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Fostering Health NC · Best Practices for Providers Building and Strengthening Medical Homes for Infants, Children, Adolescents and Young Adults in Foster Care What is Fostering Health NC? There are approximately 9,000 children in foster care in North Carolina. These children
have special health care needs. Often because of the circumstances that led them to be placed into foster care, their
physical, developmental, mental/social-emotional and oral health care has been inconsistent and sometimes impacted
by crisis or injury. Fostering Health NC, a project of the North Carolina Pediatric Society, is focused on building and
strengthening medical homes for infants, children, adolescents and young adults in foster care through integrated
communications and coordination of care through a unique partnership among local Departments of Social Services,
CCNC Networks, the pediatric care team, the child and the child's family.
A. Identifying Patients in Foster Care &
C. Types of Visits
Obtaining Medical Records
According to the AAP Standards of Care, the Initial Visit
Children entering foster care are in the custody of the local should occur within 72 hours of placement into foster care Department of Social Services (DSS). DSS is responsible for (NC Division of Social Services standard for completing this collecting and providing medical and other history about visit is within seven days). The Initial Visit should be an these children and young adults. The vast majority of assessment of acute care needs and an opportunity to get children in foster care are categorically eligible for additional information for the comprehensive visit. Note:
Medicaid. Your CCNC network staff and care managers In most cases, NC health care providers may share (CCNC network care managers and local health protected health information with other providers about a department CC4C care managers) have access to Medicaid child in DSS custody without written permission. [See the claims data through the Informatics Center and to UNC School of Government's guidance on Sharing Health information about individual patients through the Provider Information for Treatment for details and legal citations, available in the Fostering Health NC Online Library.] Portal and Case Management Information System (CMIS). Your care managers can help you identify existing children A second visit, called the 30-day Comprehensive Visit,
in foster care already in your practice and access should occur within 30 days of placement into foster care, supplemental patient history information. unless medically necessary to see the child sooner. B. Frequency of Visits
Follow-up Well-Visits should start within 60 to 90 days of
Children in foster care need to be seen early and more placement. Additional health evaluations (mental health, often to monitor, support, educate and empower children developmental, educational, and dental) should occur and youth and their foster and biological parents. The based on the child's age. Refer to the AAP Standards of American Academy of Pediatrics (AAP) and Child Welfare Care for complete details about the frequency and League of America (CWLA) have published standards for health care for children and youth in foster care which D. Relevant Codes for These Visits
specify the parameters for high-quality health care. These For the Initial Visit, outpatient E/M office visit codes for a standards are available in the AAP Standards of Care new patient visit (99201-99205) or established patient visit
handout found in the Fostering Health NC Online Library (99211-99215) are recommended. Codes should be used
and from the AAP website. [See that are appropriate for the complexity of care, level of decision making and amount of face to face time required for the services provided. Often this may be detailed Summary of the AAP Standards: Children & Young Adults enough to be a 99205 (new patient) or 99215 (established Should Be Seen Early and Often Upon Entry into Foster Care patient). The Initial Visit is intended to be brief. However, 0-6 months of age: Should be seen every month
prolonged service codes (99354-99355) can be used as
6-24 months of age: Should be seen every 3 months
appropriate. As an alternative, you can use preventive 2-21 years and times of significant change
medicine visit codes for new patients (99381-99385) or
(e.g., change in placement, reunification): established patients (99391-99395), depending on the age
Should be seen every 6 months of the child in foster care. However, remember that during According to the current NC Health Check Billing Guide, the Initial Visit you may not be able to complete all Health there is no limit on the number of well-child visits since Check components (i.e., formal developmental screening), these enhanced visits are medically necessary. therefore it may be best to use an office visit code.

Fostering Health NC · Best Practices for Providers Building and Strengthening Medical Homes for Infants, Children, Adolescents and Young Adults in Foster Care D. Relevant Codes (continued)
E. Sharing Info Among Care Team Members
For the 30-day Comprehensive Visit, consider using the In order to maximize the utility of health information, care initial consult codes (99241-99245) because a report with
team members (medical home provider, social services detailed information is being sent back to DSS with case worker, and CC4C or CCNC care manager) should recommendations about coordination of care. This level of leverage available tools, including the CCNC Provider visit will often meet the criteria for a 99244 or 99245 Portal, to preserve and exchange this information. because of the time, amount of information collected and Consider encouraging your local DSS office to adopt the level of decision making. recently drafted Health Summary Forms (posted on our The ongoing additional Follow-up Well Visits based on the online libraryin place enhanced AAP schedule are considered periodic or of DSS Forms 5243 and 5244. To ensure that the forms are interperiodic visits for children in foster care if the visit is a available to all care team members, you should send well-child visit. In those instances, use the established completed copies to your DSS contact and your patient preventive medicine visit codes based on the CCNC/CC4C care manager so he/she can upload them to appropriate age of the patient (99391-99395). However,
Provider Portal. since many of these patients are being seen for follow-up Important: While CCNC Provider Portal offers robust
for physical, developmental or mental health conditions claims-based information, it has a notable limitation. (or a combination of these), the established patient office Drugs used to treat substance abuse will not appear on
visit codes (99211-99215) are most appropriate and are
medication lists in Provider Portal. Such drugs include: likely to include the level of complexity consistent with Naltrexone – Revia, Vivitrol; Disulfiram – Antabuse; 99214 or 99215. Consider using prolonged service codes Acamprosate – Campral; Buprenorphine – Subutex, (99354, 99355) with the office visit code if there is contact Buprenex; Buprenorphine/naloxone – Suboxone, Zubsolv. beyond the usual service time for that visit code. [See the AAP Helping Foster and Adoptive Families Cope with Trauma F. Screening for Mental and Social-Emotional
Coding Tips for more detailed information: Health Concerns
Children in foster care should receive the same well-child screenings recommended by the NC Health Check Billing A NOTE ABOUT ICD-9, including V CODES:
Guide for children who are not in foster care, which Many children in foster care have multiple diagnoses and include screening for primary general health risks and you should code for all conditions addressed to support the level of complexity for a given visit. Please note that in
for the Billing Guide and see order for the visit to be counted as a well periodic or
interperiodic visit for NC Medicaid, you must include
for the CCNC Medicaid Coding V20.2 or V70.3 in the list of diagnosis codes. Additionally,
and Billing Myths.] children in foster care should be identified using the ICD 9 Children in foster care are at high risk for social-emotional
(V60.81) or ICD 10 (Z62.21) code at all visits as one of the
delay due to trauma and exposure to toxic stress. Social- diagnosis codes. Additional V codes that may be used for emotional development is impacted early and, if ignored, children in foster care can be found within the AAP Coding can lead to long term problems with health and behavior.  The PEDS or ASQ-3 is required at 6, 12, 18 or 24
months, and 3, 4, and 5 years of age and should be reported as 96110 EP. These tools screen for social-
Please also review the Healthy Foster Care America Foster emotional concerns as part of a general developmental Care Coding Fact Sheet screening but are not diagnostic tools and a child in foster care benefits from additional, more specific and the CCNC Chronic social-emotional screening. Condition Report (Fostering Health NC Online Library) for a list  The MCHAT is required at the 18 and 24 month visits
of codes commonly used with children in foster care.
and is billed as 99420 EP. This is a screen for risk of
Autism Spectrum Disorder.

Fostering Health NC · Best Practices for Providers Building and Strengthening Medical Homes for Infants, Children, Adolescents and Young Adults in Foster Care F. Screening (continued)
Symptoms and Behaviors That May Be
Secondary screening tools specific for social-emotional Observed in Children in Foster Care
development and mental health concerns include the These may indicate that a child is not coping well ASQ-SE, Childhood Depression Inventory, Beck Depression and having problems related to social-emotional Inventory, PHQ-9 Modified for Teens, Center for Epidemiological development and mental health. Studies Depression Scale, and SCARED. The Pediatric Symptom Checklist (PSC) can be used as a screening tool for primary general health risks and strengths in school age children. The PSC or Youth Feeding and Eating issues Pediatric Symptom Checklist (PSC-Y) can be used in adolescents as Toileting issues (i.e., constipation, encopresis, a secondary screen for learning, social-emotional or mental health enuresis, regression of toileting skills) concerns. These secondary screening tools should be used in addition to the PEDS, ASQ-3, or PSC (if already used as a primary Self-regulation issues (inability to console or screen) with children in foster care. Additional screening tools for soothe or calm self, impulsive actions) children and adolescents can be found in the Healthy Child and Frequent severe temper tantrums Adolescent Development Promotion and Screening for Risk Self-abuse (such as biting or hitting self) handout found in the Fostering Health NC Online Library. Screening with any of these secondary screening tools can be Aggressive with other children billed using 99420 EP for Medicaid or 99420 TJ for Health Choice.
Defiance/arguing Medicaid and Health Choice allow the use of two units of 99420 Frequently in trouble at school and with peers for fighting and disrupting Hypervigilance, anxiety, or exaggerated response Excessive crying or worrying Flat affect, withdrawn, not smiling, resists cuddling in infants (problems with attachment) Dissociation (detachment, numbing, compliance, fantasy) Difficulty acquiring developmental milestones in infants Difficulty with school skill acquisition and keeping up in school Trouble keeping school work and home life organized Losing details can lead to confabulation, viewed by others as lying Inappropriate sexual behaviors or gestures See the Resource Section at the end for more information, especially the AAP's Helping Foster and Adoptive Families Cope with Trauma: A Guide for Pediatricians.

Fostering Health NC · Best Practices for Providers Building and Strengthening Medical Homes for Infants, Children, Adolescents and Young Adults in Foster Care G. Mental/Social-Emotional Health
I. Interacting with Biological Parents/Families
Evaluation and Resources
Since the goal is often to reunite children with their All children in foster care should have a validated social- biological parents, providers should make every effort to emotional screening. Children who have a positive uphold the dignity of biological parents. Providers can do screening or a known mental health condition should have this by carefully safeguarding information they receive a comprehensive mental health evaluation by a mental about a child's case and involving biological parents to the health professional in the practice or by referral to a maximum extent possible in decisions about care. During provider in the community. For infants with a positive visits, especially visits involving both biological and foster screen, there is a critical need to perform a parents, providers should ask the child how he/she refers comprehensive evaluation for social-emotional concerns to each parent figure and use that term. Providers should and other developmental concerns with the mother/ use the term "child in foster care," not "foster child." infant dyad and not just the infant. Finally, because the health and well-being of a parent is highly correlated with the child's, providers should offer There are several resources to evaluate and address support for and facilitate a parent's emotional health and social-emotional development in infants and young well-being, providing referrals if needed. children and use of these resources is increasing across North Carolina. Again, it is important to assess the J. Transitions
mother/infant dyad and not just the infant. CC4C care Children in foster care experience many kinds of managers are a great resource to help you identify local transitions and often all at once. Examples include living in resources for children under five years of age. a new home with their foster parents, joining a new foster family, visiting biological parents, starting at a new school or child care, making new friends, and sometimes having a new medical home. Children in foster care need time to Evidence-based supports and treatments include: adjust. Having a clear routine and structure can be very Child Parent Psychotherapy, Attachment Biobehavioral helpful to children at this time. Transitional objects (e.g., a Catch Up, and Circle of Security. Older children may favorite blanket, stuffed animal or other personal item) benefit from Trauma-Focused Cognitive Behavioral can help make transitions easier. Therapy. A complete list of evidence-based treatments and referrals and community supports for the The Indiana University's School of Medicine has published mother/infant dyad in your community can be found in a handout including tips for parents. the Fostering Health NC Online Library. Additionally, the NC Child Treatment Program provides a list of providers trained in these interventions. [See Adolescents often need to improve their self-management skills in order to plan and prepare for transition from Psychotropic Medication Management: CCNC-authored
pediatric to adult health care. You can help assess their guidelines for psychotropic medication management are transition readiness with a variety of tools. available on the Fostering Health NC Online Library. The AAP offers tools specific to adolescents in foster care H. Oral Health
working on transition. [Se Almost 35% of children and adolescents enter foster care with oral health issues. It is important to link these children with dental homes to have a comprehensive oral There are a wide variety of tools for both pediatric and health evaluation within 30 days of placement into foster adult health care providers on how to address and care to address their acute and preventive dental and oral promote health care transition, which also align with the health needs. Fluoride varnishing can be performed by 2010 AAP/AFAP/ACP policy. your staff for children under three and a half years during [See Information includes the a visit. [See the CCNC Pediatric Oral Health Guidance: development of portable medical summaries and emergency plans to help with planning for emergencies.

Fostering Health NC · Best Practices for Providers Building and Strengthening Medical Homes for Infants, Children, Adolescents and Young Adults in Foster Care K. Additional Resources
Foster Care
AAP Healthy Foster Care America:
Mental Health
AAP Mental Health Initiatives:
Guide to Psychopharmacology for Pediatricians. Center for Mental Health Services in Pediatric Primary Care: Trauma
AAP's
National Child Traumatic Stress Netwo Child Trauma Academy AAP Medical Home for Children and Adolescents Exposed to Violence: Early Brain Development
AAP: Early Brain and Child Developm
Center on the Developing Child at Harvard University: Best Practices for Providers was developed by the Fostering Health NC State Advisory Team, with contributions from Marian F Earls, MD, MTS, FAAP, Director of Pediatric Programs for Community Care of North Carolina (CCNC).

Source: http://www.ncpeds.org/resource/collection/9149BF33-360B-473B-823D-991C5D13B441/Best_Practices_for_Providers_9-22-15.pdf