Supplemental Information

TEMPLATE FOR REFERRAL LETTERFROM PEDIATRICIAN TO ALLIED HEALTHAND/OR SUBSPECIALIST FORADDITIONAL EVALUATION

Date

Name of evaluator (allied healthprovider or subspecialist)

Address

RE: [patient’s name, age, and date ofbirth]

Dear Mr/Ms/Dr/[name]:

I am referring [patient’s name] for anevaluation. He/she is an [age] boy/girl with a history of [term/preterm]delivery, [no significant healthproblems] or [significant healthproblems], [normal hearing andvision screens] or [abnormal hearingand vision screens], and [previouslytypical or atypical motor, language,and social skills development] or[motor, language, or social skillsdevelopmental delays] noted.

His/her teachers and parents notea lack of progress academically,especially in [insert observationshere]. Other pertinent informationincludes [eg, results of parent andteacher questionnaires for ADHD arenegative, psychosocial factors, etc].

Please evaluate further for thepresence of [learning disabilities,intellectual disabilities, or otherconditions] that could be impedinghis/her academic progress.

I look forward to working together toidentify any important issues relatedto [patient’s name]’s academicchallenges. Please do not hesitate tocontact me with any questions.

Sincerely,

[Pediatrician’s name]

[Note that many insurers do not coverpsychological or neuropsychologicaltesting when the concern is learningdisabilities, presumably expectingthat the school will perform thoseevaluations.]

TEMPLATE FOR LETTER REQUESTINGINITIATING SCHOOL EVALUATIONWRITTEN BY PARENT(S)

[Please make sure that the letter, inits final form, conforms to local,particularly state, rules that definehow parents may request theinitiation of an IEP process.]

Date

Name of principal or special servicescoordinator

Name of school

Address of school

RE: [child’s name, age and date ofbirth]

Dear Mr/Ms/Dr/Principal/SpecialServices Coordinator [name]:

I/we would like to request anevaluation of my/our daughter/son,[insert your child’s name here], forher/his eligibility for specialeducation provisions.

[Explain here why you are requestingan evaluation. Below are examplephrases.]

Her/his doctor recommended thatI/we write this letter to ask that her/his school do psychoeducational

testing to determine why she/he isnot progressing in school.

I/we are concerned that the teacher’sreport/observations of [insert yourchild’s name here]’s inattention isinterfering with her/his ability tobenefit from the educationalenvironment.

I/we understand that the evaluationis to be provided at no charge to me/us.

I/we would appreciate meeting witheach person who will be doing her/his evaluation before he or she testsmy child so that I/we can shareinformation about [insert your child’sname here] with the person doing thetesting. I/we will also expect a copy ofthe written report generated by eachevaluation so that I/we can review itbefore any IEP/educational planningmeetings are held.

It is my understanding that I/we mayhave to provide written permissionfor these tests to be administered,and I/we will be happy to do so onreceipt of the proper forms andexplanation of the process.

Please contact me/us at your earliestconvenience so that we may begin thenext steps in planning for anevaluation.

Sincerely,

[Insert parent(s) name(s) here andsign above.]

[Insert parent(s) contactinformation.]

FROM THE AMERICAN ACADEMY OF PEDIATRICS

PEDIATRICS Volume 144, Number 4, October 2019 1

TEMPLATE FOR REFERRAL LETTER FORSCHOOL EVALUATION WRITTEN BYPEDIATRICIAN

[Please make sure that the letter, inits final form, conforms to local,particularly state, rules that definehow pediatricians may request theinitiation of an IEP process.]

Date

Name of principal or special servicescoordinator

Name of school

Address of school

RE: [patient’s name, age, and date ofbirth]

Dear Mr/Ms/Dr/Principal/SpecialServices Coordinator [name]:

I am writing this letter on behalf ofmy patient, [insert child’s name here],to request that he/she have anevaluation to determine his/hereligibility for special educationprovisions. I recommended that his/her parent(s) also request that theschool obtain psychoeducationaltesting to determine why he/she isnot progressing in school. In myevaluation, I have found [inserta brief bit of relevant clinicalinformation, if appropriate].

Please contact me if I may provideany additional information. I lookforward to receiving a copy of theevaluation results. Please [mail or fax]a copy of them to my office at [insertyour preferred method of receivingthe results (either your fax number oryour office address) or, alternatively,refer to the contact information onyour letterhead]. I have includeda copy of the parent’s/parents’ signedFERPA/HIPAA compliant formpermitting release of the informationto our office.

Sincerely,

[Insert your name here.]

[Insert your contact information.]

[Keep a copy of the letter in thepatient’s medical record in case the

family needs support in the futurethat a request for testing was made.]

LETTER OF MEDICAL NECESSITY FORPSYCHOLOGICAL ORNEUROPSYCHOLOGICAL EVALUATIONFROM PEDIATRICIAN TO INSURANCECOMPANY

Date

Name of insurance company medicaldirector

RE: [patient’s name, date of birth, andinsurance number if known]

Dear Medical Director:

I am writing this letter to documentmedical necessity for [psychological/neuropsychological] testing for mypatient, [patient’s name]. He/she isnot making expected progressacademically. On the basis of history,behavioral health history, physicalexamination, mental statusexamination, and behavioralobservations, multiple diagnostichypotheses exist, and [psychological/neuropsychological] testing is themost efficient way to contribute tothe differential diagnostic assessment[or] the [psychological/neuropsychological] evaluation willbe used to help determine the child’streatment by [formulatinga differential diagnosis, identifyingspecific targets for intervention,developing a meaningful treatmentplan, etc].

I recognize insurance-covered testingis not intended to supplant serviceswhen adequate testing services areavailable in other settings. However,in this child’s case, equivalent testingis not available through the school orother organizations. Furthermore,testing is not being requested solelyto determine appropriate academicplacement. I recognize it is the publicschool’s responsibility to conduct thetesting necessary to determine theappropriate classroom setting.

The testing results are not intended todetermine [and/or redetermine][child’s name]’s eligibility for

intellectual disability waiver services. Iunderstand that this determination [orredetermination] of eligibility is theresponsibility of the [county or stateintellectual disabilities program office].

The problems that [child’s name] isexperiencing are causing significantimpairment in his/her academicfunctioning and are not simplytransient problems expected withpsychosocial stressors.

We suspect that a cognitive or organicdisturbance likely explains this child’simpairment in academic functioning,and this needs to be assessed and/orruled out.

[Or]

Thus far, treatment [give details ofcurrent interventions or ones tried,for example, counseling, medications,speech or occupational therapy, and/or individualized educationalplanning, etc] is not achieving theexpected results, and appropriaterevisions or alternatives aresignificantly unclear without theresults of testing.

If I can provide additionalinformation, please do not hesitate tocontact me.

Sincerely,

[Pediatrician’s name]

UNDERSTANDING TEST SCORES

Pediatricians are not expected tointerpret the scores from psychologicaltesting. Nevertheless, it can be helpfulto possess a general understanding ofthe testing results that are typicallyincluded in reports. In a report, scores,strengths, and weaknesses should beintegrated and explained. Mostpsychologists and neuropsychologistswill provide clarification and furtherinformation regarding the implicationsfor pediatric patients.

In the process of designing structuredpsychological tests (eg, IQ tests,adaptive functioning measures,speech and language assessments,motor functioning assessments, etc),

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the test items are administered tomany children (presumed or assessedto have typical development for theirchronological age). This allows thetest designers to observe the range ofperformance on the test items atdifferent age groups and/ordevelopmental levels and thendetermine a normative range ofexpectable responses. The group ofchildren tested in the instrumentdesign phase is known as the“standardization sample,” and theyprovide the “norm reference” for thetest or questionnaire.

When one of these structuredpsychological instruments isadministered to an individual child, hisor her performance on a particular test(or similarly, ratings on a questionnaire)is compared with what is expected onthe basis of the performance of thestandardization sample (or the normreference group or age reference group)for the instrument.

The child’s raw score (eg, numbercorrect, points achieved, responsetime) is compared to the distributionof scores obtained in the normingprocess. The raw score is transformedinto a derived score, which representswhere in the distribution of normativescores the child’s score coincides.Several types of scores can be derivedfrom test performance. Standard scoreshave a set mean and standarddeviation (SD), which allowscomparisons across tests. For summaryscores and index scores, on intelligencetests, for example, the typical standardscore has a mean of 100 and an SD of15. Individual subtest scores (scaledscores) are often based on a mean of10 and an SD of 3. Some tests,particularly questionnaires andchecklists, are based on T-scores (meanof 50 and an SD of 10).

In interpreting behavioral rating scalesand questionnaire-measures reports, itis important to note that symptomscales are based on the number ofitems that group together ona particular dimension, for example,

depression. A high score on thesescales ($70) is deemed clinicallysignificant; however, a low score is notto be interpreted as a marker ofpositive functioning, only as anindicator of lack of endorsement of theparticular items related to thesymptom in question.

The z scores reflect the number of SDunits from the mean exactly; they arebased on a mean of 0 and an SD of 1.These derived scores provide anindication of the child’s rank or standingwithin the age reference group. Forthese scores, the distance from themean of the child’s score can berepresented in a percentile rank score.Standard scores, T-scores, and z scoreshave important advantages over the useof raw scores and of percentile rankingsin interpreting test results. Percentilerankings can drop or increase rapidlywith even small changes in the standardscore, T-score, or z score. This isbecause distribution of scores can besteep, and small changes in eitherdirection can shift percentile rankingsdramatically, although the child’s actualposition in the population is not that faroff the mean.

Psychological test scores can also berepresented in terms of grade or ageequivalents. From a psychometric(measurement) perspective, these areconsidered weak scores that do notsupport making comparisons acrossindividuals because grade- or age-level units are not equal, and scoresare not normally distributed. An age-level score is merely the age in thenormative population for which thescore is the median score.Psychoeducational andneuropsychological reports shouldinclude the scores obtained on teststhat are accompanied by an indicationof the type of score or performancelevel. Reports should also note theconfidence interval associated withscores on tests of intellectual ability.

Supplemental Fig 1 reveals thestandard curve with a mean or averagescore of 100 and an SD of 15 points.

Average intelligence is 1 SD on eitherside of the mean, so the range of averageintelligence scores is 85 to 100. Aboveaverage is 115 to 130. Below average is70 to 85. Scores that are 2 SDs belowthe mean and less (55–70) areconsidered to be in the mild intellectualdisability range (when coupled withsimilarly lowered adaptive functioningmeasures). It can be helpful to usea figure like this one to help familiesunderstand the meaning of their child’sscores on psychological tests such as IQtests and language tests.

APPROACHES TO CPT ANDINTERNATIONAL CLASSIFICATION OFDISEASES, 10TH REVISION, CODINGFOR SERVICES FOR THE CARE OFCHILDREN WHO ARE NOT PROGRESSINGACADEMICALLY

As pediatricians help more childrenwho struggle academically, theirservices expand (and so will the needto consider how best to communicateto insurers what services they haveprovided) more effectively. Theprocess remains the same: CurrentProcedural Terminology (CPT) codescommunicate the nature of theservices provided, and InternationalClassification of Diseases, 10th Revision(ICD-10) codes communicate thediagnoses that justify the serviceprovided, but new services expand thesort of codes that will be used to makesure pediatricians are paid optimallyfor the work performed. Here weprovide a brief overview of thecategories of CPT and ICD-10 codesthat can be used when describingwork performed to help childrenstruggling academically. Specific codeschange quickly over time, so forreference to specific codes, turn to thetimely resources of the AAP, availableonline at www.aap.org/coding.

Categories of CPT Codes Relevant tothe Care of Children Not ProgressingAcademically

• Time spent in interprofessionalconsultation without being in the

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same room: In this clinical report, wemake clear that when workingtoward an understanding of whya child is not progressingacademically, it is essential to workwith professionals who are able tocomplete levels of evaluation that canyield accurate, dependable answers.The pediatrician who ensures that hisor her patient receives this level ofreliable evaluation will be spendingtime with those professionalcolleagues to ensure the processcomes to an optimal conclusion. CPTcodes include codes that allow thepediatrician to charge and be paid forthis time.

• Prolonged services: CPT codesinclude codes that allow thepediatrician to bill for time spentthat extends beyond the usual timespent to deliver other servicesindicated by other CPT codes.

• Codes relating to testing: CPT codesinclude codes that allowpediatricians to bill for time spentadministering a variety of tests tomeasure the developmental andbehavioral status of a child.

• Telephone and electronic care: CPTcodes include codes that allow thepediatrician to charge for servicesprovided to the family over thetelephone and via electroniccommunications.

• Care plan oversight: CPT codesinclude codes that allow thepediatrician to charge for timespent in reviewing documents anddeveloping care plans related to thecomplex documentation andplanning for children notprogressing academically.

• Team conferences: CPT codesinclude codes that allow thepediatrician to charge for servicesprovided while arranging for andattending team conferences forchildren not progressingacademically.

• Special reports: CPT codes includecodes that allow the pediatrician tocharge for services provided whena pediatrician fills out somethingother than a standard reportingform, such as paperwork related tothe Family and Medical Leave Act,camp forms, and other things thatare not considered completion ofroutine forms, such as hospitaldischarge summaries.

• Modifiers: Modifiers are 2-digitsuffixes available to add to the 5-digit CPT code to cue payers thatthe visit had something differentabout it. Documentation of thespecial circumstances thatwarranted their use is necessary.Modifiers can be used when thephysician provides a service that isseparate and identifiable from themain service provided that day,when a procedure is performedthat is distinct from the usualprocedures performed for the mainservice provided that day, or whena service is repeated, for example,more than 1 test is given.

Strategies for Appealing DecisionsWhen Insurers Deny Payment forSubmitted Claims

Even with the availability of codes forpre- and post-visit work, such asthose for interprofessionalcommunication before and after

a referral, insurers may not pay forthese services. In some cases,pediatricians may be able to negotiatewith payers to provide payment forthe time required to conductinterprofessional communicationbefore and after a referral. In somestates, interprofessional collateralcontacts can be reimbursed in stateMedicaid plans. Some AAP chaptershave chosen to collectively negotiatewith payers on behalf of multiplemedical homes in their state in thisregard.

APPROACHES TO THE USE OF THE ICD-10 WHEN PROVIDING SERVICES FORCHILDREN WITH ACADEMIC PROGRESSPROBLEMS

ICD-10 codes designate the diagnosticbasis for the provision of servicesindicated by the CPT code on the billfor services provided. Pediatriciansproviding services to children whoare not progressing academically canrefer to a wide variety of diagnosticcategories now included in the ICD-10listing of diagnoses. These categoriesinclude the following:

• anxiety-related disorders;

• behavioral and/or emotionaldisorders;

• mood or affective disorders;

• trauma- and stressor-relateddisorders;

• neurodevelopmental and otherdevelopmental disorders;

• substance-induced anxietydisorders; and

• sets of codes that refer to thepurpose of the visit.

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SUPPLEMENTAL FIGURE 1Standard curve used to display IQ score meanings.

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PEDIATRICS Volume 144, Number 4, October 2019 5

SUPPLEMENTAL FIGURE 2Example HIPAA- and FERPA-compliant release-of-information forms in English and Spanish. CFR, Code of Federal Regulations; PCP, primary care provider;STD, sexually transmitted disease.

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SUPPLEMENTAL FIGURE 2Continued.

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SUPPLEMENTAL FIGURE 2Continued.

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SUPPLEMENTAL FIGURE 2Continued.

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SUPPLEMENTAL TABLE 4 Resources for Families

Topic Contact Information

Special educationUS Department of Education, Office of Special Education and RehabilitativeServices

http://www2.ed.gov/about/offices/list/osers/index.html

Local state department of education, special education Varies by stateCenter for Parent Information and Resources http://www.parentcenterhub.org/Local school system, special education family advisory groups Varies by local schools and districtsLocal state legal aid or advocates for children Varies by stateWrightslaw Web site www.wrightslaw.com

Learning disabilitiesNational Center for Learning Disabilities www.ncld.orgCDC learning disorders information https://www.cdc.gov/ncbddd/childdevelopment/learning-disorder.htmlThe Learning Disabilities Association of America (412) 341-1515; https://ldaamerica.org/LD Online www.ldonline.orgCouncil for Learning Disabilities (913) 491-1011; http://www.cldinternational.orgInternational Dyslexia Association (formerly Orton Dyslexia Society) (410) 296-0232; www.interdys.org or http://eida.org/

Resources for children with other specific disordersBrain Injury Association of America (800) 444-6443; www.biausa.orgThe Spina Bifida Association of America (800) 621-3141; http://spinabifidaassociation.org/The Epilepsy Foundation of America (800) 332-1000; www.epilepsyfoundation.orgChildren and Adults with Attention-Deficit/Hyperactivity Disorder (301) 306-7070; www.chadd.orgChildren’s Tumor Foundation http://www.ctf.org/Bullying https://www.stopbullying.gov/

CDC, Centers for Disease Control and Prevention; LD, learning disability.

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