Pediatric Preventive Health Guidelines



Guideline/Procedure Number: MCQG1015 (previously MPQG1015 & QG100115)Lead Department: Health ServicesGuideline/Procedure Title: Pediatric Preventive Health Guidelines?External Policy ? Internal PolicyOriginal Date: 04/25/1994Next Review Date:02/12/2021Last Review Date:02/12/2020Applies to:? Medi-Cal? EmployeesReviewing Entities:? IQI? P & T? QUAC? PQC? OPerations? Executive? Compliance? DepartmentApproving Entities:? BOARD? COMPLIANCE? FINANCE? PAC? CEO? COO? Credentialing? DEPT. DIRECTOR/OFFICERApproval Signature: Robert Moore, MD MPH, MBAApproval Date: 02/12/2020RELATED POLICIES: MCQP1021 - Initial Health Assessment and Behavioral Risk AssessmentMPQP1022 - Site Review Requirements and GuidelinesIMPACTED DEPTS: Health ServicesProvider RelationsDEFINITIONS: N/AATTACHMENTS: AAP Recommendations for Preventive Pediatric Health CarePURPOSE:To specify Partnership HealthPlan of California (PHC) policy for periodic health screening and preventive health services for members through 20?years of age provided by primary care providers. The California Department of Health Services requires that all Medi-Cal managed care health plans, including PHC; utilize the current Child Health and Disability Program (CHDP) and American Academy of Pediatrics (AAP) preventive health care recommendations, as well as the Advisory Committee on Immunization Practices (ACIP)/AAP immunization schedule, in formulating plan specific standards and guidelines. Since all PHC primary care providers who care for children are expected to be enrolled as CHDP providers, all other CHDP policies related to the provision of pediatric preventive services are applicable as well.GUIDELINE / PROCEDURE: The following standards and guidelines address periodic health screening and preventive services for low risk, asymptomatic children and adolescents. Individuals identified as being at high risk for a given condition may require screening at more frequent intervals or the performance of additional screening tests specific to the condition. High risk individuals are defined as those whose risk behaviors, family history, socioeconomic status, life style or disease or genetic condition is associated with a higher tendency to the development of a specific condition or disease.Where the AAP periodicity exam schedule is the same as the Child Health and Disability Prevention (CHDP) periodicity examination schedule, the AAP scheduled assessment must include all components required by the CHDP program for the lower age nearest to the current age of the child. A?physical examination is completed according to CHDP/AAP periodicity exam schedule and each health assessment will include:Anthropometric measurements of weight, length/height and head circumference of infants up to age 24 months.Physical examination/body inspection, including screen for sexually transmitted infection (STI)/ human immunodeficiency virus (HIV) on sexually active adolescents.Follow up care or referral is provided for identified physical and behavioral health problems as appropriate.Primary Care Providers (PCPs) must complete an Initial Health Assessment?(IHA) on all new members within 120 days of enrollment to PHC. Since the Initial Health Assessment includes the provision of an Individual Health Education Behavioral Assessment (IHEBA), also known as Staying Healthy Assessment (SHA), it must also be completed during this timeframe. If the member was already enrolled in the PCP’s practice and only the insurance coverage changed, then any physical, containing all the elements that were done within the previous 12 months, may be counted.Immunizations must be provided according to the General Recommendations on Immunization: Recommendations of the Advisory Committee on Immunization Practices (ACIP), AAP, and the American Academy of Family Physicians (AAFP). Specific to APL 18-004: Providers must ensure timely provision of immunizations to members in accordance with the most recent schedule and recommendations published by ACIP, regardless of a member’s age, sex, or medical condition, including pregnancy. Providers must document each member’s need for ACIP recommended immunizations as part of all regular health visits.When immunizations are provided at sites other than the PCP’s office, the provider should notify the PCP’s office of the immunization given and the date.If this is not possible, the member or parent/guardian of the member must be advised to provide this information to the PCP at the next visit.PCP office should be requesting previous medical record(s) to show a complete history.Unless the member has received a periodic health screening visit within the periodicity schedule in reference B, the member, or the member’s parent/guardian, must be informed at the time of each nonemergency primary care visit of the availability of services through the PCP’s practice. If the needed exam qualifies for services through the CHDP program, the member’s parent/guardian should be informed that services are available at the PCP’s practice, or at another site offering CHDP services.This requirement may be met through the provision of the PHC document Recommendations for Preventive Adolescent/Pediatric Care in reference A, or by providing a document of equivalent content.Should the member not receive periodic health screening services according to the attached schedule, either:The voluntary refusal of the member (or the parent/guardian) regarding the use of CHDP services should be documented in the member’s medical record, or:There should be documentation of an outbound phone call or written communication from the provider to the member advising of the need to schedule a periodic health screening appointment.In the case where a child scheduled for a periodic health screening visit is not seen as scheduled, the PCP’s staff should contact the member (or parent/guardian) to reschedule the visit, and document same in the medical record.Diagnosis and treatment of any medical conditions identified through the periodic health screening (CHDP) process, either by the PCP or through referral to a specialist, must be initiated within 60?days of?identification. Justification for delays beyond 60 days must be entered into the member’s medical record.Providers must enter their findings in the member’s medical record.Parents of children found to have conditions which could constitute eligibility for the California Children’s Services (CCS) Program must be informed. The PCP’s staff should initiate a referral to the county CCS office for eligibility determination.Monitoring and Quality managementTimeliness and appropriateness of pediatric preventive health will be monitored annually by completing designated Healthcare Effectiveness Data and Information Set (HEDIS?) measures (Childhood Immunization, Adolescent Immunization, Well?Child Visits in the third, fourth, fifth and sixth years of life, Adolescent Well Care Visits and Well Child Visits in the First 15 months). Documentation of children’s/adolescent preventive services will be reviewed periodically as a component of the Site Review.Developmental ScreeningBefore age 3, comprehensive developmental screening must be performed at least annually, using one of the standardized instruments listed below.Ages and Stages Questionnaire (ASQ) - 2 months to age 5Ages and Stages Questionnaire - 3rd Edition (ASQ-3)Battelle Developmental Inventory Screening Tool (BDI-ST) - Birth to 95 monthsBayley Infant Neuro-developmental Screen (BINS) - 3 months to age 2Brigance Screens-II - Birth to 90 monthsChild Development Inventory (CDI) - 18 months to age 6Infant Development Inventory - Birth to 18 monthsParents’ Evaluation of Developmental Status (PEDS) - Birth to age 8Parents’ Evaluation of Developmental Status - Developmental Milestones (PEDS-DM)These are specified by CMS pediatric core measure definition: HYPERLINK "" developmental screening using one of the instruments above must be billed using the Current Procedural Terminology (CPT) code 96110 without a modifier.Additional screening tests, such as focused screening for autism using the Modified Checklist for Autism in Toddlers (M-CHAT) or screening for social and emotional development using the ASQSE, may be performed before age 3, but must be billed using the added KX modifier: 96110.KX.Developmental screening may also be performed for children over age 3, and billed with 96110 if one of the standardized instruments in section VI.J.1 is used, or 96110.KX if a another standardized tool is used.Up to one 96110 without a modifier is payable per year. Additionally, up to one 96110.KX is payable per year.Use of the correct tools will be audited by the Patient Safety team as part of the site review process. Use of the correct billing codes will be audited with intermittent spot audits, performed by the Patient Safety team.Trauma ScreeningStarting on January 1, 2020, primary care clinicians may screen children annually up to age 19 for traumatic life events using the Pediatric ACEs and Related Life-events Screener (PEARLS), which includes screening for several social determinants of health.Coding results of screening will depend on the result of the screening.G9919: Screening performed and positive and provisions of recommendations (4 and greater)G9920: Screening performed and negative (0 to 3)The California Department of Health Care Services (DHCS) is developing recommendations for stratifying the risk, based on the screening, and tailoring interventions to this risk stratification. These recommendations are based on consensus of experts and have not yet been studied systematically. DHCS will have on-line training available in early 2020 for clinicians to learn more.At this time, trauma screening for children is recommended, but not required for primary care providers caring for children.Attestation of completion of DHCS-approved training will be through DHCS. After July 1, 2020, DHCS has stated that payment for billing trauma screening services will depend on completion of this attestation.Audit: the use of the PEARLS in association with use of the billing codes above will be audited intermittently by the Patient Safety team in the quality department.REFERENCES: AAP Recommendations for Preventive Adolescent/Pediatric Care: Access all recommendations on line for free from the links found on: and Bright Futures Schedule for Health Assessment by Age Group HYPERLINK "" Recommendations on Immunization: Recommendations of the Advisory Committee on Immunization Practices (ACIP) and CDC Recommended Childhood and Adolescent Immunization and Catch-Up Schedule, access current version from link found at: Academy of Family Physicians (AAFP) on immunization can also be found at: http:immunizationUnited States Preventive Services-Task Force (USPSTF) current recommendations, American Academy of Pediatrics (AAP) current recommendations, Center for Disease Control (CDC) 2011 Immunization Schedule. Information can also be found at: Policy Letter 18-004: Immunization Requirements publications on Health Supervision for Children with (disease/genetic condition) (Search should be done under the Policy tab)CDC Immunization Schedules: : PHC Department DirectorsPHC Provider ManualPOSITION RESPONSIBLE FOR IMPLEMENTING PROCEDURE: Chief Medical Officer (CMO)REVISION DATES: Medi-Cal10/13/95; 10/10/97 (name change only); 03/11/98; 5/17/00; 02/20/02; 10/30/02 vs. 10/16/02; 10/20/04; 04/20/05; 10/19/05; 06/21/06; 09/19/07; 03/18/09; 02/17/10; 03/16/11; 10/17/12; 10/16/13; 11/19/14; 11/18/15; 10/19/16; 09/20/17; *06/13/18; 06/12/19; 02/12/20*Through 2017, Approval Date reflective of the Quality Utilization Advisory Committee meeting date. Effective January 2018, Approval Date reflects that of the Physician Advisory Committee’s meeting date.PREVIOUSLY APPLIED TO:PartnershipAdvantage: MPQG1015 - 09/19/2007 to 10/16/2013 ................
................

In order to avoid copyright disputes, this page is only a partial summary.

Google Online Preview   Download