TeenScreen Primary Care

Incorporating Mental Health CheckupsInto Adolescent Visits

The 360° Checkup

TeenScreen Primary Care and Mental Health Checkups• The American Academy of Pediatrics calls for annual confidential

screening and referral for behavioral health problems and the Society of Adolescent Medicine supports early identifications as a critical standard of care.

• TeenScreen Primary Care provides PCPs with evidence-based practices and questionnaires to screen 11-18 year-old patients.

• Mental health checkups can be incorporated into regular preventative healthcare visits for adolescent patients.

• Primary focus on:

Early identification of mental illness

Suicide prevention in youth

Linking those in need with services

Mental Health Checkup Procedures

Screening Logistics

1. When and to whom screening will be offered and administered

2. Mental health referral network/ list of providers to share with families

3. How the screening questionnaire will be administered and scored and how the results of the screening will be shared with the primary care practitioner (PCP)

4. Who will conduct the post-screening interview/ exam and where it will be conducted

5. Who will notify parents of the screening results and assist families in need of referral

As you prepare to implement mental health checkups in your practice, it may be helpful to consider the following:

Additional information about integrating mental health checkups into your practice is available in a slide presentation, upon request by

emailing mentalhealthcheckups@childpsych.columbia.edu

Screening Questionnaire (PSC-Y)

Administration, Scoring and Interpretation

Pediatric Symptom Checklist (PSC-Y)

• 35-item youth self-report questionnaire

• Designed to detect behavioral and psychosocial problems

• Questions cover internalizing, attention, externalizing problems

• Takes 5 minutes to complete and score

• Validated and widely used (Murphy et al., 1992, 1996; Gall et al., 2000; Pagano et al., 2000)

• Two items from the Columbia Suicide Screen (CSS) (Shaffer et al., 2004)

Pediatric Symptom Checklist (PSC-Y)

Available in English, Spanish, French, Haitian-Creole and Brazilian-American Portuguese

Includes two questions addressing suicide from the Columbia Suicide Screen

Scoring the PSC-Y

•Items are scored as follows:Never = 0Sometimes = 1Often = 2

•To calculate the score of the questionnaire, add all of the items scores together

Total Score = (range 0-70)

•Note if either suicide item has been endorsed (Questions 36 & 37)

•If items are left blank they are scored as 0

•If four or more items are left blank, the questionnaire is considered invalid

Defining a Positive Screen

Cut-off point defining a positive screen:

Total Score ≥ 30- 14% of 13-18 year olds in a SBHC located in a small city scored positive

- 20% of 9-14 year olds in an inner-city public school

OR

Recent Suicidal Ideation Reported- 3% of 11-18 year olds endorsed SI on the DPS in a PC sample

OR

Past Suicide Attempt Reported- 2% of 11-18 year olds endorsed SA on the DPS in a PC sample

Interpreting the Results

The PSC-Y results are not a diagnosis.

A positive score suggests the need for further evaluation.

Both false positives and false negatives occur.

• Studies on the PSC-Y show that 2 out of 3 teens who score positive are correctly identified as having moderate to serious impairment in psychosocial functioning.

• The one teen incorrectly identified usually has at least mild impairment.

• Data on PSC-Y negative screens indicate 96% accuracy (1 out of 20 teens who score negative may be impaired).

All youth who score positive on the PSC-Y should be further evaluated by their PCP to determine if referral or follow-up is needed.

Bright Futures, 2008; http://www.brightfutures.org

Interpreting the ResultsThese are the problem areas addressed by the PSC-Y and the most

critical items associated with them. Symptoms endorsed as “often” are of greatest significance.

Conducting the Post-Screening Interview/

Exam

Post-Screening Interview

Look to see if answers cluster by internal (anxiety/depression); attention (ADHD); and/ or external (conduct/oppositional defiant disorder)

Explore symptoms that were endorsed on the screening questionnaire, including those related to functioning and impairment

Inquire about suicidal thoughts and behaviors

Assess the level of impairment caused by the symptoms at school, at home and with peers

The American Academy of Child and Adolescent Psychiatry:“When to Seek Referral or Consultation with a Child and Adolescent Psychiatrist”

Practitioners should consider the following types of referrals:

Referral for evaluation and ongoing treatment.

Referral for evaluation and initial treatment with referral back for continued care.

Consultation and an evaluation but without the assumption of ongoing medical responsibility.

Consultation and an evaluation with continued supervision of treatment provided by other practitioners.

Consultation without a face-to-face evaluation of the patient; this may occur through a treatment team within a clinic or an intervention team within a school.

American Academy of Child and Adolescent Psychiatry:“When to Seek Referral or Consultation with a Child and Adolescent Psychiatrist”

Specific Criteria for Referrals: The primary care practitioner should refer when:

There is a threat to the safety of the adolescent or the safety of others.

A significant change in emotional or behavioral functioning for which there is no obvious or recognized precipitant.

The primary caretaker has serious emotional impairment or substance abuse problem.

Evidence of significant disruption in day-to-day functioning or reality contact.

The adolescent has had a course of treatment intervention for six to eight weeks without meaningful improvement.

When the adolescent presents with complex diagnostic issues involving cognitive, psychological, and emotional components that may be related to an organic etiology or complex mental health/legal issues.

There is a history of abuse, neglect and/or removal from home, with current significant symptoms as a result of these actions.

When symptoms and family psychiatric history suggests that treatment with psychotropic medication may result in an adverse response.

When a child or adolescent has had only a partial response to a course of psychotropic medication or when any child is being treated with more than two psychotropic medications.

When a behavior that seriously interferes with the treatment of a chronic medical condition.

Reimbursement Codes

Reimbursement Codes

The Modifier 25 should be added to the visit to indicate that a significant, separately identifiable E/M service was performed in addition to the preventive medicine visit.

Evaluation/ Management CPT Codes

Initial assessment can involve a lot of time determining the differential diagnosis, a diagnostic plan and potential treatment options. Therefore, most pediatricians will report either an evaluation and management code using time as the key factor or a consultation code for the initial assessment.

New Patients

99201

99202 (20 minutes)

99203 (30 minutes)

99204 (45 minutes)

99205 (60 minutes)

Established Patients

99212 (10 minutes)

99213 (15 minutes)

99214 (25 minutes)

99215 (40 minutes)

99216

Reimbursement Codes

ICD-9 Codes

V20.0 – Well-child visits

V79.8 – Negative screening results

V40.9 – Positive screening results

Reimbursement Codes

The AAP has developed a fact sheet on coding for pediatric preventive care that provides additional information about CPT and ICD-9 codes that may be used.

–AAP Coding for Preventive Care –

Reimbursement Codes

96110: Developmental Screening

96111: Developmental Testing

In 2003, two CPT codes were approved by the Centers for Medicare and Medicaid Services (CMS) specifically related to developmental and behavioral screening in pediatrics:

Reimbursement Codes

The AAP has developed a “Coding Fact Sheet for Primary Care Physicians” about the two CPT codes specific to developmental and behavioral screening.

The PSC is listed as one of the sample testing tools that can be used under the 96110 CPT code.

–AAP Coding Fact Sheet –

Reimbursement Codes

The Mid-America Coalition on Health Care developed a work group of key stakeholders to collaboratively address the complexities surrounding diagnosis, coding and reimbursement for the management of depression in primary care. As a result, two fact sheets for primary care depression reimbursement were developed.

–Mid-America Coalition on Health Care –

Primary Care Depression Reimbursement: Tips for Physicians and Practice Managers

Primary Care Depression Reimbursement: Myths vs. Facts

Reimbursement Codes

The information and resources in this guide provide primary care health professionals with the tools they need to promote mental health in children, adolescents and their families. This excerpt from the toolkit provides information on selected CPT codes, and also includes a template letter that providers can use for documentation of the reimbursement.

–AAP Bright Futures in Practice Mental Health Toolkit –

Selected General Medicine and Behavioral Current Procedural Terminology (CPT) Codes

Template letter

http://brightfutures.aap.org/materials.html

Free Materials Available Through the National

Center

TeenScreen Primary Care Quick Start Guide

Free, comprehensive resource for healthcare providers to assist with the implementation of mental health checkups in a primary care setting.

Includes the following:

Overview of TeenScreen Primary Care

Screening Questionnaire Administration & Scoring Instructions

Screening Questionnaire (Pediatric Symptom Checklist-Youth)

Interpreting the Screening Results

Making a Referral

Coding and Reimbursement Information

Teen Brochure with PSC-Y

A free brochure designed for adolescent patients that contains the PSC-Y screening questionnaire and information about mental health screening. This brochure can be placed in the waiting room so that patients can access the screening questionnaire on their own or it can be handed out to patients as they come in for their appointment. Available in English and Spanish.

Preparing Office Staff to Implement Mental Health Checkups

• Helpful tools to help involve and prepare office staff to implement mental health checkups

• Sample staffing roles and responsibilities as they relate to tasks associated with screening

• Screening implementation checklist/ worksheet

• Also available at no cost

Free, Supplemental Materials Available Upon Request

Mental Health Checkup Resource GuideProvides additional materials you may find helpful to your implementation of mental health checkups.

Post-Screening Interview ResourcesIncludes post-screening interview checklist, information for conducting

a suicide risk assessment and sample questions by symptom area.

Tips for Integrating Mental Health Checkups into Your Practice A slide presentation is available for providers who are interesting in learning more about the logistics of mental health screening and receiving tips for integrating mental health checkups into their practices.

TeenScreen Web SiteLearn more about TeenScreen Primary Care at:

http://www.teenscreen.org/teenscreen-primary-care

Get Involved! Enroll in TeenScreen Primary Care

• Visit TeenScreen’s Web site www.teenscreen.org and sign-up to receive materials

• You can also call the National Center at 800-673-7714 or email: MentalHealthCheckups@childpsych.columbia.edu.

• Upon receiving your information, you will be sent a copy of the TeenScreen Primary Care Quick Start Guide and up to 100 teen

brochures.

• Upon receiving the new materials, you are free to begin screening!

If you are interested in starting a TeenScreen Primary Care initiative: