screens with a maximum of 4 screens)

Steps to Bill for Developmental and Behavioral Health Screening continued

3. Additional Instructions• PRIVATE INSURANCE

• When billing for more than one screen of a given type at a given visit, specify number of units performed, e.g., 96110 x 2 units and/or 96127, modifier 33 x 2 units

• MEDICAID (As of August 1, 2014)

• When one formal tool of a given type is used:• Add Modifier U3 for a positive screen (i.e., 96110-U3 OR 96127-U3)• Add Modifier U4 for a negative screen (i.e., 96110-U4 OR 96127-U4)

• If two screens of the same type have the same result, the units must be rolled into one detail line:

• For example, if two instruments billed using the 96110 code and two instruments billed using the 96127 code all result in either positive or negative scores, each type of screening will have its own single line:

1. 96110 U3 x 2; 96110 U4 x 22. 96127 U3 x 2; 96127 U4 x 2

• If screens of the same type have different results, they must be split between multiple detail lines:

• For example, if one instrument billed using the 96110 code results in a positive score and another scores negative, and one instrument billed using the 96127 code results in a positive score and another scores negative, there will be 4 detail lines:

1. 96110 U3 x 12. 96110 U4 x 13. 96127 U3 x 1 4. 96127 U4 x 1

Completing the Steps

Document screening in medical record: TSA• Tool(s) used• Score(s) Achieved• Action(s) taken- e.g., guidance

provided to parents/child, referral made

• Contact CT-AAP/AACAP Executive Director Jillian Wood with specific coding/payment problems: jwood@aap.org

• If interested in participating in a work group on reimbursement advocacy for behavioral health screening in CT, contact CT-AAP Marketing/Communications Manager:

Yvette MorettiYvette.ctaap@gmail.com(860) 525-9738

Reimbursement Challenges:

40

Advantages Afforded by Screening Outweigh Any Drawbacks 1,2

• Encourages parents to discuss developmental and behavioral health concerns

• Underscores importance of behavioral health• Greatly improves detection rates• Increases parental awareness of appropriate

expectations• Improves parental observation skills • Focuses visit• Provides a template for anticipatory guidance• May shorten visits and facilitate patient flow • Reduces “hand-on-the-door” comments• Increases parental satisfaction

Dismantling the Behavioral Health Resource Barrier

• ACCESS-Mental Health CT• Child Health and Development Institute’s

EDUCATING PRACTICES IN THE COMMUNITY PROGRAM (EPIC)

• CT Child Development Infoline-2-1-1 to connect to Birth-To-Three, HELP ME GROW, autism specific programs

• Stay Tuned: Office of the Healthcare Advocate: Behavioral Health Clearinghouse

Child Health and Development Institute (CHDI) of CT: Educating Practices in the Community Program (EPIC)

• What is EPIC?• EPIC offers in-office, evidence-based trainings to pediatric and family

medicine providers on a wide range of topics vital to the healthy development of CT’s children

• EPIC trainings are brief, timely, free, and offered in the comfort of the provider’s office over breakfast or lunch (supplied for the practice) or at another convenient time

• In addition to resource material and linkages to services in the practice’s community, participating providers now receive CME/CEU credits

• A Maintenance of Certification is available for some modules • CHDI created EPIC in collaboration with the CT chapters of the

American Academy of Pediatrics and Family Physicians• CT Children’s Medical Center’s Office for Community Child Health works

closely with CHDI in the development and delivery of several of the EPIC training modules

EPIC Trainings Most Relevant to Establishing Developmental and Behavioral Health Screening Programs

1. Behavioral Health Screening: Integration into Pediatric Primary Care. This training:• Offers practical guidelines about behavioral health (and developmental)

screening in primary care• Provides a brief orientation to the most commonly used tools (sample

measures along with scoring directions disseminated)• Reviews billing procedures

2. Addressing Postpartum Depression: Opportunities in the Pediatric Setting. This training:• Reviews the prevalence, symptoms, and broad ranging effects of postpartum

depression and anxiety on the mother, baby, and family• Imparts information on screening tools (sample measures disseminated)• Provides resource materials for educating parents• Introduces practices to local behavioral health programs and clinicians

specializing in maternal/infant care

EPIC Trainings3. Connecting Children to Behavioral Health Resources. This

training:• Introduces the practice to a continuum of behavioral health providing

agencies, programs, and individual clinicians from their local community

• A broad range of behavioral health providers typically participate; covering infants to older adolescents, addressing mild to severe disorders, describing outpatient, in-home, day treatment, substance abuse interventions and emergency mobile services

• Medicaid and private insurance referral resources represented, along with the local Regional Network Manager from the CT Behavioral Health Partnership

• Discussions are facilitated promoting streamlined referral practices and bi-directional communication on shared patients

• The development of a one-page Behavioral Health Referral Resource Decision Tree listing programs and contact information is constructed upon request by participating behavioral health providers

EPIC TRAININGS

• Additional Trainings Relevant to Developmental and Behavioral Health Screening Include:• Autism Spectrum Disorders (children younger than three)• Autism Spectrum Disorders (children older than three)• Developmental Surveillance Screening & Help Me Grow• Social and Emotional Health and Development in Infants• Trauma Screening, Identification and Referral in Pediatric Practice

• To Learn More About EPIC or to SCHEDULE Your Next Training Session, Contact:

Maggy Morales, EPIC Coordinatormamorales@uchc.edu860-679-1527

A New Screening Project from CT-AAP CQN PIAASU Project

Substance use is a major issue among children and adolescents, with alcohol, tobacco, and marijuana used most often. The rise in marijuana use, non-medical use of prescription drugs, and electronic nicotine delivery systems warrants concern for adolescents. Most young people do not seek substance abuse treatment on their own. By any definition, they are in the early stages of change so it can be difficult to determine whether an adolescent is having normal mood swings or if they are suffering from substance abuse Pediatricians have an important role in preventing, identifying, and treating substance use and mental health concerns.

PIAASU PROJECT

• Improve Substance Abuse and Mental Health Care for Adolescence in your Practice

BENEFITS TO YOUR PRACTICE

Improve care of youth with substance use and mental health concerns Meet the American Board of Pediatrics of certification requirements for quality improvement (25

credits) Receive expert coaching Receive free access to the AAP Quality Improvement Data Aggregator for 12 months Improve the efficacy and efficiency of your office system Access practical tools and effective strategies for how to integrate changes into your practice

Interested in participating in theCQN PIAASU Project?

For more information contact:• Physician Project Leader

Robert Dudley, MD(860) 490-4639DudleyR@chc1.com

• Chapter Project ManagerYvette Moretti(860) 525-9738Yvette.ctaap@gmail.com

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Conclusion

• Developmental and Behavioral health problems are worthy of screening on a universal and routine basis in pediatric primary care 1

• Common• Important• Severity and impact decreased through early detection and

subsequent intervention• Inexpensive, valid, and reliable measures available

• Screening is a good use of resources (“pay me now or pay me (more) later”)

THE OPENING OF “PANDORA’S BOX” IS LONG OVERDUE

Screening for Developmental and Behavioral Health Disorders in Pediatric Primary Care Constitutes

Sound Medical Practice

Discussion…

Questions?