District of Columbia Department of Health Care Finance Billing Changes for EPSDT

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Russell Harrell
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1 District of Columbia Department of Health Care Finance Billing Changes for EPSDT Effective October 1, 2014

2 Training Objective Identify and explain billing changes for the EPSDT program

3 Agenda EPSDT Program Overview Billing for EPSDT Services

4 Provider Packet Training Presentation DC EPSDT Well-Child Visit Billing Reference Guide

5 EPSDT Program Overview

6 EPSDT Program Overview The Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) services benefit is a mandatory benefit under the Medicaid program Known in the District of Columbia as Health Check The benefit has three major components: Access Screenings and Education Diagnosis and Treatment

Medicaid program Known in the District of Columbia as Health Check The

7 EPSDT Program Overview EPSDT services include: Early Periodic Screening and comprehensive health care to assess a child's health status, identify risks or concerns, and intervene promptly. well-child visits at recommended age-appropriate intervals (under the District s periodicity schedule) or as-needed (interperiodic). services including health history, physical exam, tests and assessments for mental, oral and developmental health, immunizations, and health guidance as recommended under the District s periodicity schedule. Diagnostic services to determine the nature and cause of identified health problems and evaluate treatment options. Treatment services, including early intervention and therapies, needed to correct or improve physical, developmental, oral health, and mental health conditions.

services including health history, physical exam, tests and assessments for mental, oral and developmental health, immunizations, and health guidance as recommended under the District s periodicity

8 EPSDT Program Overview Screening services encompass the following services: Comprehensive unclothed examination Appropriate immunizations Comprehensive health and developmental history, which includes the assessment of both physical and mental development Age appropriate developmental and mental health screening Laboratory tests Health education Vision and Hearing Screens Dental Screens

which includes the assessment of both physical and mental development Age appropriate

9 Billing for EPSDT Services

10 Billing for EPSDT Services When conducting a well-child visit (WCV), a primary care provider (PCP) must perform all components required in a visit and all age-appropriate screenings and/or assessments as required in the DC Medicaid HealthCheck Periodicity Schedule. Covered screening services are medical, developmental/mental health, vision, hearing and dental. The components of medical screening include: Comprehensive health and developmental history that assesses for both physical and mental health as well as for substance use disorders Comprehensive, unclothed physical examination Appropriate immunizations (as established by ACIP) Laboratory testing (including blood lead screening appropriate for age and risk factors) Health education and anticipatory guidance for both the child and the caregiver. EPSDT-A Guide for States: Coverage in the Medicaid Benefit for Children and Adolescents, CMS, June Available at

The components of medical screening include: Comprehensive health and developmental history that assesses for both physical and mental health as well as for substance use disorders Comprehensive,

12 Billing for EPSDT Services To bill for a well-child visit: Use the age-based CPT code ( ; ) as indicated in Table 1 Use the following ICD-9 diagnosis codes listed in Table 1 in conjunction with the CPT Code Bill for each separate assessment/screening performed using the applicable CPT code from Table 2 If a screening or assessment is positive and requires follow-up or a referral, use modifier TS with the applicable screening code that had a positive result DO NOT USE E & M OUTPATIENT VISIT CODES ( ; ) TO BILL FOR A WELL-CHILD VISIT.

the applicable CPT code from Table 2 If a screening or assessment is positive and requires follow-up or a referral, use modifier TS with the

13 Billing for EPSDT Services

14 Provider Resources

15 Provider Resources HealthCheck Training & Resource Center EPSDT Billing Manual EPSDT: A Guide for States Xerox Call Centers Provider Inquiry: (202) EDI Technical Support: (866) Provider Field Services dc.providerreps@xerox.com

North Carolina s Medicaid Early and Periodic Screening, Diagnosis and Treatment Program: Health Check

North Carolina s Medicaid Early and Periodic Screening, Diagnosis and Treatment Program: Health Check Early and Periodic Screening, Diagnosis and Treatment (EPSDT) is a comprehensive set of benefits that