Service Codes for Medicaid
Guidance clarifying Medicaid coverage of services for children with ASD per the Social
Security Act for the Early and Periodic Screening, Diagnostic and Treatment (EPSDT) benefit. Medicaid programs must cover services for beneficiaries with ASD under age 21, including Intensive behavioral Therapy and Applied Behavioral Analysis. The following document includes coverage, and provider service codes.
The American Academy of Pediatrics recommends well-child developmental screenings at 9, 18, and 30 months of age. For a full list of AAP recommended health screenings follow this link https://www.aap.org/en-us/Documents/periodicity_schedule_oral_health.pdf
Bright Futures is a national health promotion and prevention initiative, led by the American Academy of Pediatrics. The Bright Futures Guidelines provide theory-based and evidence-driven guidance for all preventive care screenings and well-child visits. Bright Futures content can be incorporated into health programs & clinics, schools, and familiy activities.https://brightfutures.aap.org/Pages/default.aspx
The CDC's Learn the Signs, Act Early Program provides information on developmental milestones from age 2 months to 5 years old. This program provides parental guidance and information for clinicians in detecting children who are not meeting normal developmental goals. http://www.cdc.gov/ncbddd/actearly/
The Ages and Stages Questionnaire ASQ -3, and ASQ-SE (social-emotional) rely on parents to observe their child and to complete the simple questionnaires about their child’s abilities. Having parents complete the questionnaires is cost effective and enhances the accuracy of screening by tapping into parents’ in-depth knowledge about their children, however, it relies soley on parent perception and not clinician observation. The healthcare provider scores the responses. There is a nominal fee to use the ASQ tools. More information is available at http://agesandstages.com/
The Denver Developmental Test is a common test administered by a clinician or trained professional. There are 125 child performance based items that are used to identify functional status in language skills, gross & fine motor ability, and personal-social development. The test is primarily based upon an examiner's actual observation rather than parental report. It enables the tester to compare a child's development with that of over 2,000 children who were in the standardized population. The Denver has been shown to miss some children with developmental disabilities and under-represent diverse populations, therefore it may not be the best tool for all children. More information is available at http://denverii.com/
The Hawaii Autism Project: Screening and Diagnostic Tools
Autism Screening Tools
The American Academy of Pediatrics recommends Autism screenings at 18 and 24 months of age.
Children found to have some level of developmental delay during a standard screening are often referred for additional evaluation. Screenings do not diagnose, but rather indicate the need for additional diagnostic evaluations. First stage screenings are key to improving early diagnosis of ASD. There are a number of screening tools to assess for ASD tendencies. The National Institute of Mental Health (NIMH) and the Centers for Disease Control (CDC) have numerous screening tools for toddlers and older children listed on these websites
The MCHAT-RF is a quick, easy to fill out and score screening tool that requires little to no training and is available free fromhttp://mchatscreen.com/
The SCQ is useful as a quick easy tool for older children. It has demonstrated good internal consistency and validity, however there is a higher false-negative with higher functioning children. Caregivers can rate the individual’s “lifetime” characteristics (which would be used to support a diagnosis) or current behaviors (which would be used to support the evaluation. http://www.wpspublish.com/store/p/2954/social-communication-questionnaire-scq
The CSBS assesses speech, social communication, and symbolic abilities of young children. It consists of three sections: a 24 item infant-toddler checklist, a caregiver questionnaire, and a face-to-face behavioral evaluation with child, parent, and clinician http://firstwords.fsu.edu/pdf/checklist.pdf
The CAST tool is a 39 item parent participation tool designed to assess severity of ASD symptoms in school-age children. Although primarily targeted to Aspergers syndrome, it covers the complete autism spectrum http://docs.autismresearchcentre.com/papers/2002_Scott_etal_CAST.pdf
Provider information for coding and billing: http://www.cdc.gov/ncbddd/autism/documents/aap-coding-fact-sheet-for-primary-care.pdf
A recent report from The United States Preventive Services Task Force (USPSTF) suggests that the current evidence is insufficient to assess the balance of benefits and harms of screening for autism spectrum disorder (ASD) in young children for whom no concerns of ASD have been raised by their parents or a clinician. It is important to note that an "insufficient" statement is not a recommendation for or against screening. In the absence of evidence about the balance of benefits and harms, clinicians should use their clinical judgment to decide if screening in children without overt signs and symptoms is appropriate for the population in their care (USPSTF, 2016). The American Academy of Pediatrics and the National Institute of Mental Health oppose the USPSTF report
Tips Regarding Referrals
Many referral agencies have specific HIPPA release documents that must be signed by the parent(s) or guardian to release information back to the referring provider. It is suggested that the referring provider complete the appropriate forms at time of referral. Experience has shown that some families do not follow through with referrals for various reasons. Therefore, the provider will not be aware of potential complications and or compliance with referral without completing the appropriate agency forms.
Childhood Developmental Screening Tools
Autism Spectrum Disorders (ASD) are a group of developmental brain disorders with a wide range of individual symptoms, from mild to severely disabling. One in 68 children have an autism disorder. This is 1.4% of children, however only 0.4% of children in Hawaii are known to have autism. Researchers have found that native Hawaiian and multi-racial children are under-identified with ASD 99% of the time. Researchers have also confirmed that diagnosis of children as young as two years old is reliable, valid, and stable, yet most children are not diagnosed until age four or older. Early intervention services have been shown to be the most effective way to improve a child's development, however intervention at any age is beneficial. Incorrect and under-diagnosis contributes to the lack of appropriate interventions with a negative impact on I.Q., functional ability, and adult productivity. Current research is focused on finding the earliest signs of autism as early intervention may prevent disabling ASD behaviors. Unfortunately, this research may be ineffective without consistent early childhood screenings.
CDC Autism Case Training (ACT) web-based continuing education course. This FREE introductory course is designed to help primary health care providers gain knowledge and skills to improve early identification of children with ASD and ensure timely and appropriate care.
Each module is eligible for CME, MOC (Part 2), CNE, and CEU credits. To get credit, you must fill out an evaluation and take a quiz at the end of each module. Click here for more information on CE credits. American Board of Pediatrics Maintenance of Certification (MOC) Part 2 credits are available to pediatricians who complete all three training modules, including the evaluation and quiz for each module. Click here for more information on getting MOC credit.
Autism Diagnostic Tools
The American Psychiatric Association provides standardized criteria to help diagnose Autism Spectrum Disorders. http://www.cdc.gov/ncbddd/autism/hcp-dsm.html
Diagnosis of ASD is challenging due to a lack of identified biological and genetic markers, a wide range of symptoms, changing diagnostic criteria, and individual perceptions of symptoms. Currently diagnosis is determined by the child's behavioral symptoms.
There are many tools to assess ASD but no single tool is used alone as the basis for diagnosis. Diagnostic tools usually rely on two main sources of information—parents’ or caregivers’ descriptions of their child’s development and a professional’s observation of the child’s behavior. In some cases, the primary care provider might choose to refer the child and family to a specialist for further assessment and diagnosis. Such specialists include neuro-developmental pediatricians, developmental-behavioral pediatricians, child neurologists, geneticists, child psychologists, and early intervention programs that provide assessment services such as Easter Seals. (CDC, 2016).
Selected examples of diagnostic tools:
Autism Diagnosis Interview – Revised (ADI-R)
A clinical diagnostic instrument for assessing autism in children and adults. This instrument focuses on behavior in three main areas: social interaction, communication and language; and restricted, repetitive, stereotyped interests and behaviors. The ADI-R is appropriate for children and adults with mental ages about 18 months and above. http://www.ncbi.nlm.nih.gov/pubmed/7814313
Autism Diagnostic Observation Schedule – Generic (ADOS-G)
A semi-structured, standardized assessment of social interaction, communication, play, and imagination for individuals suspected of having ASD. http://www.ncbi.nlm.nih.gov/pubmed/11055457
Childhood Autism Rating Scale (CARS)
Brief assessment designed for the trained clinician, suitable for use with any child over 2 years of age.
DSM-V Checklist for ASD
Gilliam Autism Rating Scale,Third Edition (GARS-3)
Widely used assessment tool with professionals in diagnosing autism in individuals ages 3 through 22.