Early and Periodic Screening, Diagnosis and Treatment EPSDT Program

1
Early and Periodic Screening, Diagnosis and
Treatment (EPSDT)Program
Department of Medical Assistance Services

• July-August 2002
• www.dmas.state.va.us

2
Upon Completion of This Training You Will
Understand

• Provider responsibilities
• Covered services/related programs
• Screening components
• Documentation guidelines
• Referrals

3
EPSDT Program

• The goal of this program is to assure that health
  problems are diagnosed and treated early before
  the problem becomes complex and treatment more
  costly.
• Provides preventative health care for children
  under the age of 21.

4
EPSDT Program

• Early- as soon as possible in the childs life or
  as soon as the childs eligibility assistance has
  been established.
• Periodic- at intervals established for screening
  by medical, dental, and other health care
  experts. The types of procedures performed and
  their frequency depend on the childs age and
  health history.

5
EPSDT Program

• Screening- the use of quick, simple procedures to
  sort out apparently well persons from those who
  have a disease or abnormality and to identify
  those in need of more definitive study of their
  physical or mental problems.

6
EPSDT Program

• Diagnosis- is the determination of the nature or
  cause of physical or mental disease or
  abnormality through the combined use of health
  history physical, developmental, and
  psychological examination, and laboratory tests
  and x-rays.

7
EPSDT Program

• Treatment- is any medically necessary treatment
  service required to correct or ameliorate defects
  and physical and mental illnesses and conditions
  discovered during a screening examination.

8
EPSDT Program-Mental Health Services
Recipients under age 21

• Inpatient Hospital Psychiatric Care
• Residential Treatment Program
• Intensive-in-Home Services for Children and
  Adolescents
• Therapeutic Day Treatment for Children and
  Adolescents

9
Required EPSDT Services

• Medical screening services
• Vision services
• Dental services
• Hearing services

10
Periodicity Schedule

• Virginia follows the American Academy of
  Pediatrics (AAP) screening schedule except for
  adolescents.
• Each of the four screens- medical, vision,
  hearing, and dental- must follow the periodicity
  schedule and the specific protocol for each age
  group, including age appropriate immunizations.

11
Periodicity Schedule

• Provided at other intervals, indicated as
  medically necessary, to determine the existence
  of a suspected illness.
• Vision screening must include diagnosis and
  treatment for defects in vision- including
  eyeglasses.

12
Periodicity Schedule

• Dental screenings must at a minimum include
  relief of pain and infections, restoration of
  teeth, and maintenance of dental health.
• Hearing screens must include at a minimum,
  diagnosis and treatment for defects, including
  hearing aids.

13
Scheduling Initial and Periodic Screenings

• The primary care physician (PCP) must
• Contact the family to schedule the initial
  screening within 30 days of effective date
• Ensure that the appointment schedule for the
  periodic screenings are timely and families are
  contacted when the next screening is due

14
Scheduling Initial and Periodic Screenings

• The screening provider must also follow up on
  missed appointments by
• Contacting the family by letter or telephone to
  provide the opportunity for another screening
  within 30 days of the original appointment
• Documenting two good faith efforts to reschedule
  appointment
• Good faith is defined as a successful contact by
  telephone or letter

15
Scheduling Initial and Periodic Screenings

• Failure of the family to keep the second
  appointment is considered a declination of that
  screening only.
• The provider must schedule the child for the next
  planned screening, following the same process.

16
Exceptions to Screening Timeliness Requirements

• Initial screening- may not correspond exactly to
  the periodicity schedule
• Off-schedule screening-used to bring child up to
  date on missed screenings
• Interperiodic screening-outside of and in
  addition to regular screening
• Partial screenings- incomplete screenings

17
Medical Screening Components
18
Comprehensive Health and Developmental/Behavior
History

• Must be obtained at initial visit from the
  parents, responsible adult, or directly from the
  adolescent.
• Must contain mental health and nutritional
  history.
• Should be obtained through interview on
  questionnaire.

19
Comprehensive Health and Developmental/Behavior
History

• Should include
• Family medical history
• Patient medical history
• Nutritional history
• Immunization history
• Environmental risk
• Family background-emotional problems, etc.
• Patient history of emotional and/or behavioral
  problems

20
Comprehensive Health and Developmental/Behavior
History

• Adolescent childrens initial history must
  include
• History of sexual activity, if appropriate
• Menstrual history for females
• Obstetrical history, if appropriate
• History must be updates at each subsequent
  screening to allow serial evaluation

21
Developmental/Behavior Assessment

• Must be conducted at each visit by observation,
  interview, history and appropriate examination.
• The assessment must include a range of activities
  using appropriate AAP guidelines.
• If suspicious, objective developmental testing
  should be administered.

22
Developmental/Behavioral Assessment

• If a child age three and older meets any of the
  following criteria by the objective test or
  exhibits the behavior they must be referred to
  the local school systems special education
  department for developmental/psychological
  evaluation
• Developmental delays
• History of poor school performance
• Poor social adjustment
• Emotional or behavioral problems

23
Developmental/Behavioral Assessment

• If school is not in session a child exhibiting
  psychological/psychiatric problems may be
  referred to the local behavioral health
  agency/community service board (CSB) or other
  qualified mental health providers.

24
Comprehensive Unclothed Physical Examination

• Must be performed at each visit and documented or
  checked by the physician in the medical record.
• Must use observation, palpation, auscultation and
  other techniques using AAP guidelines.

25
Comprehensive Unclothed Physical Examination
Must include all of the following

• Cranium and face
• Hair and scalp
• Ears
• Eyes
• Nose
• Throat

• Mouth and teeth
• Neck
• Skin and lymph nodes
• Chest and back to check for heart and lung
  disorders -by stethoscope

26
Comprehensive Unclothed Physical Examination

• Abdomen
• Genitalia
• Musculoskeletal system
• Extremities
• Nervous system

27
Comprehensive Unclothed Physical Examination

• Screen for congenital abnormalities, response to
  voices and other external auditory stimuli.
• Evaluate tanner stage and scoliosis screening
  beginning at age ten.
• Measure and evaluate height and weight on growth
  chart.

28
Comprehensive Unclothed Physical Examination

• Evaluate growth and laboratory measures to assess
  nutritional status and eating habits.
• Must include blood pressure measurement for
  children age three and older.

29
Comprehensive Unclothed Physical Examination

• Excessive injuries or bruising that may indicate
  possible abuse must be noted in the childs
  record and by state law must be reported to the
  Dept. of Social Services.

30
Appropriate Immunizations

• Participate in the vaccines for children program
  (VFC).
• Ensure children are immunized according to the
  ACIP and AAP guidelines.
• Status must be reviewed from the medical record
  interview the parent at each visit.
• Parents refusal must be documented- signed and
  dated by the parent in the medical record.

31
Appropriate Immunizations

• Document any condition that warrants a deferral
  of necessary immunizations and reschedule at the
  earliest opportunity.
• Age appropriate immunizations are a federally
  required screening component. A screening is not
  considered complete unless all required
  components due are administered. Failure to
  comply may result in denial of payments.

32
Laboratory Procedures

• Must be performed in accordance with EPSDT
  screening periodicity schedule and AAP
  guidelines
• May be billed separately if performed in office
• Specimen collection should be in-house
• One handling fee can be billed if test performed
  by outside lab
• Must comply with CLIA act of 1988 and possess a
  certificate of registration or waiver

33
Laboratory Procedures

• The following procedures are required
• Neonatal screening
• Sickle cell screening
• Lead toxicity screening
• Required for 12 and 24 months/36 and 72 months if
  not previously screened
• Venipuncture is preferred
• Use lab that participates with VDH
• If child has elevated blood lead (EBL) levels,
  refer to the VDH clinical guidelines and contact
  Lead Safety Virginia Program [phone]

34
Laboratory Procedures

• Anemia screening
• Must be performed according to EPSDT periodicity
  schedule
• Involves hematocrit or hemoglobin values
• Should be administered more frequently if
  medically indicated
• Urinalysis
• A dipstick urinalysis must be performed in
  accordance with the EPSDT periodicity schedule

35
Health Education

• Must be provided at each screening.
• Help children/parents understand childs health
  status and provide information that emphasizes
  health promotion and preventive strategies.

36
Health Education

• Health education has two components
• Anticipatory guidance- provides the family with
  information on what to expect in the childs
  current and next developmental phase. The AAP
  provides guidelines for topics.

37
Health Education

• Health supervision summary- provider summarizes
  results of screenings, lab tests, reviews health
  status and discusses specific problems. Schedules
  treatment or gives referral if needed if not,
  schedules next screening.

38
Vision Screening
39
Vision Screening

• Must be performed beginning at age 3.
• Purpose is to detect potentially blinding
  diseases and visual impairments. Includes
• Subjective screening- part of the physical exam
• Objective screening- distance visual acuity,
  color perception and ocular alignment tests

40
Vision Screening

• Acceptable distance visual acuity tests
• LEA symbol chart 10 (ages 3-4) 15 line
  (gtage 5)
• ETDRS distance chart
• ETDRS near chart
• Snellen E charts
• HOTV chart

41
Hearing Screening
42
Hearing Screening

• To detect sensorineural and conductive hearing
  loss, congenital abnormalities, noise-induced
  hearing loss, central auditory problems, or a
  history of conditions that may increase the risk
  for potential hearing loss.
• Has subjective and objective components.

43
Hearing Screening- Subjective Component

• Subjective screening- part of the history and
  physical examination.
• Children who are at risk, should be monitored
  every six months up to age 3.
• School-age children should be screened at
  5,10,12,16, and 18.

44
Hearing Screening- Subjective Component

• Risk factors for additional screenings
• Concerns regarding hearing, speech language or
  learning disabilities
• Family history of hereditary or delayed onset of
  sensorineural hearing loss
• Craniofacial anomalies including those with
  morphological abnormalities of the pinna and ear
  canal
• Bacterial meningitis

45
Hearing Screening- Subjective Component

• Stigmata or other finding associated with
  sensorineural hearing loss, a conductive hearing
  loss or both
• Neurofibromatosis type II or neurodegenarative
  disorders
• Head trauma with loss of consciousness or skull
  fracture
• Reported exposure to damaging noise levels or
  ototoxic drugs
• Recurrent/persistent otitis media with effusion
  for at least three months

46
Hearing ScreeningObjective Component

• For children over 3 years of age
• Pure tone screening using pure tone audiometer or
  Welsh Allyn Audioscope
• Air conduction screening shall occur at 500,
  1000, 2000 and 4000 hertz.
• Equipment should be calibrated yearly

47
Dental Screening
48
Dental Screening

• Oral inspection must be performed as part of each
  physical exam
• Must note
• Tooth eruption
• Caries
• Bottle decay
• Developmental anomalies
• Malocclusion
• Pathological conditions
• Dental injuries

49
Dental Screening

• Initial dental referral must be provided at the
  initial medical screening on any child age 3 or
  older unless it is known and documented that
  regular dental care is already being received.

50
EPSDT Referrals

• When an EPSDT screening indicates the need for
  diagnosis or treatment of a condition or
  abnormality, the progress notes must also
  indicate the same. The child may be referred for
  medically necessary specialty care if the
  screening provider is not able to provide the
  treatment.

51
EPSDT Referrals

• If the screening provider is not the childs PCP,
  the screening provider must contact the childs
  PCP to request a referral and authorization for
  treatment. This includes referrals to
  opthamologists or optometrists for follow up eye
  care.
• All referrals must be documented in the childs
  medical record.

52
EPSDT Referrals

• A dated written referral must be given to the
  recipient or parents or forwarded to the referred
  provider. The following must be included on the
  referral
• Name of the child
• Medicaid ID number
• Date of the screening
• Abnormality noted

53
EPSDT Referrals

• Name, address, phone and fax number of the
  childs PCP
• Name of the physician or other health care
  provider whom this referral applies
• Signature of the referring provider

EPSDT referrals must be followed up within 60
days to ensure that the child received the
requested treatment.
54
Optional Screening Procedures
Provider must document medical necessity (risk
factors)

• Tuberculin test
• Cholesterol screening
• Sexually transmitted disease screening
• Cancer screening
• Pelvic examination

55
Documentation

• Records must be retained for five years
• Documentation must be clear and legible
• Records must contain documentation of
• Reason for the visit
• Date services were performed, specific test or
  procedures, their results and the signature of
  the staff member who performed the service and
  their title

56
Documentation

• Medical contraindication or a written statement
  from a parent for immunizations due and not given
  and attempts by provider to bring the child up to
  date on immunizations
• Medical contraindication or reason for delay in
  vision or hearing screening if not done on the
  same day as medical screening

57
Documentation

• Any screening component not completed, the reason
  it was not completed and attempts made by the
  provider to complete the screening
• Missed appointments and two good faith efforts to
  reschedule

58
Documentation

• Referrals made for diagnosis, treatment for
  conditions found in screenings and follow up to
  assure services were provided within 60 days of
  screening
• Date next screening is due
• Direct referral for age appropriate dental
  services

59
Other Related Services

• Babycare
• WIC
• Head Start and Healthy Start
• Teen pregnancy prevention program
• Early intervention program
• Resource Mothers Program
• Linkages with schools
• Client Medical Management

60
Other Related Services

• FAMIS-
• Well child exams- not an EPSDT service
• Immunizations covered- however not with the VFC
  program- reimbursement is provided for vaccine
  and administration

61
Special Billing Instructions

• Laboratory tests
• May be billed separately
• Reimbursement to the provider actually rendering
  the service
• Screening provider may bill for handling charge
  if specimens sent to an outside lab

62
Special Billing Instructions

• Complete initial and periodic screenings
• Use preventative CPT codes
• Do not bill these codes if unclothed exam not
  performed
• Sick visits
• Bill preventive codes if screening is performed
• Bill appropriate CPT codes if screening is
  incomplete

63
Special Billing Instructions

• Interperiodic and partial screenings
• Use preventive codes if screening is complete
• Use EM codes if screening is incomplete
• Hearing and/or vision screening
• Use assigned age specific codes for objective
  tests
• Codes can also be used as part of mass screening
• Do not bill on date of medical screening

64
Special Billing Instructions

• Note
• Contact each HMO you participate with, for
  billing instructions for recipients in the
  managed care program

65
Recipient Appeals Process

• Must be appealed in writing by the recipient or
  parent
• Must be filed within 30 days of the date of the
  final decision notification
• Must be directed to

Appeals Division Department of Medical Assistance
Services 600 East Broad Street, Suite
1300 Richmond, VA 23219
66
Provider Appeals

• Process has 3 phases
• Written response and reconsideration to
  preliminary findings - (30 days to submit info)
• The informal conference - (15 days to request
  informal conference)
• The formal evidentiary hearing

67
Title
Department of Medical Assistance Services
Medicaid Eligibility and Billing on the
HCFA-1500

• July-August 2002
• www.dmas.state.va.us

68
As a Participating ProviderYou Must-

• Determine the patients identity.
• Verify the patients age.
• Verify the patients eligibility.
• Accept, as payment in full, the amount paid by
  Medicaid.
• Bill any and all other third-party carriers.

69
RECIPIENT ELIGIBILITYMEDICAID CARDS
70
Eligibility Medicaid
Recipients enrolled in the traditional Medicaid
Program will be identified by a Virginia Medicaid
Eligibility Card. Eligibility can be verified
by Automated Voice Response System (AVRS),
Provider Helpline or other system options.
71
Auto Voice Response System(AVRS)
Recipient Eligibility Check Status Claim Status
Richmond Area 965-9732 or 965-9733 All
Other Areas 800-884-9730
72
Recipient Eligibility Card
CASE I.D. NUMBER
PLUS
123-456789
I.D. NUMBER
01-5
02-3
03-8
04-6
05-4

73
Recipient Eligibility Card
BIRTH DATE
SEX
10 31 195309 22 195504 05 198501 14
198911 02 1990
FMMMF

74
Recipient Eligibility Card
THE FOLLOWING INDIVIDUALSARE ELIGIBLE THROUGH
THELAST DAY OF
April 2002
SI
NAME
CBAAA
DOE, JANEDOE, SAMDOE, TEDDOE, ALLENDOE, ANN

75
Recipient Eligibility Card
THE FOLLOWINGINDIVIDUALSARE ELIGIBLE FROM
BEGIN DATE
04 01 0204 01 0204 01 0204 01 02 04
01 02

76
Recipient Eligibility Card
THE FOLLOWING INDIVIDUALSARE ELIGIBLE THROUGH
THELAST DAY OF
April 2002
SI
NAME
CBAAA
DOE, JANEDOE, SAMDOE, TEDDOE, ALLENDOE, ANN

77
Recipient Eligibility CardInsurance Information
CASE I.D. NUMBER
PLUS
123-456789
I.D. NUMBER
CARRIER BEGIN DATE
182182
02-3
04 01 0204 01 02
02-3
Chap. 3

78
Recipient Eligibility CardInsurance Information
TYP
POLICY / MEDICARE
Chap. 3

79
Eligibility Medallion II HMO
You will be able to identify recipients enrolled
in a Medallion II HMO by their member ID Card.
The recipients enrolled in a Medallion II HMO
will carry a card bearing the name of the one if
the following plans Carenet, Sentara Family
Care, Healthkeepers Plus, VAPremier, or Unicare.
80
Client Medical Management(CMM)
Recipient Monitoring Unit 888-373-0589 804-
786-6548
81
IMPORTANT CONTACTS

• Provider Helpline
• Recipient Helpline
• AVRS- Medicaid Eligibility
• Billing Inquiries
• Forms and Invoices
• Provider Enrollment

82
PROVIDER HELPLINE
Claims, covered services, billing inquiries
Department of Medical Assistance Services 600
East Broad Street, Suite 1300 Richmond, VA 23219
800-552-8627 804-786-6273
83
Recipient Helpline
Claims, covered services, billing
inquiries 804-786-6145
84
Automated Response System(ARS)

• Automated Response System
• Recipient Eligibility (REVS)
• Claim Status
• Check Status

800-884-9730 804-965-9732 804-965-9733
85
Billing Inquiries
Customer Service Department of Medical Assistance
Services 600 East Broad Street, Suite
1300 Richmond, VA 23219
86
Forms and Manuals
DMAS Order Desk Commonwealth Mailing Systems 1700
Venable Street Richmond, VA 23222 Order
Desk 804-780-0076 Fax Number 804-780-0198
87
Provider Enrollment
New provider numbers or change of address First
Health Provider Enrollment Unit First Health-
VMAP PEU P. O. Box 26803 Richmond, VA
23261-6803 888-829-5373 804-270-5105 804-270-7027
- Fax
88
Electronic Claims Coordinator
First Health Services Corporation Electronic
Claims Coordinator E-mail edivmap_at_fhsc.com Phone
[phone] Option 2 Fax [phone]
89
Basic Billing - HCFA-1500EPSDT Program Services
90
Timely Filing

• ALL CLAIMS MUST BE SUBMITTED WITHIN ONE YEAR
  FROM THE DATE OF SERVICE
• EXCEPTIONS Retroactive Eligibility/Delayed
  Eligibility Previously rejected or denied
  claims
• Submit claims with documentation attached
  explaining the reason for delayed submission.

91
HCFA-1500 FORM
Use ONLY the original
RED
WHITE
and
(12-90)
Invoice
Photocopies are not
acceptable!
92
Block 1 Check Medicaid
MEDICAID
CHAMPUS
1. MEDICARE
(Medicare )
(Medicaid )
(Sponsor's SSN)
CHECK ONLY ONE BLOCK

93
BLOCK 1a Recipient ID Number
1a. INSURED'S I.D. NUMBER (FOR PROGRAM
IN ITEM 1)
123456789 01 4
(Be sure to include all 12 digits)

94
Block 2 Patient's Name
2. PATIENT'S NAME (Last name, First Name, Middle
Initial)
Smith, Sam

95
Block 10 Accident-Related
10. IS PATIENT'S CONDITION RELATED TO
a. EMPLOYMENT? (CURRENT OR PREVIOUS)
YES
NO
PLACE (State)
b. AUTO ACCIDENT?
YES
NO
c. OTHER ACCIDENT?
NO
YES
You MUST check YES or NO for a, b c

96
Block 10d Conditional Use
10d. RESERVED FOR LOCAL USE
ATTACHMENT
You MUST use the word "ATTACHMENT"
if you attach anything to the HCFA form.

97
Blocks 17 and 17a- Conditional
17. NAME OF REFERRING PHYSICIAN OR OTHER SOURCE
17- Name of the Recipients PCP
(primary care physician) 17a- PCPs 7-digit
Medicaid provider ID
17a. ID NUMBER OF REFERRING PHYSICIAN
(Medicaid 7-digit provider ID)


98
Block 21 Diagnosis Codes
21. DIAGNOSIS OR NATURE OF ILLNESS OR INJURY
78650
1.
3.
2.
4.
May enter up to 4 codes
Omit decimals

99
Block 24A Dates of Service
24. A
DATE(S) OF SERVICE
From
To
MM DD YY
MM DD YY
02
02
04
01
04
01
1
04
02
01
30
02
04
2
Both FROM and TO dates
must be completed
DATES MUST BE WITHIN THE SAME CALENDAR MONTH

100
Block 24B Place of Service Block 24C Type of
Service
B
C
Place
Type
of
of
Service
Service
12
1
1- Medical Care
11- Office
Physicians Manual Chapter V, pages 13-14

101
Block 24D Procedure Codes
D
PROCEDURES, SERVICES, OR SUPPLIES
99384
(Explain Unusual Circumstances)
CPT/HCPCS
MODIFIER
H
22
85022


Physicians Manual Chapter V- Modifiers
102
HIPAA and Local Codes

• To establish uniform data standards, Local Codes
  will be eliminated and replaced with National
  Standard HCPCS and CPT codes.
• There are several national organizations
  responsible for defining and maintaining codes.

103
HIPAA and Local Codes

• DMAS homegrown codes now utilized will be
  replaced and National codes representing these
  services will be used for submitting Medicaid
  claims.
• Bottom Line-
• No More Local Codes!

104
Block 24E Diagnosis Code
21. DIAGNOSIS OR NATURE OF ILLNESS OR INJURY
V202
38120
1.
3.
37200
2.
4.
E
DIAGNOSIS
CODE
1
1,2,3

105
Block 24 F Charges
F
CHARGES
Enter the usual
and customary charges

106
Block 24G Days or Units
G
DAYS
OR
Enter the number of times the procedure, service,
or item was provided during the service period.
UNITS
1
31

107
Block 24H EPSDT/FAMILY PLAN
H
EPSDT FAMILY PLAN
1-Early and Periodic Screening, Diagnosis and
Treatment Program Services 2- Family Planning
Service



1
108
24J COB Other Insurance 24K Other Insurance
Paid
J
K
RESERVED FOR
LOCAL USE
COB
Attach denial from other carrier

109
Block 31 Signature Date
31. SIGNATURE OF PHYSICIAN OR SUPPLIER
INCLUDING DEGREES OR CREDENTIALS
(I certify that the statements on the reverse
apply to this bill and are made a part thereof.)
SIGNED
DATE
If there is a signature waiver
on file, you may stamp, print,
or computer-generate the signature.

110
Block 33 Provider ID and Address
33. PHYSICIAN'S, SUPPLIER'S BILLING NAME,
ADDRESS, ZIP CODE
PHONE
765432 1
PIN
GRP
Be sure to put the MEDICAID
7-digit ID number!

111
Block 22 Adjustments and Voids
22. MEDICAID RESUBMISSION
CODE
ORIGINAL REF. NO.
532
345674213
Adjustment or
From original
Void
remittance
Resubmission
Code
Physicians Manual Chapter V, pages 11-12

112
Problems being encountered withHCFA-1500 Claims
Submission
BLOCK
PROBLEM AREA
Block 1
Incorrect block checked
Block 1a
Incorrect Recipient's ID
Block 10d
Incorrect information entered
All of Block 24
Comments entered in blocks
Block 24E
Diagnosis code written out
Blocks 24 J K
(J) left blank (K) incorrect info.
Block 33
Not entering Provider ID by "PIN"

113
Remittance VoucherSections of the Voucher

• APPROVED - for payment.
• PENDING - for review of claims.
• DENIED - no payment allowed.
• DEBIT- Adjusted claims creating a
  positive balance.
• CREDIT - Adjusted/Voided claims creating a
  negative balance.

114
Remittance VoucherColumns of the Voucher

• Recipient's Identification Number
• Reference Number
• Visits/Units/Studies

115
PRESENTING...
The MedicaidTOP TEN
116
TOP 10 DENIAL REASONS
117
Thank You
www.dmas.state.va.us