The history of the AAP vision screening policy updates

Over the last 15 years, the American Academy of Pediatrics (AAP) has revised its vision screening policy statements to encourage instrument-based ocular screening for patients who are too young for a visual acuity test.

To paint the evolution, here’s a brief timeline:

2002: Use of Photoscreening for Children’s Vision Screening1

  • The AAP first defines photoscreening and lists its potential benefits.
  • The AAP concludes that “photoscreening needs to be studied more extensively. The AAP favors additional research of photoscreening devices and other vision screening methods in large, controlled studies to elucidate validity of results, efficacy, and cost-effectiveness”.

2003: Eye Examination in Infants, Children, and Young Adults by Pediatricians Policy Statement2

  • AAP’s 2003 vision screening policy statement recommends that pediatricians perform an ocular history, vision assessment, external inspection of the eyes and lids, ocular motility assessment, pupil examination, and red reflex examination for children from birth to age 6.
  • For children ages 3-6, the AAP recommends that an age-appropriate visual acuity measurement and an attempt at ophthalmoscopy also be performed.

2012: Instrument-Based Pediatric Vision Screening Policy Statement3

  • The AAP “supplants the 2002 position paper” due to new clinical studies that show that “photoscreening instruments, which assess both eyes simultaneously, have been found to be useful for screening children”.
  • The new policy statement says that “instrument-based screening may be electively performed in children 6 months to 3 years of age…Instrument-based screening, if performed and interpreted correctly by appropriately trained individuals, usually identifies the presence and magnitude of optical and physical abnormalities of the eyes.”

2015: The AAP revises its vision screening policy statement with two notable standard of care updates:4

  • Annual photoscreening is now recommended for children beginning at ages 1-3.
  • Visual Acuity Testing is now recommended for children beginning at age 4 when possible.

Why did the AAP update their vision screening policy to recommend photoscreening?

  • Vision disability is the single most prevalent disability among children.2
  • Regular vision screening assessments in early childhood reduce the risk of persistent amblyopia at 7 years of age by more than 50%.  Eye examinations and vision assessments are critical for the detection of conditions that often result in visual impairment, signify serious systemic disease, lead to problems with school performance, and, in some cases, threaten a child’s life. 1
  • Ocular problems can also be the first indicator of general health concerns.3
  • “We wanted to make it easier for pediatricians so they had one document to look at that covers screening and eye exams throughout the entire childhood,” said Sean Donahue, M.D., Ph.D., FAAP, a pediatric ophthalmologist and lead author of the 2015 AAP vision policy update report. 3

Pediatric vision screening guidelines and care were not sufficient

The updated guidelines have already helped pediatricians understand how their previous care was not sufficient to meet the vision needs of young patients. In particular:

  1. Waiting until a child can perform a Snellen exam (i.e. wall chart) means catching vision disorders when their treatment outcomes are lower and learning disabilities have often developed.
  2. While an ophthalmoscope is helpful for identifying retina diseases and other conditions, they are not useful for catching amblyopia by detecting its main causes.
AAP Vision Screening Guidelines is Critical

Emphasis on Instrument-Based Screening

“A key section in the (2015) report,” according to Dr. Donahue, is the discussion of instrument-based screening, which has been endorsed by the Academy and the U.S. Preventive Services Task Force (USPSTF) as a valid method for screening very young children.³

Instrument-based screening “is quick and requires less attention from the child compared with traditional visual acuity screening, also has the best success in children…”7

This is not surprising given the poor predictive value of traditional screening.6

But why aren’t all pediatricians using instrument-based methods?

Dr. Donahue soberly points out that, “Despite the long-standing recommendations from various professional societies and organizations for all young children to be evaluated, implementation into regular clinical practice has remained less than ideal. Fewer than 20% of children receive adequate screening. Today, too many eye diseases go undetected at a stage where intervention would have otherwise been effective. As a result, amblyopia remains the most common cause of monocular visual impairment among children, as well as young and middle-aged adults.”7

The Economic Barrier

The barrier keeping many pediatricians from photoscreening is the misperception that it’s expensive. This was even cited as the main barrier in the 2012 introduction of instrument-based screening:

“The instruments themselves often cost thousands of dollars, in addition to the costs of printers and supplies for each test performed. There are additional indirect costs, including space and staff time required to perform these tests, as well as physician time to interpret them.”3

Interestingly, there are NO barriers mentioned in the 2015 vision policy update.

Another factor to the economic equation is reimbursement. While you can get reimbursed for photoscreening via CPT codes 99174 and 99177 and the USPFTF ranked the photoscreening test a B8, photoscreening reimbursement is still variable by state. (Grade B means that the USPSTF recommends the service)

Therefore, practices must make a difficult choice: buy a screener that costs as much as a car and hope for sufficient reimbursement OR continue missing children with early vision issues.

Enter GoCheck Kids’ low-cost solution

With zero upfront costs, no per test fees and a small month-to-month subscription fee, practices can now affordably AND accurately photoscreen their young patients for amblyopia risk factors.

Furthermore, practices can try GoCheck Kids free for 30 days allowing them to verify that reimbursement is adequate to offset costs.

Dr. Donahue says this about GoCheck Kids:

“The availability of GoCheck Kids is particularly intriguing. GoCheck Kids is a comprehensive pediatric vision screening app for smartphones, with mobile photoscreening and digital visual acuity. Its photoscreening functionality efficiently detects risk factors for amblyopia in real-time. A real advantage of GoCheck Kids is that it is a downloadable mobile application and, therefore, portable, affordable, and easily accessible to providers and patients. For a monthly subscription, a physician is provided unlimited utilization, breaking even after only 4-6 reimbursable tests.” 7

More and more pediatricians are responding with GoCheck Kids

“More and more pediatricians are meeting the AAP screening guidelines with positive economics. Aggregate reimbursements are also more than adequate to cover the costs and nurse’s time.”

– Dr. Roy Benaroch, Pediatrician at Pediatric Physicians

“GoCheck Kids enabled us to stop missing kids and deliver on the AAP’s guidelines in the most cost- and time-efficient manner.  We’re grateful there are zero upfront costs. It says a lot about their commitment to providers that they take on the financial risk instead of us.”

-Dr. Natasha Burgert – Pediatrician at Pediatric Associates

“We looked at other higher-cost, single-purpose screeners, but they did not make economic sense. Instead, with GoCheck Kids we were provided the photoscreener at no cost to the practice, and avoided the burden of added equipment costs that the other screeners required.”

-Dr. Suzy McNulty, Pediatrician at Mia Bella Pediatrics

Want to learn more? Sign up for a free vision screening assessment, and learn how you can meet the AAP’s vision screening recommendations by joining us in our mission to screen 20 million children by 2020.


Showing 5 comments
  • Michael W. Cater, M.D.

    The methodology seems to be effective for detecting amblyopia early. However, whether this is a cost effective modality for a physician’s practice depends on many factors including PPO reimbursement rates and one’s patient mix which could include non payers such as Medicaid/Cal Optima and HMO programs in which there will be no reimbursement. As was stated in the AAP 2012 Policy Statement on “Instrument-Based Pediatric Vision Screening” “Adoption of this new technology is highly dependent third-party policies, which could present a significant barrier to adoption”. Pediatrics 2012; 130:983-986.

    • Zac Litwack

      Hi Dr. Cater – Totally agree. In fact, I have a second edition of this post that includes reimbursement as part of the economic barrier equation. I plan to update today.

      While you can get reimbursed for photoscreening via CPT codes 99174 and 99177 and the United States Preventative Task Force ranked the photoscreening test a “B,” (recommended) reimbursement is still variable by state. This is one of the primary reasons we give practices a risk-free trial – so that they can feel out reimbursement amounts.

      P.S. Your office is about to onboard GoCheck Kids. We look forward to you joining our mission to screen 20 million kids by 2020!

  • Kelly Curtin

    Where are the references for this article listed? I see a superscript but no recorded references

    • Zac Litwack

      Hi Dr. Curtin – If you scroll all the way to the bottom of the page you will see the references. (under the footer)

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