FAQs

​FAQs


If you don't see your question answered here or you would like additional information, please contact our screening hotline by calling 888-227-1782 (toll-free) or emailing screening@aap.org.​

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    Billing and Coding

    ​How do I bill for screening?

    Please refer to the AAP Coding Factsheets for the most up-to-date information. Relevant factsheets include: Bright Futures and Preventive Medicine, Developmental Screening/Testing and Emotional Behavioral Assessment, Depression, and Trauma.​

    Should you have other billing and coding questions, please visit Coding at the AAP or email your questions to the AAP Coding Hotline

    Screening Tools

    What does "validated screening tool" mean?
    A validated screening tool is one that has been measured for reliability (consistent results), validity (accurate results for the target problem and population), and sensitivity (probability of accurate identification of a patient with a condition). Using a validated tool is the best way to accurately identify concerns and minimize the risk of missing subtle problems. The screening tools page provides links to validated tools that can be used to screen for development and maternal depression. While there are validated questions available for various social determinants of health, there isn't a single, validated tool that covers all domains. The social determinants of health screening tools listed on our screening tools page are considered promising and several are undergoing further reliability, validity, and sensitivity testing.

    Should I do social determinants screening if there aren't validated tools?
    Experts agree that screening for social determinants of health using a standardized tool can help identify families in need1. Social determinants screening tools cover a range of different topics.  Reviewing risk factor prevalence statistics for your community can help inform the type of social determinants questions appropriate for your population. To better understand your patient population's demographics, you can search for data using The Heller School for Social Policy and Management, the Kids Count Data Center, and the County Health Rankings & Roadmaps websites.

    What are the pros and cons of each tool?
    Finding the best tool for your practice depends on several considerations. To find a good match for your situation, check out our screening tools webpage.​

    Why can't I use the Denver?
    There is evidence2 that suggests that the Denver Developmental Screening Test II (DDST-II) has limited specificity, meaning there may be numerous false positive results, and consequently, this tool has not been used widely since the 1990s. There are several more effective screening tools that have been validated and can be used to screen for developmental milestones. 

    Is the tool in my EMR a validated screener?
    While EMRs vary, you would need to confirm that the tool available in your EMR is a set of questions that has been validated. We recommend referring to the screening tools page and consulting with your practice IT staff for further information.

    EMR

    ​How do I record results in my EMR?

    The structure and flexibility of EMRs make it challenging to present a standard answer to this question. Some practices have had success with entering screening results into the appointment record and transferring notes about positive results to the patient history note. Other practices have developed a dummy desktop (or fake provider) where referrals are sent so that multiple staff members can go in and review for follow-up purposes.

    Some screening tools are interoperable with EMR systems, meaning that they will work directly within the EMR to keep records of screening results. Other tools, such as the Child Health Improvement through Computer Automation (CHICA) system, work alongside EMRs to streamline the screening process through programmed administration of screens to families, alerting health care providers to results, and prompting follow-up on referrals.

    ​​How do I set this up in my EMR?

    Considering the variation in EMRs, we recommend working with your EMR provider to develop a way to indicate when screenings are needed, record results, and track referrals. 

    Legal Issues
    ​​Can I legally screen for parent or caregiver concerns as a pediatric provider?

    It is legal to administer a caregiver-focused health risk assessment instrument for the benefit of the patient. As such, in May 2016, some state Medicaid agencies began covering maternal depression screening as part of the well-child visit3.

    Does malpractice cover concerns related to maternal depression or other caregiver issues?
    This should be discussed with your insurance provider, but experts agree that with regards to the legal and ethical concerns related to screening for maternal depression, it's purported that, "the benefits of screening outweigh the risks."4 Click here to read the AAP policy statement on maternal depression screening. ​

    For policy statements and clinical reports related to other family concerns, including poverty and toxic stress, access the AAP Resources: Screening, Referral, and Follow-up section of the social determinants of health practice resources webpage.

    State medical associations are equipped to provide additional information on state-specific legislation and coverage.

    ​Where do I document the results of caregiver screenings?

    This should be discussed with practice administrators. Some clinics find it helpful to save scanned copies of caregiver screening results in the patient's charts, while others create "hidden" notes within their EMR to record screening scores and plans for follow-up. Still other providers prefer not to document results in their EMR at all for confidentiality reasons, but instead create a systematic method for referral and follow-up that ensures that resources and services are provided to those in need.

    When am I mandated to report concerns and where do I report them?
    Physicians, nurses, and other health care workers are all mandated reporters of child maltreatment, which may include abuse or neglect. In addition, some states require health care personnel to report domestic violence; click here for more information about these regulations. For more details and state-specific regulations, refer to the Mandatory Reporters of Child Abuse and Neglect Guidebook presented by the Child Welfare Information Gateway.​

    Referrals

    What do I do with a positive screen?
    A positive screen is not a diagnosis; therefore, it is important to engage in a conversation with the caregiver(s) to ensure the answers provided on the screening tool accurately reflect the child or family's status. The clinician should then interpret the screening results in the context of this conversation as well as clinical observations and mutually agree on the next steps with the family.​

    How do I talk to parents?
    ​​​It can be difficult to have conversations with a family about sensitive topics such as maternal depression or social determinants of health. Therefore, convers​ations should balance promoting family strengths with addressing concerns and should include an explanation of what the screening results mean and the follow-up plan. It can also be helpful to use motivational interviewing techniques and the Common Factors approach to engage the family in the discussion. Common Factors are effective family-centered techniques that health care providers can use during interactions with any patient or family.

    For more information about family-centered care, visit the  Family Voices website or access the resources provide by the National Center for Medical Home Implementation.

    How​ do I address language and cultural issues in discussing screenings and making a plan with families?

    Using a parent advocate that understands the patient's culture, establishing a parent group, or linking families with a parent support organizations such as Family Voices or Parent to Parent can be effective ways of addressing language and cultural barriers by increasing a sense of social support for families and assisting with cultural translation5. Establishing a parent advocate program can also benefit the provider by increasing awareness of family needs.

    ​How do I track referrals and follow up on their results?

    There are a multitude of ways that practices have had success in tracking that a referral was made and its outcome. One clinic successfully created a "dummy desktop" (fake provider) in their EMR so that all charts that are referred can be sent there as a reminder for follow-up. A care coordinator then makes the calls and records outcomes directly in the EMR.  Another practice prints out a copy of the patient's chart and physically files the piece of paper in a folder at the nurse's desk as a reminder for follow-up calls. Again, the nurse will then record outcomes of the call directly into the EMR. A different practice prints out an additional patient label and puts it in a folder that is checked once a week for new follow-up needs and highlighted when complete.

    ​How do I identify and connect with service providers in my community/state for referrals?

    There are many ways to begin identifying and connecting with community or state service providers. Examples of categories to list in a resource directory include community mental health providers, early childhood education providers such as Head Start, housing advocates, homeless shelters, food banks, domestic violence support services, local contact people for Part C of the Individuals with Disabilities Education Act (IDEA) (includes early intervention services for children aged 0-2 years), local contact people for Part B of IDEA (includes special education and related services), local disability organizations, parent support organizations, and legal services. You can also check with your local/state health department, child and family services, or other community organizations, who often have existing resource lists.

    If you already have an idea of what services you need to connect with, you can try visiting their website and emailing or calling them directly to gather details about their eligibility, service caps, wait time, service area, fees, and other information. It is recommended that you reach out to the service provider to ensure that any information posted online is current. This connection can be a great way to begin building a referral partnership.

    ​What if I encounter a positive screen but don't have a resource to provide to the family?

    This is a common concern of those who are new to screening. While the likelihood of there being a complete void of resources is very low, it is helpful to plan for how you will offer support to families in case of long waiting lists or an absence of local services.

    When services are unavailable or difficult to access, health care providers can still have an important impact on families by building a therapeutic relationship and implementing a common factors approach to their care. The common factors approach involves practicing effective family-centered techniques during interactions with patients and families. These skills include offering hope, communicating empathy, and building a partnership with the family in caring for their child's health. ​

    For additional information on diagnosis and management, please refer to the topic area of interest on our Practice Resources page.

    Other
    ​How do I avoid burnout?

    Screening for and addressing maternal depression or social determinants of health concerns can be very meaningful to both the family and practice staff. Doing so can enrich primary care by building stronger relationships between providers and families and mitigating the effects of circumstances that can negatively impact children's health, development, and safety. In the context of a culture that supports staff wellness, this process is rewarding; without such supports, there is a risk of chronic, vicarious trauma, sometimes called "compassion fatigue," which can lead to poor patient care and high staff turnover. Vicarious trauma is identified by the American Counseling Association as the "emotional residue" that health care providers experience after discussing pain, fear, and hardship with patient families6. One can mitigate these effects through good self-care practices, increasing awareness of the impact of stress, encouraging a supportive organizational culture, and implementing reflective supervision to address feelings that come from patient interactions7. Clinicians also report that incorporating strengths-focused dialogue into conversations can offset internalization of suffering through a focus on the positive aspects of a situation.

    Refer to the Center for Health Care Strategies, Inc. staff wellness infographic for more information.

    ​I don't have time to do all this, how do I prioritize?

    Creating and implementing a practice workflow for screening, referral, and follow-up and/or using a team-based care model can help to alleviate time constraints by making the process more efficient. Many practices have found ways to incorporate the AAP's screening recommendations into their well child visits.  However, it can take time to find the process that works best for your practice. Start with small steps (perhaps adding one new screening for one visit) and build from there.

    Some aspects of the process will improve over time, as providers build up their clinical skillset. Offering training opportunities to bolster knowledge, attitudes, and skills can help staff members become more competent and comfortable in these areas. When warranted, access the support of a care coordinator, behavioral health professionals or social workers to help.

    ​How do I advocate within my system for needed supports for screening, referral, and follow-up?

    Share with your colleagues the evidence that substantiates the importance of screening and the need for early intervention to make long-term impacts on child and family health. Communicate about the workflows that practices have used to successfully integrate screening within the time constraints of the well-child visit. Point them to the resources related to coding and billing for further information about how to receive payment for these services.

    ​What is the difference between surveillance and screening?

    Surveillance is a longitudinal, continuous process based on clinical judgement that includes eliciting and attending to concerns, maintaining a history of findings, making observations, and identifying risk and protective factors. The AAP recommends conducting surveillance at every visit. Screening should occur at the recommended visits using a validated tool for developmental and maternal depression screenings, or when a concern is expressed. For social determinants of health, it is recommended to use a tool appropriate to the patient population at every visit.

    ​​The population that my practice serves is primarily middle class or affluent. Why do I need to screen for social determinants of health?

    Adverse Childhood Experiences (ACEs) such as abuse, neglect, substance use by a parent, and parental divorce happen in every community. In fact, the CDC-Kaiser Permanente Adverse Childhood Experience (ACE) Study -- one of the largest investigations of the impact of ACEs on health -- found that among almost 20,000 participants, who were predominately white and middle-class with some college education, 26% had experienced at least one ACE. 

    In addition, though less common in some areas, poverty does occur in every community. A job layoff can leave a previously affluent family suddenly struggling to make ends meet. It is impossible to tell by looking at a child whether the family is experiencing financial strain. 

    Screening only certain families attaches stigma. Universal surveillance and screening is recommended for every practice. You can explore further resources and tools for screening for social determinants of health on this site.

​Click here ​for the citations for this page.