1 EPSDT & PPHSD Early and Periodic Screening, Diagnosis and Treatment (EPSDT) Services and Preventive Pediatric Healthcare Screening and Diagnosis (PPHSD) Services Billing Guidelines for MassHealth Physicians and Mid-level Providers
2 b Billing Guidelines for MassHealth Physicians and Mid-level Providers
3 i Contents Introduction page 1 Service Codes and Modifiers page 2 Billing Scenarios Initial and Subsequent Well-Child-Care Visits page 6 Initial Well-Child-Care Visits for Newborns page 7 Sick Care Provided During a Well-Child-Care Visit..... page 8 Well-Child Care Provided During a Sick-Care Visit..... page 9 Follow-up Care for Behavioral Health Issues Identified During a Screening page 10 Teen s First Pelvic Exam During a Well-Child-Care Visit page 11 Periodic Well-Child-Care Visits Occurring Within One Year page 12 Questions and Answers page 13 Important Numbers page 15
5 1 Introduction All MassHealth members under the age of 21 who are enrolled in MassHealth Standard and CommonHealth are eligible for screening and diagnosis services provided according to the Early and Periodic Screening, Diagnosis and Treatment (EPSDT) Services Medical Protocol and Periodicity Schedule (the Schedule). MassHealth members under the age of 21 enrolled in MassHealth Basic, Essential, Prenatal, and Family Assistance are eligible for the same screening and diagnosis services provided according to the Schedule through the preventive pediatric healthcare screening and diagnosis (PPHSD) services program. The Schedule, found in Appendix W of all MassHealth provider manuals, indicates at what age MassHealth children, adolescents, and young adults should receive well-child care, and describes the various screening and diagnosis services (health, vision, dental, hearing, behavioral health, developmental, and immunization status) that are required for the visit to be considered a comprehensive EPSDT or PPHSD exam. The Schedule also requires providers to furnish screening and diagnosis services to MassHealth Members under the age of 21 any time there is a concern about their health, even if it is not time for a regular visit according to the Schedule. These Billing Guidelines, in their entirety, do NOT apply to community health centers or to providers within the community health center setting. Community health center providers should refer to their MassHealth provider manual for instructions on billing. MassHealth and the Massachusetts Chapter of the American Academy of Pediatrics jointly prepared this booklet about billing for well-child care provided in accordance with the EPSDT and PPHSD regulations and the Schedule. The billing scenarios and accompanying questions and answers in the booklet are not meant to describe all well-child billing procedures. Rather, they are included to offer some guidance about how to bill for representative samples of services, and to clarify when visits are payable by MassHealth specifically as well-child care visits provided in accordance with the Schedule. Correctly billing for EPSDT and PPHSD services is important since it allows MassHealth to accurately credit providers for furnishing well-child care and to track well-child care provided to its members. Proper billing practices also allow eligible providers to receive an enhanced fee when all components of the well-child-care visit are delivered as described in the Schedule.
6 2 Billing Guidelines for MassHealth Physicians and Mid-level Providers For purposes of this booklet, both EPSDT and PPHSD screening and diagnosis services will be referred to as well-child services or visits that are delivered according to the Schedule in Appendix W of all MassHealth provider manuals. For MassHealth Standard and CommonHealth members under the age of 21, MassHealth providers may be reimbursed for medically necessary services described in 130 CMR (A)(1) that are covered by federal Medicaid law, but are not specifically included as covered services under any MassHealth regulation, service code list, or contract, by submitting a request for prior authorization in accordance with 130 CMR The provider s request must include, without limitation, a letter and supporting documentation indicating the medical need for the requested service. MassHealth may approve a request for a service for which there is no established payment rate. If so, MassHealth will establish the appropriate payment rate on an individual-consideration basis in accordance with 130 CMR Service Codes and Modifiers MassHealth uses Healthcare Common Procedure Coding System (HCPCS) service codes and modifiers. New-Patient Service Codes Initial comprehensive preventive medicine evaluation and management of an individual, including an age and gender appropriate history; examination; counseling/anticipatory guidance/risk factor reduction interventions; the ordering of appropriate immunization(s); and laboratory/diagnostic procedures for new patients infant (under 1 year old) early childhood (aged 1 through 4 years) late childhood (aged 5 through 11 years) adolescent (aged 12 through 17 years) years
7 3 Established-Patient Service Codes Periodic comprehensive preventive medicine reevaluation and management of an individual, including an age and gender-appropriate history; examination; counseling/anticipatory guidance/risk factor reduction interventions; the ordering of appropriate immunization(s); and laboratory/diagnostic procedures for established patients infant (under 1 year old) early childhood (aged 1 through 4 years) late childhood (aged 5 through 11 years) adolescent (aged 12 through 17 years) years Add-on Service Code Well-child care services must be billed using separate service codes in order to receive an enhanced payment for delivery of all age- and riskappropriate components of the Schedule. The first claim line must list the appropriate preventive medicine service code from the lists above ( and ). The second claim line must contain the EPSDT add-on Service Code S0302. The appropriate use of S0302 will result in providers receiving an enhanced payment when all screening services are delivered according to the Schedule. S0302 Completed Early and Periodic Screening, Diagnosis and Treatment (EPSDT) Service (List in addition to code for appropriate evaluation and management service. The add-on code may be applied only to Service Codes and , and may be used for EPSDT and PPHSD services.) Codes Listed in Appendix Z The services that are listed in Appendix Z of all MassHealth provider manuals include common preventive care services that may be billed to MassHealth in addition to the evaluation and management (E/M) code and the EPSDT add-on code (S0302). The services listed are behavioral health, vision and hearing screenings, and certain laboratory tests. Note that this is not an exhaustive list and that there are additional codes that may be billed that are not listed. Providers should refer to Subchapter 6 of their provider manual for an extensive list of codes.
8 4 Billing Guidelines for MassHealth Physicians and Mid-level Providers The behavioral health screening code (96110) can be claimed only if the provider has performed the screening using a MassHealth-approved, standardized behavioral health screening tool. The list of acceptable tools can be found in Appendix W. Service Code requires modifiers that are servicing provider specific and that indicate whether or not the screen shows a behavioral health need was identified. Modifiers for Use with Service Code Servicing Provider Physician, Independent Nurse Midwife, Independent Nurse Practitioner, Community Health Center (CHC), Outpatient Hospital Department (OPD) Nurse Midwife employed by Physician or CHC Modifier for Use When No Behavioral Health Need Identified* U1 U3 Modifier for Use When Behavioral Health Need Identified* U2 U4 Nurse Practitioner employed by Physician or CHC Physician Assistant employed by Physician or CHC U5 U7 U6 U8 * Behavioral health need identified means the provider administering the screening tool, in her or his professional judgment, identifies a child with a potential behavioral health services need. Example: Billing for a well-child visit provided by a physician to a new patient, three months old. Line 1: Line 2: S0302 On additional claim lines, add any service codes for allowable screenings or tests. If Service Code is claimed for a behavioralhealth screen, add the appropriate modifier.
9 5 Example: Billing for a well-child visit provided by a physician to an established patient, aged five. Line 1: Line 2: S0302 On additional claim lines, add any service codes for allowable screenings or tests. If Service Code is claimed for a behavioralhealth screen, add the appropriate modifier. Mid-Level Practitioner Modifiers The following modifiers must be used when billing for services that were delivered by a non-independent nurse practitioner, non-independent nurse midwife, or physician assistant employed by a MassHealthenrolled physician. The modifier should be used only with the E/M service code, not with the add-on EPSDT Service Code S0302 or when claiming for the behavioral health screenings with Service Code For Service Code 96110, use the modifiers as explained above. Nurse Practitioner SA A non-independent nurse practitioner who is employed by a physician Nurse Midwife SB A non-independent nurse midwife who is employed by a physician Physician Assistant HN Bachelor s degree level (Use to indicate the physician assistant.) Example: Billing for a well-child visit provided by a nurse practitioner (employed by a physician) to an established patient, aged five Line 1: SA Line 2: S0302 On additional claim lines, add any service codes for allowable screenings or tests. If Service Code is claimed for a behavioralhealth screen, add the appropriate modifier.
10 6 Billing Guidelines for MassHealth Physicians and Mid-level Providers Billing Scenarios 1. Initial and Subsequent Well-Child-Care Visits Example of Service Provided: A 12-year-old child is new to a provider s practice. The first visit to the office is for episodic health care, such as an upper-respiratory infection, and is provided by the physician. The second visit the following week is for a routine evaluation and well-child care. During the second visit, a nurse practitioner employed by the physician delivered the full range of well-child care according to the Schedule, except for what was already provided during the first visit. Appropriate Billing: The first visit should be billed under the appropriate E/M service code for the episodic health-care office visit. Do not bill the EPSDT add-on code S0302, since the full range of well-child care was not delivered at this episodic care visit. For example, the provider might bill as follows. Line 1: The second visit should be billed as follows for a completed initial wellchild visit for an established patient, provided by the nurse practitioner. Line 1: SA Line 2: S0302 On additional claim lines, add any service codes for allowable screenings or tests. If Service Code is claimed for a behavioralhealth screen, add the appropriate modifier.
11 7 2. Initial Well-Child-Care Visits for Newborns Example of Service Provided: A newborn is seen by a physician in the hospital for an initial evaluation and a discharge history and physical examination. Appropriate Billing: To bill for a well-child-care visit to a newborn while in the hospital, the provider must visit the newborn at least twice before the newborn leaves the hospital, as described in the example. The initial history and physical exam is payable as a hospital inpatient visit. The second visit for a discharge history and physical exam and all other screens required for the newborn is payable as a well-child-care visit provided in accordance with the Schedule. The first visit may be billed as a newborn hospital inpatient visit as follows. Line 1: The second visit may be billed as a well-child visit for an established patient as follows. Line 1: Line 2: S0302
12 8 Billing Guidelines for MassHealth Physicians and Mid-level Providers 3. Sick Care Provided During a Well-Child-Care Visit Example of Service Provided: An eight-year-old established patient comes in for a routine well-child visit. Upon examination, the physician finds that the child has significant wheezing and a history suggestive of asthma. Although the child visited the office primarily for wellchild care, a portion of the visit involves evaluation, intervention, and education about asthma. Appropriate Billing: The purpose of the child s visit was for routine well-child care. Therefore, this visit may be billed as a well-child visit. As long as all of the screenings are completed according to the Schedule, the provider may bill the S0302 add-on code and receive the enhanced payment. Use the diagnosis code appropriate for the condition for which the child was treated. Line 1: Line 2: S0302 Line 3: 96110, with modifier U1 or U2. Line 4: (Screening test of visual acuity, quantitative, bilateral) Line 5: (Pure tone audiometry [threshold]; air only)
13 9 4. Well-Child-Care Provided During a Sick-Care Visit Example of Service Provided: A 2 ½ -year-old is brought in with a rash. The child s existing physician notices that the child never had a two-year-old well-child visit. The provider has the time to perform the required screenings and does so. Appropriate Billing: Since all of the required screenings, as outlined in the Schedule, were provided, the visit can be billed as a completed well-child visit using the appropriate preventive medicine visit service code, and add-on code S0302, plus the diagnosis code appropriate for the condition for which the child was treated. Line 1: Line 2: S0302 On additional claim lines, add any service codes for allowable screenings or tests. If Service Code is claimed for a behavioral health screen, add the appropriate modifier. Alternative Scenario: If the provider had been unable to complete all of the required screenings at the first visit, bill the first visit using the appropriate service code. For example, Line 1: The same child returns two weeks later and the nurse practitioner, who is providing services in collaboration with the physician, completes all screenings according to the Schedule. The second visit may be billed as follows. Line 2: SA Line 3: S0302 On additional claim lines, add any service codes for allowable screenings or tests. If Service Code is claimed for a behavioralhealth screen, add the appropriate modifier.
14 10 Billing Guidelines for MassHealth Physicians and Mid-level Providers 5. Follow-up Care for Behavioral Health Issue Identified During a Screening Example of Service Provided: A 15-year-old is seen by a pediatrician for an initial well-child visit. The physician completes the physical exam and required screenings, including an approved, standardized behavioral-health screening tool and the anticipatory guidance topics. The physician determines that additional follow-up is necessary for a potential behavioral health need identified during the screening and schedules a return visit with the physician assistant. Appropriate Billing: The first visit may be billed as an initial well-child visit. The behavioral health screening can also be billed. Line 1: Line 2: S0302 Line 3: with modifier U1 or U2 On additional claim lines, add any service codes for allowable screenings or tests. Bill the second visit with the physician assistant using the appropriate service code and modifier for an office visit, plus the diagnosis code appropriate for the condition for which the teen was seen. For example: Line 1: HN
15 11 6. Teen s First Pelvic Exam During a Well-Child-Care Visit Example of Service Provided: A 16-year-old female comes in for an annual well-child-care visit as an established patient. During the exam, the independent nurse practitioner determines that the teen should have her first complete pelvic exam. Appropriate Billing: The provider may bill for a well-child visit. According to the Schedule, there are certain screening requirements that vary with the member s age and the clinician s discretion. Providers should refer to the EPSDT or PPHSD regulations and Appendix W in their MassHealth provider manual for more detailed information about the screening requirements for each visit. Line 1: Line 2: S0302 On additional claim lines, add any service codes for allowable screenings or tests. If Service Code is claimed for a behavioralhealth screen, add the appropriate modifier.
16 12 Billing Guidelines for MassHealth Physicians and Mid-level Providers 7. Periodic Well-Child-Care Visits Occurring Within One Year Example of Service Provided: A 12-year-old was seen in October for a complete well-child exam and the following September is seen by the physician for a school sports physical exam. At this visit all screenings were completed according to the Schedule. Appropriate Billing: The provider may bill for a well-child visit using the add-on service code to receive an enhanced payment. Providers do not have to wait the full interval between well-child-care visits, as specified by the Schedule, to receive payment. Line 1: Line 2: S0302 On additional claim lines, add any service codes for allowable screenings or tests. If Service Code is claimed for a behavioralhealth screen, add the appropriate modifier.
17 13 QUESTIONS AND ANSWERS Q A Q A six-year-old receives a behavioral-health screen using a MassHealth-approved screening tool and audiometric and vision tests at the time of the annual well-child-care visit in the primary care provider s office. Can these tests be billed in addition to the well-child visit? Yes. Payments for the approved behavioral-health screening tool, audiometric test, and the bilateral quantitative test of visual acuity, which are included in the Schedule, are in addition to and separate from the fee for an initial or periodic visit. Payment for those tests may be claimed separately. A four-year-old comes to the office for a routine wellchild-care visit. The child is unable to cooperate for hearing and vision testing. To ensure that the child s evaluation is complete, the physician makes a referral for purposes of performing these tests. Since the physician did not perform the hearing and vision testing, but made a referral, has the provider fulfilled the screening requirements for billing a well-child-care visit in accordance with the Schedule? A Yes. If the provider makes a good-faith effort to ensure that these tests are completed, the provider may bill for the wellchild-care visit provided in accordance with the Schedule. The primary care provider must coordinate with the testing provider to ensure that all the required well-child service components are completed, and that the results are made part of the child s medical record. The primary-care provider remains responsible for ensuring that all necessary screening and testing procedures are delivered to the child.
18 14 Billing Guidelines for MassHealth Physicians and Mid-level Providers Q A 14-year-old, who has a commercial insurance plan in addition to MassHealth, comes to the office for a wellchild-care visit. The provider delivers all of the screening procedures as described in the Schedule. Must the provider bill the other insurer first? A No. Providers are not required to first submit well-child-care claims to the other insurer before submitting the claims to MassHealth. Providers with additional questions about billing procedures should call MassHealth Customer Service at
19 15 Important Numbers MassHealth Customer Service (Billing Issues) PCC Plan Hotline for PCC Plan Providers For more copies of this booklet, mail or fax your request to: Fax: Mailing Address: MassHealth ATTN: Forms Distribution P.O. Box 9118 Hingham, MA 02043
20 EPSDT-BG (Rev. 04/09) Commonwealth of Massachusetts Executive Office of Health and Human Services MassHealth
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