General Issues

2.0 USING PEDS and PEDS:DM

3.0 PEDS Accuracy

4.0 Other questions from the field

5.0 Questions about licensing, electronic medical records, and PEDS Online

General Issues

1.1. How does PEDS work?

Answer: PEDS has three steps: 1. Give parents the PEDS Response Form to complete or use it as an interview. 2. Take the PEDS Score Form and find the right column for the child’s age. Put a check in each box when parents’ had a concern. The directions at the bottom show you the correct path to follow on the PEDS Interpretation Form. 3. Follow the directions on the PEDS Interpretation Form for deciding when to refer, screen further, give advise, wait and see, or reassure.

1.2. Implementing PEDS in a busy practice

Answer: To implement PEDS easily in primary care, it is optimal—if not essential—to involve your front office staff in the process. While their first reaction may be to groan and say there is too much paperwork already, there are several things you can do to make it work smoothly and easily. This involves giving the staff a strong rationale for using PEDS and lots of control in how it is delivered. 1. First give the office staff some background information on why screening is important. 2. Second, let them know that a PEDS Response Form needs to be given to every family before they see the provider, but let the staff decide where and when (e.g. in the mail or over the phone along with an appointment reminder, at-check in, when seeing the medical technician, when ushered to an exam room, etc.) 3. Office staff will also need to ask families discreetly whether they would like to complete the measure on their own or need someone to go through it with them in order to circumvent literacy issues. 4. Give office staff the option of administering an interview version when needed and scoring the measure. This speeds things up for the professional staff. However, if the office staff are unwilling to do this, the offer will at least let them see that the entire burden of screening is not falling on their shoulders and that it is shared with others in the office.

1.3. Why can’t I photocopy or otherwise reproduce PEDS?

Answer: First, photocopying is theft. It is illegal under the Bourne Convention and carries a minimum penalty of $200,000. This extends to electronic reproduction including posting copyrighted measures on websites. Second, even when, as is the case with some tools, photocopying is permitted, it is not cheaper. Photocopying costs—a lot. Per page it is a minimum of 53¢ if a physician photocopies, 35¢ if a nurse photocopies it, and 23¢ if office staff photocopies it. And, that's just for a single page! For a more detailed explanation, see this page Third, you should be readily able to cover the minimal cost of PEDS (which is less than $0.50 for print and less than $1.00 for electronic) from reimbursement for well-visits especially now that the 96110 procedure code for screening carries separate reimbursement. If you are not getting reimbursed appropriately, please appeal your claims and contact the AAP's Office of Billing and Coding (www.aap.org) Fourth, revenues from PEDS sales support foreign- language translations and quality improvements to the tool, ensure the availability of its author to consult with providers and researchers, provide a living wage to employees of the publishing companies, and enable PEDS to be restandardized and validated periodically so that its psychometric underpinnings remain current and empirically sound.1.3. What happened to the 30-day exam?

1.4. What happened to the 30-day exam?

Answer: The 30-day examination program has been discontinued. In its stead, we have an 8-page booklet that explains PEDS and how it works, and includes sample forms to give you a feel for the test. We also have a case example on the site that shows completed PEDS Forms. You can download a copy of the PEDS Brochure by clicking here and download a case example clicking here

1.5. Is there an electronic version of PEDS?

Answer: PEDS is online for parents at www.forepath.org and available electronically in versions suitable for PDA's and electronic medical records. If interested, please contact us [online@pedstest.com] but also see the additional FAQs at the bottom of this page.

1.6. Why did the Forms change in February, 2005

Answer: We removed the numbering from both questions and scoring because some clinicians thought that anything problematic mentioned in Question 1 required a check in the first box on the Score Form, that concerns raised in response to Question 2 required a check in the second box on the Score Form, Question 3 to the third box, and so on. This is not how to score PEDS. Rather, all the things that parents write in must be categorized into the various developmental domains and the boxes on the Score Form which should be checked only for the categories of concern. So, removing the numbering helps alert clinicians to categorize, not “score by numbers”. We added a division on Path B to better guide clinicians when health concerns are the main issue. For example, a concern about whether a child is eating enough or sleeping well, now prompts providers to view existing height and weight charts, review sleeping behaviors, offer patient education, etc. Such responses constitute a second-stage screen but with an initial focus on health-related issues. Overall, it is critical to make copious use of the PEDS Brief Guide and adhere carefully to the directions therein.

1.7. Why do I need PEDS?

Answer: 1. The Denver/PDQ were not standardized except in Colorado. What do these measures have to say about children residing elsewhere? Very little! 2. The Denver/PDQ were not validated and the authors provided no proof that the items actually work. Research by other authors indicate they don't. 3. The Denver/PDQ are too long for primary care. Using selected items probably degrades accuracy even further. 4. Administering informal measures and making clinical observations take more time than it takes to give PEDS. 5. Informal checklists lack proof and decision support. If a patient fails one item, do you refer? Or do you wait until two items are failed? Three? What's the right thing to do? Who knows? What if your patient can do all items. Do you know he or she is OK? No! 6. PEDS provides clear guidance on when to refer and when not to refer. It is OK to look further at children's skills. But, it is not OK to over-ride the evidence PEDS provides (e.g., predictive concerns) with informal measures that lack any proof.

1.8. Can I laminate PEDS?

Answer: No! (although we can license such applications if your office can count PEDS’ use and establish a license agreement with us). Contact [online@pedstest.org] for assistance. Revenues from PEDS sales fund foreign language translations, validation, standardization, and accuracy studies. Revenues from PEDS are funneled into research and they also provide salaries for the staff [http://www.pedstest.com/content.php?content=staff.html] who work for EV Press and their families Our overhead is low (lower than many charities) and we provide such support services as slide shows for "train the trainers", trainees, ongoing FAQs, a discussion list on early detection, etc. We encourage you instead, to purchase PEDS for each child with whom you work. The cost is less than $0.30 per encounter. You can bill and receive often generous reimbursement via the 96110 screening procedure code. This will more than cover not only the cost of PEDS but also your time. As importantly, if you laminate PEDS, you will not have a record of what the parent said. This makes longitudinal monitoring and follow-up impossible. You need to keep the PEDS Response Form in the chart at least until the next visit when a new one is completed. And, you need to keep track of each child's results and decisions on the PEDS Score/Interpretation Form that should also remain in the child's chart. So, purchase PEDS, use our online application, contact us for support and advice, and... "do the right thing".

1.9. Should parents fill out a new form with each visit?

Answer: No! Development develops and developmental problems do too. Giving parents the same form again may coerce them into giving the same answers as they gave at the last visit even though their child may now be lagging in language or other critical skills. PEDS questions help parents think about development like professionals do, as a range of domains. The second(+) time through it, they have often thought more carefully about how their children are doing and need to be free to express that. A fresh form is essential. If providers are concerned about having too many forms in the chart, remove the last one and just keep the current one. Revenues from PEDS are used to continually improve the measure—just in the way that paying for vaccines goes to ensure they combat the latest version of flu. Developmental measures are expensive to create and maintain and clinicians need to be encouraged to respect that. But if providers are uncomfortable with PEDS, with its focus on parents' concerns, they may prefer a different approach. Please read about the PEDS:Developmental Milestones (PEDS:DM) which is a validated and accurate method for screening and monitoring children's skills: (www.pedstest.com/dm). PEDS+the PEDS:DM is an optimal approach to both screening and surveillance and both approaches involve only 16 - 18 items at each well visit while giving clinicians a range of information on how best to address parents' concerns in light of how their children are actually doing.

1.10. What is the difference between PEDS and PEDS:DM?

Answer: For compliance with the AAP's new statement you'll need both tools. PEDS elicits parents' concerns (in 10 questions, the same ones at each visit) and should be used at every well-child encounter. The PEDS:DM can either be used simultaneously or when PEDS calls for additional information before deciding whether a referral is needed. The PEDS:DM is 6 - 8 items per encounter and can be administered by parent-report or directly to children. Each one samples a different developmental domain: fine and gross motor, receptive and expressive language, self-help, social-emotional, and for older children math, reading, and spelling/writing. Both measures span the 0 to 8 year age range. So in 16 - 18 items (about five minutes of parents' time), you can provide longitudinal monitoring and address parents' concerns. As an aside, the PEDS:DM is entirely laminated comes with supplemental measures (such as the Modified Checklist of Autism in Toddlers) which the AAP suggests at 18 months for all children, as well as other tools (like parent-child interactions measures, a mental health screen for older children, etc.) for a more expanded response to meet the AAP reccomendations. There's a single longitudinal recording form that covers both measures that's kept in the chart. See PEDS:DM

1.11. Why would I want to elicit even more parents' concerns?

Answer: Parents’ concerns have ways of cropping up at inopportune times. You can prevent that by pre-empting them. With PEDS, you allow parents to express their thoughts before you work with them. This enables you to prepare, collect your thoughts and resources, and respond wisely. PEDS virtually eliminates “doorknob” concerns—the “oh by the way” ones that crop up unexpectedly at the end of an encounter and often take time from the next child and family, disrupt patient flow, etc.

1.12. I notice problems all the time. Why do I need PEDS?

Answer: First PEDS helps you ask well. Parents don’t respond to some types of questions. Parents with limited education don't always know you are interested in development. Asking carefully, let them know that developmental behavioral issues are a part of your services. Second, PEDS guides you in how best to deal with concerns once they are raised. Some concerns are not significant predictors of problems, while others are. PEDS tells you children’s level of risk for developmental and behavioral problems and what to do next. It will keep you from deferring, deferring, deferring when you should be referring, referring, referring and will keep you from referring for unneeded services, as well. Finally, PEDS reduces or eliminates "doorknob" concerns—those "oh, by the way" questions that can come up just when you think you’ve finished an encounter and that can disrupt the flow of families through your office.

1.13. Reimbursement for 96110 from Medicaid and private payers

Answer: Following discussions with the AAP, CIGNA HealthCare (CIGNA) issued clarifications for coding and payment for claims for limited developmental testing. The carrier verified that it will pay for both the preventive medicine evaluation and management (E/M) service in addition to the limited developmental testing (reported as CPT code 96110). Claims submitted with the preventive medicine E/M code and CPT code 96110 appended with modifier 59 (distinct procedural service) will be automatically processed in CIGNA claims system. Also, effective May 1, 2008 as an alternative acceptable modifier billing mechanism, CIGNA will also pay CPT code 96110 as a separate and distinct procedure, when submitted with a preventive medicine E/M service code appended with modifier 25. However, claims submitted with modifier 25 appended to the preventive medicine E/M service code requires manual processing by CIGNA, which may extend the claims processing timeframe. Horizon Blue Cross Blue Shield of New Jersey, the state’s largest insurer, has agreed to pay on claims using modifier 59. Originally slated to be valid January 1, 2009, Horizon has agreed to pay claims using modifier 59 as of October 1, 2008. Pediatricians experiencing denials from CIGNA for claims reporting CPT code 96110 should contact the AAP Coding Hotline at aapcodinghotline@aap.org.

1.14. What to do when a child's score renders multiple PEDS paths

Answer: Yes, Path A and B concerns override Path C (because children with a high risk of developmental problems often have behavioral ones too). So best to refer and see what shakes out in terms of need for special services. If a child doesn't qualify, then return to Path B (which prompts for Head Start, preschool, parent training, etc.) along with much watchful waiting and more frequent re-screening than usual. At that point, provide parents the kind of in-office counseling/parent education needed for Path C kids.

1.15. What should I do when I disagree with PEDS' results?

Answer: The evidence remains with the abundant research behind PEDS; and the predictive value of parents' concerns to identify probable problems. Avoid using informal milestones checklists to dis-confirm a concern because checklists are known to miss 70% of children with problems. If more information is needed on a child's actual skill levels, use a high quality second-stage screen such as PEDS:Developmental Milestones to confirm or dis-confirm delays. Nevertheless, sometimes parents are clearly expressing a concern about their own knowledge of child development (e.g., "What should my child be doing at this age?"). These families clearly need parenting information. Still, they are also families at risk of having a child with delays. Administering an additional screen is wise, as are referrals to Head Start, quality preschool/day care programs, and/or parent training programs. In addition, vigilant "watchful waiting" is needed and thus more careful monitoring of progress.