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October 2009 Healthwatch/Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) Presented by EDS Provider Relations.

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Presentation on theme: "October 2009 Healthwatch/Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) Presented by EDS Provider Relations."— Presentation transcript:

1 October 2009 Healthwatch/Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) Presented by EDS Provider Relations

2 2/ October 2009 HealthWatch/EPSDT Objectives To have a general understanding of the following: HealthWatch/EPSDT are used interchangeably Basics of the IHCP HealthWatch/Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) Program EPSDT Screenings When to refer members for treatment EPSDT billing guidelines Immunizations and Vaccine for Children Program Lead poisoning prevention and testing Who to contact if you have questions

3 3/ October 2009 HealthWatch/EPSDT Overview of Indiana Health Coverage Programs

4 4/ October 2009 HealthWatch/EPSDT IHCP HealthWatch/EPSDT Provider Manual

5 5/ October 2009 HealthWatch/EPSDT Early - Identifying problems early, starting at birth Periodic - Checking children's health at periodic, age- appropriate intervals Screening - Doing physical, mental, developmental, dental, hearing, vision, and other screening tests to detect potential problems Diagnosis - Performing diagnostic tests to follow up when a risk is identified, and Treatment - Treating the problems found

6 6/ October 2009 HealthWatch/EPSDT Early and Periodic Screening, Diagnosis and Treatment, (EPSDT) is also referred to as HealthWatch in Indiana HealthWatch/EPSDT service is Indiana Medicaid's comprehensive and preventive child health program for individuals under the age of 21 The EPSDT program is expected to assure that health problems are diagnosed and treated early, before they become more complex and their treatment more costly

7 7/ October 2009 HealthWatch/EPSDT The EPSDT program consists of two main components: (1) assuring the availability and accessibility of required health care resources; and (2) helping Medicaid recipients and their parents or guardians effectively use these resources The EPSDT program is designed to enhance primary care with an emphasis on prevention and early intervention

8 8/ October 2009 HealthWatch/EPSDT HealthWatch/EPSDT Member Population Who is eligible for EPSDT services? Medicaid Eligible children from birth to their 21 st birthday EPSDT member population comes from three Medicaid Programs: –Hoosier Healthwise –Care Select Wards and Fosters –Healthy Indiana Plan (HIP) Members under 21 years

9 9/ October 2009 HealthWatch/EPSDT Which Provider Specialties Can Be HealthWatch/EPSDT PMPs? A Hoosier Healthwise or Care Select PMP must be a physician licensed in one of the following specialties: –General Practice, Family Practice, General Pediatrics, General Internal Medicine, or OB/GYN Physicians interested in becoming PMPs are also required to contract with one or more of the following managed care organizations (MCOs) to participate in the risk-based managed care network: Anthem, Managed Health Services (MHS), or MDwise Specialists may also serve as PMPs in Care Select, if Chosen by the member (Specialist are not auto-assigned), and Sign an Addendum with one or both of the care management organizations (CMOs): MDwise or ADVANTAGE Health Solutions

10 10/ October 2009 HealthWatch/EPSDT HealthWatch/EPSDT Covered Services

11 11/ October 2009 HealthWatch/EPSDT HealthWatch/EPSDT Covered Services T he periodic schedule for EPSDT screenings, adopted from the American Academy of Pediatrics (AAP), is as follows: –Newborn –2 to 4 days, if the newborns left the hospital < 48 hours after delivery –by 1 month of age –2 months of age –4 months of age –6 months of age –9 months of age –12 months of age –15 months of age –18 months of age –Once every year from ages 2 to 20 years Detailed information can be found in the HealthWatch/EPSDT Provider Manual, located at –Appendix A: Periodicity and Screening Schedule Periodicity Recommendations

12 12/ October 2009 HealthWatch/EPSDT HealthWatch/EPSDT Covered Services Screenings are the foundation of the EPSDT program Screenings must include the following: Comprehensive health and developmental history, including review of both physical and mental health development Comprehensive unclothed physical exam Appropriate immunizations according to age and health history Laboratory tests including a lead toxicity screening, as appropriate Nutritional assessment Health education, including anticipatory guidance Vision screens Hearing screens Dental screens –Detailed information can be found in the HealthWatch/EPSDT Provider Manual, located at –Appendix A: Periodicity and Screening Schedule

13 13/ October 2009 HealthWatch/EPSDT HealthWatch/EPSDT Covered Services Immunizations: Consult the CDC/ACIP or AAP Web sites for the current immunization schedule. CDC National Immunization Program (NIP): American Academy of Pediatrics Red Book: The Vaccines for Children (VFC) is a federally funded program that makes certain vaccines available, at no cost to providers, for administration to children age 18 years and younger, who meet one or more of the following: –On Medicaid –Without health insurance –American Indian or Alaskan Native VFC in Indiana Complete enrollment materials, attend an orientation, and meet requirements to participate in the program Contact the ISDH Immunization Program at for more information

14 14/ October 2009 HealthWatch/EPSDT HealthWatch/EPSDT Covered Services To participate in the VFC program, providers must : Meet refrigerator/freezer storage requirements –Freezer only needed if carrying varicella Follow all VFC storage and handling requirements Have working fax machine Properly maintain a vaccine inventory Screen for VFC Eligibility Anyone who provides medical care to eligible children can be a VFC provider: Private physicians, local health departments, RHCs, FQHCs

15 15/ October 2009 HealthWatch/EPSDT About CHIRP Statewide Immunization Registry provided by the Indiana State Department of Health Secure, no-cost, Internet-based application Training available at no cost For more information or to enroll, visit or call ISDH at www.chirp.in.gov

16 16/ October 2009 HealthWatch/EPSDT EPSDT Vaccine Safety: Reliable Resources Indiana State Department of Health CDC: Vaccine Safety Institute for Vaccine Safety Immunization Action Coalition

17 17/ October 2009 HealthWatch/EPSDT HealthWatch/EPSDT Covered Services Laboratory tests including a lead toxicity screening, as appropriate EPSDT requires that every Medicaid eligible child receive a blood test at 12 months and 24 months Testing should be done in conjunction with an EPSDT visit If both blood lead tests are below the action level of 10 μg/dL (micrograms/deciliter), no additional testing is required, unless the childs environment changes ISDH, through the Indiana Childhood Lead Poisoning Prevention Program (ICLPPP), monitors lead poisoning in Hoosier children who receive screening Detailed information can be found in Section 3 of the HealthWatch/EPSDT Provider Manual, located at

18 18/ October 2009 HealthWatch/EPSDT HealthWatch/EPSDT Blood Lead Level Testing Three basic ways to test –Venous testing –Filter paper –Hand-held device testing The coverage and reimbursement rate for code is expanded to include tests administered using filter paper and handheld testing devices in the office setting – Assay of lead (venous blood) –83655 U1 - Assay of lead, using filter paper –83655 U2 - Assay of lead, using handheld testing device When using 83655, utilize the correct diagnosis code depending on the basis of the test –V20.2 = tests to rule out lead poisoning –V15.86 = those who already have been diagnosed as having lead poisoning

19 19/ October 2009 HealthWatch/EPSDT HealthWatch/EPSDT Covered Services Nutritional Assessment Evaluate the patient for normal health and growth Offer information about Special Supplemental Program for Women, Infants, and Children (WIC) The purpose of WIC is to improve participants health and quality of life by providing nutrition education and counseling, medical and social referrals, and supplemental food to eligible women and children. To qualify for WIC, participants must meet the following three criteria: –Be an Indiana resident –Have an income at or below 185 percent of the FPL –Be at medical or nutritional risk Participants are limited to pregnant women, breastfeeding women up to one year after delivery, postpartum women up to six months after delivery, infants, and children younger than 5 years old For more information, visit the Web site at

20 20/ October 2009 HealthWatch/EPSDT HealthWatch/EPSDT Covered Services Health Education and Anticipatory Guidance Health education that is appropriate for the age of the children in the home –Injury prevention –When to call the doctor/visit the ER –Home hazards – weapons, poison, lighter/matches Anticipatory guidance for the family should be geared to questions, issues, or concerns for that particular child and family –Auto Safety – Car seat installation, seatbelt use, backseat safety –Sleep patterns – Back to Sleep, appropriate bedtime –Use of smoke detector

21 21/ October 2009 HealthWatch/EPSDT HealthWatch/EPSDT Covered Services Vision observation and screenings: Up to 3 years and at 6, 8, 14, 16, and 18 years –Visual observation with an external eye examination –Subjective screening by history 3 to 5 years and at 10, 12, and 20 years –Annual objective screening test by standard testing method –If warranted, refer child to an appropriate specialist Consult the IHCP HealthWatch/Early and Periodic Screening, Diagnosis and Treatment Provider Manual for more information –Detailed information can be found in Section 4 of the HealthWatch/EPSDT Provider Manual, located at –Appendix A: Periodicity and Screening Schedule

22 22/ October 2009 HealthWatch/EPSDT HealthWatch/EPSDT Covered Services *Hearing tests are given by the Dept. of Education in grades one, four, seven, and 10 th. Screening efforts should not be duplicated unless rescreening is necessary. Confirmation of screening results may come from the childs school or parents. AgeHearing Screening Schedule Newborn Subjective screening, by history; to be performed on patients at risk 2-4 days, by 1 month, 2, 4, 6 and 9 months visits Subjective screening, by history 12 months to 4 years visit Range during which an objective screening may be provided, with objective screening, by standard testing method is recommended at age 4 years. 5 year visitObjective screening, by standard testing method 6 and 8 year visitsSubjective screening, by history 10, 12, and 18 years visits Objective screening, by standard testing method, not to be duplicated if screened within the school system.* 14, 16, and 20 years visits Subjective screening, by history

23 23/ October 2009 HealthWatch/EPSDT HealthWatch/EPSDT Covered Services AAPD Recommendations6-12 months months 2-6 years 6-12 years >12 years Clinical oral examination. Assess oral growth and development by clinical exam. Caries-risk assessment. Anticipatory guidance/counseling Injury prevention counseling Counseling for nonnutritive habits Radiographic assessment, and Prophylaxis and topical fluoride Must be repeated regularly and frequently to maximize effectiveness; and Timing, selection, and frequency determined by childs history, clinical findings, and susceptibility to oral disease. Counseling for speech/language development. Assessment for pit and fissure sealants Transition to adult dental care Assessment and treatment of developing malocclusion Assessment and/or removal of third molars Counseling for intraoral/peri-oral piercing Substance abuse counseling Dental Screening

24 24/ October 2009 HealthWatch/EPSDT Referrals

25 25/ October 2009 HealthWatch/EPSDT Refer to a licensed vision care provider when objective vision screening methods indicate a need Refer newborns identified under the universal newborn hearing screening (UNHS) program to First Steps Refer older children for testing and treatment to an Audiologist when screening results identify possible deficiency. The dental referral must be for an encounter with a licensed dentist for diagnosis and, if necessary, treatment –Detailed information can be found in Section 4 of the HealthWatch/EPSDT Provider Manual, located at –Appendix A: Periodicity and Screening Schedule Referrals HealthWatch/EPSDT Covered Services

26 26/ October 2009 HealthWatch/EPSDT Referrals to a specialist may also occur at times other than those described by the periodicity schedule, when deemed medically necessary Specialist would include, but are not limited to: Vision Care Specialist, Licensed Audiologist, or Dentist PMP should maintain documentation of all referrals, along with results in the members record Additional common referral sources: Indiana State Department of Health Indiana Family Helpline Indiana Quitline QUIT- NOW ( ) Indiana First Steps HealthWatch/EPSDT Covered Services Referrals

27 27/ October 2009 HealthWatch/EPSDT Billing

28 28/ October 2009 HealthWatch/EPSDT HealthWatch/EPSDT EPSDT Billing Guidelines EPSDT Screening CPT® CodeICD-9 Coding Reimbursement Fees EPSDT Visit (all components documented) Initial/New Patient: Established Patient: Evaluation and Management: New Patient: Established Patient: V Routine infant or child health check Use additional ICD-9-CM codes to identify: special screening examinations performed. EPSDT visits must be billed with V20.2 and one of the CPT codes listed. These visits are eligible for additional reimbursement. Reimbursement: Initial/New Patient, EPSDT $75 Established Patient, EPSDT $62 Well-Child Visit Provide and document preventive care at any visit. Include age appropriate medical history, physical exam, and health education. A comprehensive prenatal visit can also meet the requirements for a well-child visit. Preventive Visits: Initial/New Patient – Established Patient Prenatal Care: and V70.0 or V70.3 – V70.9 or V20.2 (see EPSDT Visit above) Additional reimbursement is available only if the ICD-9 code is V20.2 – refer to the EPSDT Visit explanation. Reimbursement (if billed with V70.0 or V70.3-V70.9): Initial/New Patient, Well-child $63-$69 Established Patient, Well-child $50-$56 Prenatal Care Visit: $40-$43

29 29/ October 2009 HealthWatch/EPSDT HealthWatch/EPSDT EPSDT Billing Guidelines EPSDT Screening CPT® CodeICD-9 CodingFees Sick Visit plus EPSDT (2 visit codes) Preventive visit code and w/ modifier -25 V20.2 must be used as the primary diagnosis for the appropriate preventive visit. The appropriate presenting diagnosis must also be included with the CPT code for the sick visit Sick visits depend on complexity and Doctor/Patient relationship (new/established) Reimbursement: $19-65

30 30/ October 2009 HealthWatch/EPSDT HealthWatch/EPSDT Billing Guidelines Indicate an EPSDT service on claims as follows: –CMS-1500: Mark Y in box 24H –ADA2006: Mark X in box 1 (EPSDT/Title XIX) Office visits without all the EPSDT components should be reported by using CPT ® codes and When an EPSDT visit and an established sick visit are provided on the same day, providers can bill for reimbursement of both services Refer to the IHCP HealthWatch/Early and Periodic Screening, Diagnosis, and Treatment Provider Manual for required screenings, referrals, and immunizations Detailed information can be found in Section 3 of the HealthWatch/EPSDT Provider Manual, located at ihcp/Publications/manuals.htmwww.indianamedicaid.com/ ihcp/Publications/manuals.htm

31 31/ October 2009 HealthWatch/EPSDT HealthWatch/EPSDT Billing Guidelines The individual components of the EPSDT exam are not separately billable Immunizations, blood draws or other lab tests are separately billable with the exception of the blood level testing Services provided at a Federally Qualified Health Center (FQHC) or Rural Health Clinic (RHC) must be billed appropriately using T1015 for non-RBMC members FQHC or RHC services provided to RBMC members must be billed according guidelines established by the members MCO/CMO

32 32/ October 2009 HealthWatch/EPSDT HealthWatch/EPSDT Billing Guidelines EPSDT periodic well child screenings do not require prior authorization Prior authorization may be required for additional treatments clinically indicated by the EPSDT screening Providers should contact the members MCO/CMO for prior authorization requirements Refer to the IHCP Fee Schedule at for more information and specific reimbursement rates

33 33/ October 2009 HealthWatch/EPSDT HealthWatch/EPSDT Immunizations/VFC EPSDT providers are encouraged to participate in the Vaccines for Children (VFC) Program The VFC Program reduces cost as a barrier to vaccination and enables better access to healthcare If a member is VFC eligible, the administrative fee must be billed to Medicaid, not to exceed $8 Detailed information can be found in Section 3 of the HealthWatch/EPSDT Provider Manual, located at ihcp/Publications/manuals.htmwww.indianamedicaid.com/ ihcp/Publications/manuals.htm

34 34/ October 2009 HealthWatch/EPSDT HealthWatch/EPSDT Partners Anthem –http://www.anthem.comhttp://www.anthem.com – MDwise –http://www.mdwise.comhttp://www.mdwise.com – Managed Health Services –http://www.managedhealthservices.comhttp://www.managedhealthservices.com – ADVANTAGE Health Solutions –http://www.advantageplan.comhttp://www.advantageplan.com –

35 35/ October 2009 HealthWatch/EPSDT Helpful Tools IHCP Web site at HealthWatch/EPSDT Provider Manual IHCP Provider Manual (Web, CD-ROM, or paper) Customer Assistance – , or –(317) in the Indianapolis local area Written Correspondence –P.O. Box 7263 Indianapolis, IN Provider Relations field consultant EPSDT coordinator Office of Medicaid Policy and Planning Avenues of Resolution

36 36/ October 2009 HealthWatch/EPSDT Questions

37 October 2009 EDS and the EDS logo are registered trademarks of Hewlett-Packard Development Company, LP. HP is an equal opportunity employer and values the diversity of its people. © 2009 Hewlett-Packard Development Company, LP. Office of Medicaid Policy and Planning (OMPP) 402 W. Washington St, Room W374 Indianapolis, IN EDS, an HP Company 950 N. Meridian St., Suite 1150 Indianapolis, IN 46204


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