016.06.05 Ark. Code R. 099

Current through Register Vol. 49, No. 10, October, 2024

Rule 016.06.05-099 - Child Health Services / Early and Periodic Screening, Diagnosis and Treatment (EPSDT) Provider Manual Update Transmittal #71

Section II

Child Health Services/Early and Periodic Screening, Diagnosis, and Treatment

211.000 Introduction

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.

212.000 Scope

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.

213.000 Provider's Role in the Child Health Services (EPSDT) Program

The following steps are necessary in order to complete a Child Health Services (EPSDT) screen:

A. When a child arrives for a Child Health Services (EPSDT) screening appointment, ask to see the current Medical Assistance Identification Card (Medicaid Card). Verify Medicaid eligibility electronically before services are rendered.

B. Screen the child according to the procedures outlined in Sections 215.000, 216.000, 217.000, 218.000 or 219.000 of this manual. All elements of the screen must be completed and documented before the screen is considered complete. This includes the evaluation of lab results and the provision of or referral for immunizations.

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.

C. Record the screening findings on the DMS-694 or on the American Dental Association (ADA) form for dental screens. View or print a DMS-694 sample form. The DMS-694 screening form or the ADA (dental) form must be completed on each individual screened for Child Health Services (EPSDT) in order to comply with federal reporting and Child Health Services (EPSDT) requirements. The DMS-694 will record whether each of the recommended screening procedures required by the periodicity schedule is performed, whether referral is necessary for health problems discovered during the screen and the date of the required referral appointment if one is made. Providers must be careful to complete Section I of Form DMS-694 or the ADA (dental) form using the beneficiary's name and Medicaid ID number exactly as shown on the Medicaid card.

D. Talk to the parent about the screening results, explaining in detail the findings and any recommendations for diagnosis and treatment.

E. If the child needs further diagnosis and/or treatment, complete the referral section of the DMS-694 by checking the appropriate referral box.

F. Upon completion of the EPSDT screening, mail the original DMS-694 form to the EDS Claims Department, or file electronically using the 694 format. Retain copy 3 for the provider files. View or print the EDS Claims Department contact information.

G. If the screener provides treatment as a result of the screening, the charges for the treatment procedures may be submitted on the DMS-694 form. Do not submit charges for office visit services on the DMS-694.

H. Treatment services offered as a result of a Child Health Services (EPSDT) screen are not limited to the Medicaid services specified under "Scope of Program" in Section I of this manual. If a condition is diagnosed through a Child Health Services (EPSDT) screen that requires treatment services not normally covered under the Arkansas Medicaid Program, those treatment services will also be considered for reimbursement.

I. When a provider performs a Child Health Services (EPSDT) screen and/or refers the patient to another provider for services not covered by Arkansas Medicaid, the referring provider must give the beneficiary a prescription for the services. The prescription must indicate the services being prescribed and state the services are being prescribed due to a Child Health Services (EPSDT) screen.

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.

J. The provider may verify whether a periodic screen is due under the appropriate periodicity schedule by means of an electronic eligibility verification transaction. The system's response display will reveal each type of screen, e.g., medical, visual, dental and hearing and the date of the last screen of each type indicated by the provider initiating the eligibility verification transaction.

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.

242.100 Procedure Codes

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)
99431¹99432¹99435¹	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

1 Exempt from PCP referral requirements

2 Covered when specimen is referred to an independent lab

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."

242.130 Restrictions on Duplication of Services

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

242.150 Limitation for Laboratory Procedures Performed as Part of EPSDT Screens

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

2/6/2006