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Presented by: Aixa I. Silvera -Schwartz, MD, FAAP. Recommendations for Preventative Pediatric Health Care. Review of AAP/Bright Futures Guidelines for Pediatric Well Visits. DISCLOSURE.

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presented by aixa i silvera schwartz md faap
Presented by: Aixa I. Silvera-Schwartz, MD, FAAP

Recommendations for Preventative Pediatric Health Care



In the past 12 months, I have had no financial relationships with the manufacturer (s) of any commercial product (s) and/or provider(s) of commercial service (s) discussed in this presentation.



  • To discuss importance of the American Academy of Pediatric Guidelines as they pertain to Well Child Visits.
  • To help determine benchmarks of quality healthcare and establish standards of delivery matrices for pediatric population.
  • To discuss what is to be accomplished at each visit as determined by AAP/ Bright Future guidelines.
  • To discuss the impact on clinic revenue by ensuring maximum reimbursement; CMO's requesting adherence to the guidelines

Visit Intervals

Infancy (Newborn to <9m/o)

Every newborn should be seeing the first week of discharge ideally 3-5 days and then at one month. Most important issues to address, weight, jaundice, breast feeding.

Then at 2, 4, 6, 9 m/o

Early Childhood (12 m/o to 4 y/o) visits 12, 15, 18 ,24 and 30 months old; then 3,4 y/o

CMO’S wants us to adhere to the guidelines a minimum of 6 visits till 15m/o

Middle Childhood (5 y/o to 10 y/o)

Adolescence (11 y/o to 21 y/o)



Weight (All Visits)

Length / Height (All Visits)

Head Circumference (< 2 y/o)

BMI (> 2 y/o)

Blood Pressure (> 3 y/o)

Under 3 y/o: In Children with Specific Risk Conditions



Risk assessment performed

Physical Exam and history

Vision screening in the office at 3, 4, 5 and 6y/o, and then every two years there after or by risk assessment; “unless new to the practice”

At 3y/o if patient uncooperative, rescreen within 6 months;

Ref.:; 111/4/902

Sensory Screening -- Vision


Sensory Screening -- Hearing

  • Newborn hearing screen results/documentation (OAE)
    • If failed then referred before 3 months.
    • Ref.:; 106/4/798
  • Hearing screening in office at 4,5 and 6y/o and then every other year at ages 8 and 10 and then by risk assessment, “unless new to the practice.

Developmental / Behavioral Screening Procedure

Developmental Behavioral Screening or Surveillance is required at every EPSDT (Health Check) visit. Standardized Developmental Screening Assessment Tools (that score sensitivity and specificity in the 70-80 percent range) will be required effective October 1, 2006 at age 9 months, 18 months, and 24 months. The 36 months developmental screening is recommended, but not required. The recommended screening tools include ASQ, PEDS, PSC (all recommended screening tools are listed in appendices). Documentation: Screening, history and physical findings must be documented in the medical record. Include type/name of tool used for screening.

Ref: Policies and Procedures for Health Check Services (EPSDT)

Georgia Department of Community Health

1 July 2010


Developmental Surveillance

Five Components

Elicit and attend to the parents

Document and maintain a developmental history

Make accurate observations

Identify the risk and protective factors


Maintain accurate records

Document the process and findings


Developmental/Behavioral Assessment

developmental screening tools
Developmental Screening Tools

Screening Questionnaires

PEDS Score (Two to ten minutes)

Sensitivity: 74% to 79% (moderate)

Specificity: 70% to 80%

Ages Stages Questionnaires (Ten to 15 minutes)

Sensitivity: 70% to 90% (moderate to high)

Specificity: 76% to 91% (moderate to high)

Either one definitely performed at 9 m/o, 18 m/o, and 24 m/o

Also used if there is a + risk assessment based on surveillance algorithm

developmental screening tools16
Developmental Screening Tools

Screening Questionnaires

MCHAT (5-10 min)

23 Questions

Five to 10 minutes

Several versions/languages

Sensitivity: 85 % to 87% (Moderate)

Specificity: 93% to 95% (High)

Autism screening to be performed at 18 m/o and 24 m/o;

By surveillance (algorithm) if any risk factors present (16 to 48 m/o)


physical examination procedures
Physical Examination Procedures

“At each visit age appropriate examination is essential, with infant totally unclothed, older child undressed and suitably draped.”

physical examination procedures18
Physical Examination Procedures
  • Newborn Screening
    • Done according to State Law
    • Review results and initiate referrals or retesting as needed
  • Accomplish between first visit and no later than 2 months. infants whose test results are unavailable at the time of the Health
  • Check visit must have a specimen collected immediately unless the results are pending due to processing.
  • Newborn screening results are available online through the State Electronic Notification Surveillance
  • System (SendSS). The registration process to access newborn metabolic screening results at:


  • Every visit is an opportunity to update and complete a child’s immunizations
  • The Recommended Childhood Immunization Schedule should be followed.
  • DCH recommends that all Health Check providers enroll in Vaccines for Children. If you are not a VFC
  • provider, vaccines are to be provided and only the administration fee will be reimbursed. All vaccines
  • administered must be documented in the medical record and in Georgia Registry of Immunization
  • Transaction and Services (GRITS).

Physical Examination Procedures

  • HB/Htc
    • Varies from State to State
    • In Georgia
      • Mandatory at 1 y/o and 2 y/o
      • Based on risk assessment at all times
      • Ref: MMWR. 1998; 47 (RR-3): 1-36.:
      • “An infants diet is a reasonable predictor of iron status in late infancy and early childhood (23,48). Infants fed mainly iron-fortified formula (> 1 mg iron/100kcal formula) (8) are not likely to have iron deficiency anemia at 9 m/o. The effect of prolonged exclusive breast feeding on iron status is not well understood. One study stated that exclusively breastfeeding for > 7months is protective against iron deficiency.”

Lead Screening:

Varies from State to State


Mandatory at 1 y/o and 2 y/o

Always give screening questionnaire until age 6


Since 1989, federal law has required that children enrolled in Medicaid and PeachCare for Kids must have their blood lead levels measured at both 12 months and 24 months of age. Children between the ages of 36 and 72 months must receive a blood lead test if they have not been previously tested for lead poisoning regardless of whether the child has been determined to be at low or high risk for lead exposure.

Completing a lead risk assessment questionnaire DOES NOT count as a lead screening and does not meet Medicaid and PeachCare for Kids requirements. The child’s medical record must also document all lead testing services rendered and the resulting values. If the lead test results are not included in the medical record, the provider’s office may receive a request for a Corrective Action Plan (CAP)

Physical Examination Procedures


Physical Examination Procedures

  • Tuberculosis Screening:
  • >A risk assessment is required at 1, 6, 12, and 18 months and then annually beginning at 24 months. A validated questionnaire is available on page 234 in Bright Futures Guidelines 3rd Edition
  • If + risk, complete PPD
physical examination procedures23
Physical Examination Procedures

Dyslipidemia Screening

All children older than 2y/o

Most current recommendation:

Does your child have parents or grandparents who have had a stroke or heart problem before age 55? q Yes q No q Unsure

Does your child have a parent with an elevated blood cholesterol (240 mg/dL or higher) or who is taking cholesterol medication? q Yes q No q Unsure

Ref: {Pediatrics June 2008;122;198-208}

physical examination procedures24
Physical Examination procedures

STI Screening: From 11y/o all sexually active patients should be screen for STD

Cervical Dysplasia Screening: All sexually active girls should be screen as part of pelvic exam beginning within 3 years of onset of sexual activity or age 21 (whichever comes first)

oral health
Oral Health

Oral health risk assessment. If the primary water source is deficient in fluoride, consider oral supplementation.

3-6 y/o determine whether the patient have a dental screening completed.

anticipatory guidance
Anticipatory Guidance

Specific guidance by age as listed by the Bright Futures Guidelines.

{all visits}

basics for wcc visits
Basics for WCC visits

What is considered a new Patient (For billing purposes)?

IAW MEDICAID guidelines, any patient who have not been seen in the clinic or same practice for the last three years.

basics for wcc visits28
Basics for WCC visits


When measuring weight, head circumference and length verify units used; especially with the use of EHR this will default and plot automatically.

Could result in incorrect plots in the Growth charts.

When in doubt, re-measure.

basics for wcc visits29
Basics for WCC visits

Age 1 and 4 WCC cannot occur prior to the respective birthday as they will not receive the immunizations associated with these ages.

Attention to detail must be stressed to ensure that they do not have to return, needlessly tying up a second appointment, for these shots!


Interperiodic Health Check Screens

An interperiodic Health Check Screen may be performed when medically necessary and at least 3 months since the last Health Check Screen for non-foster care children. The diagnosis code V70.3 will indicate this is an Interperiodic Health Check Screen.

For foster care children, an interperiodic Health Check Screen may be performed when medically necessary, upon the request by Division of Family & Children’s Services, or as listed below.


These are examples of the circumstances when an interperiodic Health Check Screen is


1. When a child requires either a kindergarten, foster care, adoption or sports physical outside the regular schedule.

2. Upon referral by a health, developmental or educational professional based on their determination of medical necessity.

Examples of referral sources may include Head Start, Agricultural Extension Services, Early Intervention Programs or Special Education Programs.

In each of these circumstances, the screening provider must specify and document

in the child’s medical record the reason necessitating the interperiodic screening.

Interperiodic Health Check Screens for non-foster care children are not allowed if

provided < three (3) months from the DOS of a complete ‘periodic’ Health Check screen.

Use only the diagnosis code V70.3 to be paid for this visit.