016-06-05 Ark. Code R. § 99
Child Health Services/Early and Periodic Screening, Diagnosis, and Treatment
A comprehensive medical screening program for all eligible Medicaid children requires the medical provider to assume overall responsibility for detection and treatment of conditions found among these young patients. This means the provider should have knowledge of specialized referral services available within the community and should maintain continuing relationships with physician specialists. It also requires the provider to work closely with the Arkansas Department of Health and Human Services office staff to ensure that eligible children in need of medical attention take full advantage of the medical services available to them.
The screening procedures outlined in Sections 213.000 and 215.000 of this manual are considered the minimal elements of a comprehensive screening. Other procedures may be included depending upon the child's age and health history. Each of the screening procedures is based on recommendations from the federal Department of Health and Human Services and the American Academy of Pediatrics. Each screening should be billed separately, providing the appropriate information for each of the applicable screening components. Other specific procedures may be used at the screener's discretion as long as the following federally mandated components are included in the complete medical screening procedure: observe and measure growth and development, give nutritional advice, immunize, counsel and give health education and perform laboratory procedures applicable for the age of the child.
Requirements for Periodic Medical, Visual, Hearing and Dental Screenings
Distinct periodicity schedules have been established for medical screening services, vision services, hearing services and dental services (i.e., each of these services has its own periodicity schedule). Periodic visual, hearing and dental screens should not duplicate prior services.
The Child Health Services (CHS) Early and Periodic Screening, Diagnosis and Treatment (EPSDT) Program is a federally mandated child health component of Medicaid. It is designed to bring comprehensive health care to individuals eligible for medical assistance from birth to age 21. Even if the person eligible for medical assistance is a parent, he or she is eligible for Child Health Services (EPSDT) if under age 21. Physicians and other health professionals who provide Child Health Services (EPSDT) screening may diagnose and treat health problems discovered during the EPSDT screening or may refer the child to other appropriate sources for such care.
The following is a broad definition of the components of the Child Health Services EPSDT program.
Early means as soon as possible in the child's life, or as soon as his or her family's eligibility for assistance has been established.
Periodic means at intervals established for screening by medical, dental, visual and other health care experts. The types of screening procedures performed and their frequency will depend on the child's age and health history. In Arkansas, the medical periodic screening schedule has been established following the recommendations of the American Academy of Pediatrics.
Screening is the use of quick, simple procedures to sort out apparently well persons from those who may have a disease or abnormality and to identify those in need of a more definitive examination.
Diagnosis is the determination of the nature or cause of a disease or abnormality through the combined use of health history, physical, developmental and psychological examination, laboratory tests and X-rays.
Treatment means physician, hearing, visual or dental services or any other type of medical care and services recognized under state law to prevent, correct or ameliorate disease or abnormalities detected by screening or by diagnostic procedures. Treatment for conditions discovered through a screen may exceed limits of the Medicaid Program. Services not otherwise covered under the Medicaid Program will be considered for coverage if the services are prescribed by a physician as a result of an EPSDT screen. The services must be medically necessary and permitted under federal Medicaid regulations.
The following steps are necessary in order to complete a Child Health Services (EPSDT) screen:
A full medical screen must, at a minimum, include: a comprehensive health and developmental history (including assessment of both physical and mental health development); a comprehensive unclothed physical exam; appropriate immunizations according to age and health history; laboratory tests (including appropriate blood lead level assessment); and health education (including anticipatory guidance).
All parts of the screening package must be furnished to the Child Health Services (EPSDT) participant in order for the screening to qualify as a full medical Child Health Services (EPSDT) screening service.
I mmunizations that are appropriate based on age and health history, but which are contraindicated at the time of the screening, may be rescheduled at an appropriate time or referred to another provider.
The prescription for services must be dated by the provider referring the patient. The prescription for the non-covered service is acceptable if services were prescribed and the prescription is dated within the applicable periodicity schedule, not to exceed a maximum of 12 months.
The Department of Health and Human Services (DHHS) county offices will continue to refer Medicaid beneficiaries to providers for Child Health Services (EPSDT) screens. However, a provider may initiate the health screen for an eligible beneficiary at the appropriate time without a referral from the DHHS county office.
An eligible child must be referred by the PCP, if the child is to be screened by a provider who is not the PCP.
See section 212.000 for EPSDT screening terminology.
Claims for EPSDT medical screenings must be billed electronically or using the DMS-694 EPSDT paper claim form. View or print a DMS-694 sample claim form.
Procedure Code | Modifier 1 | Modifier 2 | Description |
99381-99385 | EP | U1 | EPSDT Periodic Complete Medical Screen (New Patient) |
99391-99395 | EP | U2 | EPSDT Periodic Complete Medical Screen (Established Patient) |
994311 994321 994351 | EP EP EP | Initial Newborn Care/EPSDT screen in hospital | |
991731 | EP | EPSDT Periodic Vision Screen | |
V5008 | EP | EPSDT Periodic Hearing Screen | |
D01201 | CHS/EPSDT Oral Examination | ||
D01401 | EPSDT Interperiodic Dental Screen, with prior authorization | ||
99401 | EP | EPSDT Health Education - Preventive Medical Counseling | |
364152 | Collection of venous blood by venipuncture | ||
83655 | Lead |
Immunizations and laboratory tests may be billed separately from comprehensive screens.
The verbal assessment of lead toxicity risk is part of the complete CHS/EPSDT screen. The cost for the administration of the risk assessment is included in the fee for the complete screen.
Laboratory/X-ray and immunizations associated with an EPSDT screen may be billed on the DMS-694 EPSDT claim form.
When billing on paper, the EPSDT screening services must be billed with a type of service code "6."
For billing on paper, immunizations must be billed with a type of service code "1."
Services must be filed with the appropriate national procedure codes and applicable modifiers.
The following procedure codes with the applicable modifier represent an EPSDT Periodic Complete Medical Screen that includes both hearing and vision screens.
EPSDT Periodic Complete Medical Screen claims must be filed with the appropriate CPT-4 procedure codes and modifier. Procedure codes 99381 through 99385 (New Patient), with modifiers EP and U1, and procedure codes 99391 through 99395 (Established Patient), with modifiers EP and U2, will represent an EPSDT periodic complete medical screen, which includes both hearing and vision screens.
Immunizations and laboratory tests may be billed separately.
Example for EPSDT Periodic Complete Screen for an established patient:
99391, Modifiers EP and U2 = EPSDT Periodic Complete Medical Screen
Child Health Services (EPSDT) screens do not include laboratory procedures unless the screen is performed by the beneficiary's primary care physician (PCP) or is conducted in accordance with a referral from the PCP.
The following tests are exempt from this limitation and may continue to be billed in conjunction with an EPSDT Screen performed in accordance with existing Medicaid policy:
81000- | Urinalysis, by dip stick or tablet reagent for bilirubin, glucose, hemoglobin, ketones, leukocytes, nitrite, pH, protein, specific gravity, urobilinogen, any number of these constituents; non-automated, with microscopy |
81001 - | Urinalysis, by dip stick or tablet reagent for bilirubin, glucose, hemoglobin, ketones, leukocytes, nitrite, pH, protein, specific gravity, urobilinogen, any number of these constituents; automated, with microscopy |
81002- | Urinalysis, by dip stick or tablet reagent for bilirubin, glucose, hemoglobin, ketones, leukocytes, nitrite, pH, protein, specific gravity, urobilinogen, any number of these constituents; non-automated, without microscopy |
83020 - | Hemoglobin, electrophoresis (e.g., AZ, S, C) |
83655 - | Lead |
85013- | Blood count; spun microhematocrit |
85014- | Blood count; other than spun hematocrit |
85018- | Blood count, hemoglobin |
86580 - | Skin test; tuberculosis, intradermal |
86585 - | Tuberculosis, tine test |
Claims for laboratory tests, other than those specified above, performed in conjunction with an EPSDT screen will be denied, unless the screen is performed by the PCP or in accordance with a referral from the PCP.
The following screens will be affected by this policy:
Procedure Code | Modifier 1 | Modifier 2 | Description |
99381-99385 | EP | U1 | EPSDT Periodic Complete Medical Screen (New Patient) |
99391-99395 | EP | U2 | EPSDT Periodic Complete Medical Screen (Established Patient) |
016.06.05 Ark. Code R. § 099