Added Value: Psychological Services in Pediatrics

Reimbursement by Medicaid, the Children’s Health Insurance Program and private insurers for health care services is changing rapidly. Payment is moving away from fee for service to providing additional payment for quality of service and outcomes. This is potentially a positive trend for those working in primary care pediatrics who have focused effort on prevention and guidance services.

Pediatricians and nurse practitioners put in that extra time, make those phone calls, and provide the extra help to families that are so integral to great care but that are not reimbursed. For those of you who go the extra mile and whose patients experience better health and health outcomes, you may, under value-based reimbursement, finally be rewarded financially for your efforts.

A psychologist can assist your practice in managing the move to value-based reimbursement. Generally, payment models fall into four categories:

• Fee for service
• Fee for service, with additional payment for quality (e.g., all children are vaccinated on schedule)
• Fee for service, with payment for outcome (e.g., children with asthma are not in the emergency room as often)
• Per member per month payment, with payment for quality and outcome—instead of billing each service, you receive a global payment and an additional bonus if goals are met

The key to success in these new models is correctly identifying areas for improvement (e.g., vaccinations, attending recommended well child visits, or better management of asthma), setting benchmark goals, and meeting those goals. Most of the areas identified on payers’ scorecards involve the behavior of parents or children—and having a psychologist on your team can help you and your team set and reach those goals.

A psychologist can assist you or your staff in working with parents reluctant to vaccinate their children, or the noncompliant adolescent who is diabetic, or the anxious parents of a child with asthma so they don’t call 911 each time their child starts to wheeze. Working with families to establish healthy routines and helping your office develop information for parents on everything from getting kids to eat vegetables to setting limits on screen time are all areas where psychologists—experts in child behavior—can help families keep kids healthy and assist your practice in meeting its goals.

Screening for developmental concerns, particularly in the 14 scheduled visits in the first four years of a child’s life, is now considered an essential component of care. Screening for behavior concerns at annual well visits or possibly as part of a sick visit is also essential for care (Godoy, et al., 2017).

Screening has several steps, and a psychologist can help develop a screening protocol that is effective, efficient and meets the needs of your patients and office. The first step is identifying an effective screening method and determining how it will be administered. Methods can include a pre-visit via email, iPad or paper in the waiting room, or by a face-to-face interview with parents who may have reading difficulty. Screening methods must be developed and normed in the language of the parents.

After the screening is administered, someone must determine how the scoring is to be completed, compared to a reference range and the data recorded in the chart for the staff members involved. How the primary care provider transmits results to the parents, as well as the plan for continuing the child’s care after the office visit, needs to be outlined.

Each screening can be billed as a separate CPT (current procedural terminology) code with some reimbursement, but for this to be effective, someone must determine the workflow from check-in to checkout, how screening fits in, and who administers and scores it and makes sure it all flows efficiently. Some screening tools can now be interfaced with electronic records, and others generate reports that can be used to refer the child for further evaluation and/or educational services as needed.

A psychologist is the expert who can choose the appropriate screening and administration methods; coach the office staff to administer, interpret and enter data; and develop the referral sources for developmental, behavioral and educational services for your patients, especially those with behavioral issues identified through the screening process.

Once set up, an effective developmental and behavioral screening protocol will not only generate additional fee-for-service revenue, but meeting screening goals for your patient panel may well result in additional quality payments in a pay-for-quality system. An effective screening program is an essential service for patients and families, and when done well, can generate both fee-for-service billing and, potentially, payments for quality.

Screening: CPT Coding

• CPT 96110: Screening for development of age-appropriate skills.
• CPT 96127: Screening for emotional and behavioral difficulties.

Both to be carried out by office staff, scored and entered in chart for primary care provider to review.

Pediatric visits to discuss behavioral problems take more time than visits for a medical concern. Uncomplicated acute sick visits average 12 minutes in duration, and uncomplicated behavior visits, such as follow-up for attention-deficit/hyperactivity disorder (ADHD), an average of 19 minutes. Complicated acute sick visits average about 19 minutes, while complicated visits with behavior concerns average over 31 minutes (Gouge, Polaha, Rogers, & Harden, 2016). However, when visits are scheduled, the time allotted is the same—often 15 minutes per patient. If several behavior cases are scheduled, it does not take long for you to fall behind.

There are three potential solutions to this problem:

• The scheduler could screen and identify behavioral cases ahead of time and allocate more time for those visits, so that the provider sees fewer patients but stays on schedule.
• The office could choose to reduce the number of slots per hour to three without screening. Although fewer patients would be seen overall, this allows time to account for the behavior cases. However, even at three per hour, a few complicated behavior cases will cause a provider to fall behind.
• The scheduler could assign behavior cases to a psychologist for a planned half-hour visit or direct the patient to the psychologist once the behavioral challenge is identified.

One study with five full-time primary care providers (PCPs) compared clinic days with a psychologist present to days without the psychologist. Results showed that, on average, behavior visits for the PCP when the psychologist was present were now of the same duration as acute sick visits, and thus, more patients could be seen. Overall, the PCPs as a group were able to bill for 42 percent more patients on those days. In other words, having one full-time psychologist increased efficiency more than if the practice had hired another provider for that day (Gouge et al., 2016).

A recent JAMA Pediatrics review identified ADHD as the second largest cost for child health care in the United States, with $20.6 billion spent—two-thirds on office visits and one-third on medications (Bui et al., 2016). ADHD also results in increased spending in settings other than health care, estimated to be in excess of $24 billion in education, mental health and other youth service sectors (Pastor, Reuben, Duran, & Hawkins, 2015). With up to 10 percent of children identified as having ADHD, this is both a high cost and a time-consuming condition seen in all offices.

With a psychologist in the office, effective multimodal treatment of ADHD can be carried out at lower cost and with good outcomes and high family satisfaction. A high-cost condition can be addressed effectively and efficiently, benefiting the family, the payer, and the practice.

A psychologist can assist after an initial screening by:

• Conducting an initial evaluation that would include all the elements identified in the AAP/American Academy of Family Physicians guidelines for diagnosis
• Screening for learning difficulties (which are highly prevalent in this population)
• Contacting the schools with appropriate documentation for their evaluation and intervention services

Psychological interventions for ADHD include parent management training, which has a very strong evidence base. This can easily be done in the pediatric office in either a group or an individual family format, and it results in improvement, with or without stimulant medication, at lower cost (Page et al., 2016). For children requiring monthly prescriptions for stimulants, follow-up visits can be coordinated at the same time with the psychologist, who can gather data on home and school functioning, collect follow-up behavior checklists that also assess side effects and present that information to the provider prior to prescription refill.

Another high-frequency behavioral condition in children and adolescents is depression—costing more than $5 billion per year, with over $1 billion for inpatient expenses, another $3 billion for office visits and the rest for medication. Because of black box warnings against using antidepressants in children, many families prefer psychotherapy, which has been shown to be a safe and effective treatment that can be delivered in primary care settings (Asarnow, Rozenman, Wiblin, & Zeltzer, 2015; Dickerson et al., 2018). Structured short-term therapy for depression can be conducted individually or in groups, with effective long-term positive outcome.

As with ADHD, adherence to treatment is higher and stigma lower when it is delivered through primary care visits.

Psychologists can independently bill evaluation and therapy services delivered in primary care settings for reimbursement once the office address is registered with payers. For children who have mental health diagnoses, this would include all the appropriate individual, family and group psychotherapy codes. For children who have medical diagnoses only, psychologists can bill for Health and Behavior codes to address behavioral, social and psychophysiological conditions in the treatment or management of patients diagnosed with physical health problems. In both situations, the office should verify with payers which codes are active. In addition, the provider can bill a care coordination charge once per month (99484) to help cover the costs of coordination for patients who are managed by both the psychologist and the pediatrician.

With a psychologist in your practice, the primary care team will see improvements in efficiency and access to services for your patients, along with additional reimbursement through a new billing stream—all of which achieve the aims of keeping your patients healthier at the best value for your practice.

Asarnow, J. R., Rozenman, M., Wiblin, J., & Zeltzer, L. (2015). Integrated medical-behavioral care compared with usual primary care for child and adolescent behavioral health: A meta-analysis. JAMA Pediatrics, 169(10), 929–937. doi:10.1001/jamapediatrics.2015.1141

Bui, A. L., Dieleman, J. L., Hamavid, H., Birger, M., Chapin, A., Duber, H. C. . . . Murray, C. J. (2017). Spending on children’s personal health care in the United States, 1996-2013. JAMA Pediatrics, 171(2), 181–189. doi:10.1001/jamapediatrics.2016.4086

Dickerson, J. F., Lynch, F. L., Leo, M. C., DeBar, L. L., Pearson, J., & Clarke, G. N. (2018). Cost-effectiveness of cognitive behavioral therapy for depressed youth declining antidepressants. Pediatrics. Advance online publication. doi:10.1542/peds.2017-1969

Godoy, L., Long, M., Marschall, D., Hodgkinson, S., Bokor, B., Rhodes, H., . . . Beers, L. (2017). Behavioral health integration in health care settings: Lessons learned from a pediatric hospital primary care system. Journal of Clinical Psychology in Medical Settings, 24(3–4), 245–258. doi:10.1007/s10880-017-9509-8opens in new window

Gouge, N., Polaha, J., Rogers, R., & Harden, A. (2016). Integrating behavioral health into pediatric primary care: Implications for provider time and cost. Southern Medical Journal, 109(12), 774-778. doi:10.14423/SMJ.0000000000000564

Page, T. F., Pelham, W. E., Fabiano, G. A., Greiner, A. R., Gnagy, E. M., Hart, K. C., . . . Pelham, W. E. (2016). Comparative cost analysis of sequential, adaptive, behavioral, pharmacological, and combined treatments for childhood ADHD. Journal of Clinical Child & Adolescent Psychology, 45(4), 416–427. doi:10.1080/15374416.2015.1055859

Pastor, P., Reuben, C. A., Duran, C. R., & Hawkins, L. D. (2015). Association between diagnosed ADHD and selected characteristics among children aged 4-17 years: United States, 2011-2013 (NCHS Data Brief No. 201). Hyattsville, MD: National Center for Health Statistics. Retrieved from https://www.cdc.gov/nchs/products/databriefs/db201.htm

Wilson, J. L. (1964). Growth and development of pediatrics: Presidential address—1964. Journal of Pediatrics, 65(6, Pt. 2), 984-991. doi:10.1016/S0022-3476(64)80031-7