KAN Be Healthy Billing Bulletin

KAN Be Healthy Billing Bulletin

KAN BE HEALTHY BILLING BULLETIN Table of Contents KBH (EPSDT) Program 1 KBH Periodicity Schedule 1 KBH Billing Options 2 KBH Codes 4 KBH Standards of Practice 6 KBH Indicator Values 8 KBH Referral Values 9 RHC & FQHC Registered Nurse 9 KHPA Medical Programs as the Secondary Insurance 9 Reimbursement 10 Examples of KBH Billing 12 KBH Billing Graph 16 Note: Codes, reimbursements, and limitations listed in this document are subject to change. Refer to your provider manuals and provider bulletins for the most current information. CPT codes, descriptors, and other data only are copyright 2011 American Medical Association (or such other date of publication of CPT). All rights reserved. Applicable FARS/DFARS apply. Information on the American Medical Association is available at http://www.ama-assn.org.

KAN Be Healthy (EPSDT) Program The Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) service was defined by law as part of the Omnibus Budget Reconciliation Act of 1989 (OBRA 89) legislation. In addition, Section 1905 of the Social Security Act (the Act) requires that any medically necessary healthcare service listed in section 1905(a) of the Act be provided to an EPSDT beneficiary even if the service is not available under the State s plan to the rest of the population. KAN Be Healthy (KBH) is the Kansas name for the federally mandated EPSDT program. KBH promotes regular health screens with the goal of preventing, detecting, and correcting medical conditions before further advancement. The KBH screening program provides services to children, teenagers, and young adults. Title XIX beneficiaries under the age of 21 are eligible for KBH. KBH Periodicity Schedule The optimal KBH screen frequency reflects the American Academy of Pediatrics (AAP) periodicity schedule, which is at birth, three to five days after birth, one, two, four, six, nine, 12, 15, 18, 24, and 30 months, then annually for years three through 20. To encourage participation every year, KBH medical screens may be completed at anytime. Emergent concerns relating to poor American child health outcomes, such as childhood obesity, adolescent onset hyperglycemia, and reduced physical activity, have illustrated an acute need for preventive and aggressive monitoring of children s health and development as well as education and anticipatory guidance. With recent studies indicating the long-term health effects of increased bacterial loads due to poor dental hygiene, the State of Kansas encourages providers to remember the importance of regular dental referrals for KBH beneficiaries. Refer to Section VIII of the Dental Provider Manual to review the Preventive Pediatric Dental Care Recommendations. KAN Be Healthy Billing Bulletin Page 1

KBH Billing Options The following information outlines three KBH screening billing options for the enrolled provider. For specific program requirements (minimum documentation requirements, benefits, and limitations), refer to the provider manuals. KBH Billing: Option One When billing modifier EP with one of the Current Procedural Terminology (CPT ) Evaluation and Management (E & M) preventive medicine (99381 through 99385 or 99391 through 99395) or office visit (99202 through 99205 or 99213 through 99215) codes, providers must conform to the following requirements: Bill modifier EP only with an E & M preventive medicine or office visit code. A wellness diagnosis code (V20.0 through V20.2, V20.31, V20.32, V70.0, and/or V70.3 through V70.9) must be billed with the E & M office visit code, or the claim will deny and the four KBH screens will not update. Immunization administration, laboratory, and blood lead analysis may be referred to another provider if the screening agent is unable to provide. Follow referral requirements as outlined in Section 2020 of the General Benefits Manual. Blood lead collection may not be referred to another provider. This is a requirement of participating KBH providers. Rural Health Clinic (RHC) or Federally Qualified Health Care (FQHC) registered nurses who complete a KBH screen are instructed to use the TD modifier. Providers, including mid-level practitioners (ARNP/PA), are reimbursed at the EP modifier rate. If the billing provider is an FQHC or RHC, reimbursement is consistent with the encounter rates. Minimum documentation of the following 12 components is required: Medical history Physical growth Body systems (cardiovascular/pulmonary gastrointestinal, central nervous system, musculoskeletal, genital/urinary, and integumentary systems) Developmental/emotional Nutrition Health education and anticipatory guidance Blood lead screening/testing Laboratory (CBC with differential and other as needed) Immunizations Hearing screen Vision screen Dental screen Documentation must be maintained in the beneficiary s permanent medical record. Refer to Section 8000 of the KAN Be Healthy Provider Manual for complete, minimum documentation requirement information. Documentation by exception is not accepted. KAN Be Healthy Billing Bulletin Page 2

KBH Billing: Option Two E & M preventative medicine codes 99381 through 99385 or 99391 through 99395 without modifier EP update the four KBH screens. Documentation must reflect the code s definition and be maintained in the beneficiary s permanent medical record. Documentation by exception is not accepted. KBH screening components that have been completed and documented are billed separately. For example, the KBH screening provider completed the documentation requirements for the E & M preventive medicine code as well as a developmental screen, hearing screen, vision screen, laboratory, and immunizations. Bill the developmental, hearing, vision screen, laboratory, and immunization codes separately from the E & M office visit code. Mid-level practitioners (ARNPs/PAs) are reimbursed 75% of the allowed amount. KBH Billing: Option Three E & M office visit codes 99202 through 99205 or 99213 through 99215 with a wellness diagnosis but without modifier EP update the four KBH screens. Use an E & M office visit code when a visit was scheduled with the intent of completing a KBH screen, but abnormalities were observed and diagnosed. Bill a wellness diagnosis code (V20.0 through V20.2, V20.31, V20.32, V70.0, and/or V70.3 through V70.9) with the E & M office visit code to update the four KBH screens. KBH screening components that have been completed and documented are billed separately. For example, the KBH screening provider completed the documentation requirements for the E & M office visit code and a developmental screen, hearing screen, vision screen, laboratory, and immunizations. Bill the developmental screen, hearing screen, vision screen, laboratory (excluding blood lead), and immunization codes separately from the E & M office visit code. Mid-level practitioners (ARNP/PA) are reimbursed 75% of the allowed amount. Documentation by exception is not accepted. KAN Be Healthy Billing Bulletin Page 3

KBH Codes KBH screens are updated under the following conditions: A CMS-1500 paper or an electronic claim is submitted by an enrolled provider. A claim is submitted with a KBH program-recognized code. The claim is adjudicated (paid or denied). Ensure documentation supports the code billed. (Managed care organization [MCO] KBH screens are updated once the encounter data is received. MCO encounter claims must also follow the above billing conditions in order to update the KBH screens.) KHPA Medical Programs does not reimburse for collection of blood lead specimen; it is considered a component of the KBH screen. If a provider elects to complete the KBH screen but bill component codes, the blood lead specimen collection must be performed as required. Documentation must reflect the code billed and reimbursed. For example, when submitting a claim with code 99393 for a five-year-old beneficiary, the performing provider must complete and maintain the following documentation within the beneficiary s permanent record: comprehensive history, comprehensive exam, counseling/anticipatory guidance/risk factor reduction interventions, and ordering of appropriate lab/diagnostic procedures for the established patient. E & M preventive medicine and newborn codes that update the beneficiary s medical, vision, hearing, and dental screens are listed below. 99381 99382 99383 99384 99385 99391 99392 99393 99394 99395 99431 99432 99435 When claiming one of the following ten E & M office visit codes with the intention to complete, document, be reimbursed, and update the KBH screens, the codes must be used in conjunction with diagnosis codes V20.0 through V20.2, V20.31, V20.32, V70.0, V70.3 through 70.9. The CMS website has further information, https://www.cms.gov/medicaidearlyperiodicscrn/01_overview.asp#topofpage. New Patient The following office or other outpatient visit codes for the evaluation and management of a new patient require at least three key components. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the beneficiary s and/or family s needs. 99202 99203 99204 99205 Established Patient The following office or other outpatient visit codes for the evaluation and management of an established patient require at least two of the three key components listed. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the beneficiary s and/or family s needs. 99213 99214 99215 The following codes update the KBH medical screen only every 270 days (nine months). 59400 59409 59410 59425 59426 59510 59514 59515 59610 59612 59614 59618 59620 59622 KAN Be Healthy Billing Bulletin Page 4

When a pregnancy diagnosis is the primary diagnosis, the KBH medical screen updates only every 270 days (nine months) with the following codes. 99056 99058 99281 99202 99203 99204 99205 99213 99214 99215 The following codes update the KBH medical screen for only a 30-day period when the beneficiary is screened in the hospital setting. 99221 99222 99223 99291 99295 The following codes update the KBH vision screen only. These codes are billable by an ophthalmologist or optometrist. 92002 92004 92012 92014 The following code updates the KBH vision screen only. This code is billable by KBH medical screeners. 99713 The following dental screen procedure codes update the KBH dental screen only. These codes are billable by dental providers. D0120 D0140 D0150 D0170 D9420 Professional providers and clinics (excluding local health departments and FQHCs) can provide topical application of fluoride (without prophylaxis) for eligible children, up to three applications per beneficiary per calendar year. Providers are to submit claims using code D1203. The following KBH hearing screen codes update the KBH hearing screen only. 92551 92552 92553 92555 92556 92557 92582 92587 Another KBH Component Developmental Screening 96110 KAN Be Healthy Billing Bulletin Page 5

KBH Standards of Practice Recommendations from the Kansas Chapter of the AAP has prompted the following revisions to the KBH Standards of Practice: Beneficiaries under six years of age. A standardized developmental screening tool must be completed and interpreted. The report must be documented at each KBH screen and be maintained in the beneficiary s permanent medical record. The AAP identified in their 2006 Policy Statement that the Denver Developmental Screening Test II (DDST II) has a low-to-moderate sensitivity and specificity rating. Examples of more sensitive and specific screening tools that may be used are: 1. Ages and Stages Questionnaires (ASQ) also available in Spanish, French and Korean for use with children four months to five years of age 2. Parent s Evaluations of Developmental Status (PEDS) also available in Spanish and Vietnamese for use with children birth to eight years of age 3. Modified Checklist for Autism in Toddlers (MCHAT) also available in Spanish, Turkish, Chinese and Japanese for use with children 15 to 30 months of age a. If a child is being seen regularly and developmental surveillance is provided at every KBH visit, use the MCHAT tool during the above time frames to assess for speech language developmental delays and/or autism spectrum disorders. b. If, however, the child is only being seen sporadically, both a general developmental tool and the MCHAT should be administered at the above time frames to ensure appropriate developmental milestones are being met and to rule out potential speech language developmental delays and/or autism spectrum disorders. Beneficiaries ages six years and older. Complete at least one of the following: 1. General developmental and emotional observations, which must minimally include information regarding exercise, sleep habits, emotional, peer interaction, school (grade, average grades, days missed, vocational, and special education/needs), and any other significant information as needed) 2. A standardized developmental screening tool with interpretation and report Note: An example of a screening tool for six years and older is the Pediatric Symptom Checklist. The completed report and tool must be maintained within the beneficiary s permanent medical record, as well as any referrals for services. Note the directives on the following page when determining if the test performed meets the criteria for billing code 96111. KAN Be Healthy Billing Bulletin Page 6

From the Desk of Sandra Akpovona, KHPA Program Manager KBH Clarification Regarding Codes 96110 and 96111 October 1, 2009 Developmental Screening and Surveillance vs. Developmental Testing When performing developmental screening, code 96110 is most suitable for use during periodic KBH visits with approved providers. This code can be billed with the code V20.2 or other well-child diagnoses. For complete code definitions, please refer to the CPT codebook. When developmental surveillance or screening suggests an abnormality in a particular area of development, more extensive formal objective testing is needed to evaluate the concern. The code 96111 is diagnostic and must not be billed with a wellness diagnosis including V20.0 through V20.2, V20.31, V20.32, V70.0, or V70.3 through V70.9. This code is used when further assessment of motor, language, social, adaptive and/or cognitive functioning by standardized developmental instruments are warranted when it is suspected that a child has an exceptionality, deficit or developmental delay. A child seen for a periodic KBH screen must receive a developmental surveillance. If the child demonstrates a need for further extensive developmental testing, the provider must document this need in the KBH screening documentation and either have the child return for extended testing at another time or initiate a referral to another provider for extended testing. KAN Be Healthy Billing Bulletin Page 7

Vaccine for Children Immunization Administration 90460 90461 90471 90472 90473 90474 A vaccine procedure code must be billed for each administration unit. For example, three immunizations were administered to a five-year-old child. The immunizations administered were MMR (90707), DTaP (90700), and IPV (90713). Bill these vaccine codes in addition to administration codes 90471 (one unit) and 90472 (two units). Use the following resources to determine coverage and pricing information. For accuracy, use your provider type and specialty as well as the beneficiary ID number or benefit plan. Information from the public website is available at: https://www.kmap-state-ks.us/provider/pricing/refcode.asp. Information from the secure website is available under Pricing and Limitations after logging on at: https://www.kmap-state-ks.us/provider/security/logon.asp. Laboratory Complete blood count with automated differential WBC (85025) 1. Infants: once between the ages of nine and 12 months, perform and document the initial screen results. 2. Adolescent males: routinely at age 15. Annually thereafter if any of the following apply: A student athlete A vegetarian 3. Adolescent females: routinely at the age of menarche. Annually thereafter if any of the following apply: History of heavy menstrual flow (soaking more than three pads per day) A student athlete A vegetarian KBH Indicator Values KBH and family planning indicator values are used for reporting purposes. Refer to the indicator values, definitions, and billing instructions below. E: KBH indicator F: Family planning indicator B: KBH and family planning indicator Y: EPSDT (KBH) indicator on 837 professional claim 2400 Loop, SV111 data element Y: Family Planning indicator on 837 professional claim 2400 Loop, SV112 data element Note: Document the appropriate indicator value in Field 24 H of the CMS-1500 claim form. KAN Be Healthy Billing Bulletin Page 8

KBH Referral Values KBH referral values are used for the Centers for Medicare & Medicaid Services (CMS) reporting purposes. Refer to the referral values, definitions, and billing instructions below. When a referral value is present, an EPSDT indicator must also be present. Document one referral value per submitted claim as applicable. Referral values are used after a KBH screen has been completed. AV: Upon completion of the KBH screen, the screening provider initiated a referral; the beneficiary refused this referral. ST: A new referral request has been initiated, and the beneficiary accepted the referral. S2: An abnormality was observed during the KBH screen; however, the beneficiary is currently under treatment for the observed condition. It is recommended providers submit a paper or electronic claim in an 837 professional format. Referral values are to be claimed in Field 24 J on the CMS-1500 paper claim form. When submitting an electronic 837 professional claim with a KBH referral value, document the value within the X12 claim level 2300 loop. Within loop 2300, there are multiple segments. Bill KBH referral values in the CRC segment with appropriate data elements as follows: CRC01 = ZZ CRC02 = Y CRC03 = the appropriate referral value, which is AV, ST, or S2 Note: The Health Insurance Portability and Accountability Act (HIPAA) has labeled this CRC segment with the name of EPSDT Referral. Rural Health Clinic and Federally Qualified Health Center Registered Nurse Registered nursing staff who complete a KBH screen within a RHC or FQHC must claim the TD modifier with each KBH code billed. Refer to the RHC/FQHC Provider Manual for specific benefits and limitations. KHPA Medical Programs as the Secondary Insurance KBH screens update under these conditions: an enrolled provider submits a claim; the claim has a KBH program-recognized code, and the claim has adjudicated (paid or denied). Claims with these conditions are important for required reporting purposes. Every April, an annual CMS 416 Annual Participation Report is required to be filed with CMS. Note: Submit a claim even when the beneficiary has a primary insurance (third party liability [TPL]) as these screens are used to report the State of Kansas participation rate. Review the following billing options when the beneficiary has TPL and KHPA Medical Programs secondary insurance: When not seeking reimbursement o Submit a claim with $0.00 throughout the CMS-1500 claim form ($0.00 for all charges on the claim form). o Submit a claim with the TPL explanation of benefits (EOB) attached. Indicate the TPL paid amount in the Amount Paid field and $0.00 in the Balance Due field. Seeking reimbursement o Submit a claim with the TPL EOB attached. Indicate the TPL paid amount in the Amount Paid field and the remaining dollar amount in the Balance Due field. Refer to the TPL information in Section 3100 of the General TPL Payment Provider Manual. KAN Be Healthy Billing Bulletin Page 9

Reimbursement Current rate information is available at https://www.kmap-state-ks.us/provider/pricing/hcpcssearch.asp. E & M preventive medicine codes and modifier EP update all four KBH screens. Code Modifier 99381 99385 EP 99391 99395 EP 99202 99205 EP 99213 99215 EP Note: E & M office visit codes with modifier EP must have a wellness diagnosis (V20.0 through V20.2, V20.31, V20.32, V70.0 and/or V70.3 through V70.9) included, or the claim will deny and the KBH screen will not update. Refer to Section 8000 of the KAN Be Healthy Provider Manual for minimum documentation requirements when billing an E & M preventive medicine or office visit code with modifier EP. E & M preventive medicine codes (without modifier EP) update all four KBH screens. 99381 99382 99383 99384 99385 99391 99392 99393 99394 99395 E & M office visit codes (without modifier EP) update all four KBH screens when billed with a wellness diagnosis code (V20.0 through V20.2, V20.31, V20.32, V70.0 and/or V70.3 through V70.9). 99202 99203 99204 99205 99213 99214 99215 Vision codes update the KBH vision screen only. 99173 92002 92004 92012 92014 Hearing codes update the KBH hearing screen only. 92551 92552 92553 92555 92556 92557 92582 Developmental Screening Code 96110 KAN Be Healthy Billing Bulletin Page 10

Vaccine for Children Immunization Administration Codes 90471 90472 90473 90474 90460 90461 Laboratory Codes 85025 The following codes require MD/DO or ARNP/PA counsel. KAN Be Healthy Billing Bulletin Page 11

Examples of KBH Billing First Scenario: Karen, a four-year, eight-month old beneficiary, was seen for an initial visit and KBH screen. 1. Karen s mother completed an office family and patient history form. 2. Karen s height and weight measurements were taken and her BMI was computed and plotted on a BMI for Age Growth Chart. Karen s apical pulse and blood pressure were taken and written in the progress notes. The screening provider reviewed Karen s history with her mother as well as her height, weight, and vital sign findings. Throughout the visit, the screening provider also completed, interpreted, and documented the following procedures: Ages and Stages Questionnaire (developmental screening tool) with a report included in the documentation of the screen Nutrition status (24-hour recall and food allergies) Risk factors and anticipatory guidance regarding nutrition, development, and safety/poisons Audiology hearing screen per a pure tone audiometry test in conjunction with the Hearing Developmental Screen interview tool Near and distance acuity screens using Tumbling E and Snellen eye chart with pictures Comprehensive, unclothed physical screen (gastrointestinal, central nervous, musculoskeletal, integumentary, cardiovascular/pulmonary, and genital/urinary systems) Oral/dental cavity (dental screen) 3. After the physical screen was completed, Karen and her mother were encouraged to complete a blood lead test due to Karen s risk history and since there were no previous results on file. 4. Immunizations were administered (DTaP, IPV, and MMR). KBH Billing Components 99382 with modifier EP 90471 90472 90700 90713 90707 KBH Billing Components 99382 without modifier EP 90471 90472 90700 90713 90707 96110 92552 99173 KAN Be Healthy Billing Bulletin Page 12

Second Scenario: Bailey, a six-year-old beneficiary, was seen for a KBH screen by his PCCM. 1. Bailey s father completed an office history form, and it was reviewed. 2. Bailey s current history revealed that he has had a cough for the last week and his ears hurt. 3. The screening provider completed an exam, which focused on Bailey s complaints. An otoscopic exam revealed Bailey s tympanic membranes were red and bulging. 4. Due to the abnormalities observed in each ear, the provider elected to defer the KBH exam until a later date. 5. The results were reviewed and documented in Bailey s chart. The screening provider diagnosed Bailey with an ear and throat infection and initiated treatment. 6. A follow-up visit was scheduled in one month, unless Bailey s symptoms became worse. KBH Billing Components 99213 & V20.2 as one diagnosis code (The visit was scheduled with the intent to complete a KBH screen; however, abnormalities were voiced and observed.) KAN Be Healthy Billing Bulletin Page 13

Third Scenario: Bailey was seen for a follow-up and KBH screen four weeks later. 1. Bailey s mother reviewed the office history form on file, and no changes were reported. 2. Bailey s present condition reported clear nasal drainage and an unproductive cough that caused occasional chest discomfort but denied any ear pain. 3. Before completing a comprehensive exam, the provider collected and reviewed Bailey s vital signs, height and weight, computed his BMI, and recorded these on the BMI for age growth chart. 4. The screen included a head-to-toe, all body system physical screen, including oral/dental screen; near and distance acuity vision screen; risk factors and anticipatory guidance activity; sleep habits; and safety habits. 5. Bailey was verbally screened for blood lead poisoning risk factors, and the previous blood lead poisoning results were reviewed. 6. Bailey s nutrition was reviewed, and verbal education provided. 7. The screening provider also reviewed the Pediatric System Checklist. The provider ensured the results were interpreted and reviewed with Bailey s mother. The form was then signed, dated, and placed in Bailey s chart with a report indicating the findings. 8. Bailey s tympanic membranes were visualized to determine the infection had resolved, and an evoked acoustic emissions screen was completed to ensure he had no hearing deficits. The screening provider reviewed the findings from the evoked acoustic emission screening and included this documentation in the KBH documentation. 9. Bailey s immunizations were updated by administering a DTaP, IPV, and MMR. 10. Laboratory was not collected at this time; the required Complete Blood Count with Automated Differential was collected one year ago, and no abnormal results were noted at that time. KBH Billing Components 99213 and modifier EP 90471 90472 90700 90713 90707 At least one wellness diagnosis code must be billed. KBH Billing Components 99213 with at least one wellness diagnosis 99173 96110 92587 90471 90472 90700 90713 90707 KAN Be Healthy Billing Bulletin Page 14

Fourth Scenario: Phoebe was seen for her 17-year-old KBH screen. 1. Phoebe completed an office history form, which included self and family history. 2. The screening provider completed a comprehensive exam, which included a head-to-toe screen of each body system. 3. The screening provider completed a near and distance acuity screen (vision screen). 4. The screening provider completed an observation of her oral/dental cavity. The provider noted Phoebe brushes her teeth three times a day, flosses once a day, and saw Michael Eyetooth, DDS, two months ago. 5. The screening provider reviewed the Pediatric Symptom Checklist developmental screen. The provider ensured the results were interpreted, and the findings were documented and reviewed with Phoebe. The form was then signed, dated, and placed in Phoebe s chart. 6. Phoebe s nutritional screen was reviewed. Phoebe indicated she follows a vegetarian diet. 7. Activity, sleep habits, and emotional status (such as school/educational standing and issues, exercise habits, peer and family interactions) were reviewed. Phoebe indicated she was on the cross-country track team. 8. Risk factors, such as substance abuse precautions, peer pressure, unhealthy eating habits, safety/poisons, seat belt use, self breast exams, sexuality, and assurance of most recent tetanus booster (immunization) were discussed. 9. A paper hearing screen form was completed, and a referral was initiated with the local health department for an audiometer screen. When the results are received, the provider will determine if further screening is warranted. 10. The screening provider determined Phoebe to be in very good health. The Gardasil vaccine was discussed, and a gynecological visit was scheduled. On review of her vegetarian status and involvement in the cross-country track team, Phoebe meets the criteria for an annual CBC with differential; therefore a blood specimen was obtained and sent to the lab. KBH Billing Components 99394 with modifier EP 85025 OR KBH Billing Components 99394 96110 99173 85025 KAN Be Healthy Billing Bulletin Page 15

KBH Billing Graph Billing E & M Preventive Medicine or Office Visit Codes E & M preventive medicine code Modifier EP Other Component Parts or Visit Billed Diagnosis Code KBH Screens Updated Claim Status * Payment Amount With No Any All four Paid EP rate Depending Depending Initial E & M preventive upon initial upon initial With Yes Any detail medicine code detail detail paid processed processed E & M office visit code With No Wellness All four Paid EP rate E & M office visit code With No Not wellness E & M office visit code With Yes Wellness E & M preventive medicine code None Denied $0.00 Depending upon initial detail processed Initial detail paid Without Yes Any All four Paid E & M office visit code Without Yes Wellness All four Paid E & M office visit code Without Yes Not wellness * This claim status is an example when benefits and limitations are met. None Paid Depending upon initial detail processed Usual rate (ARNP/PA @ 75%) Usual rate (ARNP/PA @ 75%) Usual rate (ARNP/PA @ 75%) KAN Be Healthy Billing Bulletin Page 16