Arkansas Administrative Code › Agency 016 - DEPARTMENT OF HUMAN SERVICES › Division 06 - Medical Services › Rule 016.06.05-099 - Child Health Services / Early and Periodic Screening, Diagnosis and Treatment (EPSDT) Provider Manual Update Transmittal #71

Current through Register Vol. 49, No. 6, June, 2024
Section II
Child Health Services/Early and Periodic Screening, Diagnosis,
				and Treatment
211.000
Introduction
A comprehensive medical screening program for all eligible
				Medicaid children requires the medical provider to assume overall
				responsibility for detection and treatment of conditions found among these
				young patients. This means the provider should have knowledge of specialized
				referral services available within the community and should maintain continuing
				relationships with physician specialists. It also requires the provider to work
				closely with the Arkansas Department of Health and Human Services office staff
				to ensure that eligible children in need of medical attention take full
				advantage of the medical services available to them.
The screening procedures outlined in Sections
				213.000 and
				215.000 of this manual are
				considered the minimal elements of a comprehensive screening. Other procedures
				may be included depending upon the child's age and health history. Each of the
				screening procedures is based on recommendations from the federal Department of
				Health and Human Services and the American Academy of Pediatrics. Each
				screening should be billed separately, providing the appropriate information
				for each of the applicable screening components. Other specific procedures may
				be used at the screener's discretion as long as the following federally
				mandated components are included in the complete medical screening procedure:
				observe and measure growth and development, give nutritional advice, immunize,
				counsel and give health education and perform laboratory procedures applicable
				for the age of the child.
Requirements for Periodic Medical, Visual, Hearing
				and Dental Screenings
Distinct periodicity schedules have been established for
				medical screening services, vision services, hearing services and dental
				services (i.e., each of these services has its own periodicity schedule).
				Periodic visual, hearing and dental screens should not duplicate prior
				services.
212.000
Scope
The Child Health Services (CHS) Early and Periodic Screening,
				Diagnosis and Treatment (EPSDT) Program is a federally mandated child health
				component of Medicaid. It is designed to bring comprehensive health care to
				individuals eligible for medical assistance from birth to age 21. Even if the
				person eligible for medical assistance is a parent, he or she is eligible for
				Child Health Services (EPSDT) if under age 21. Physicians and other health
				professionals who provide Child Health Services (EPSDT) screening may diagnose
				and treat health problems discovered during the EPSDT screening or may refer
				the child to other appropriate sources for such care.
The following is a broad definition of the components of the
				Child Health Services EPSDT program.
Early
means as soon as possible in the
				child's life, or as soon as his or her family's eligibility for assistance has
				been established.
Periodic
means at intervals
				established for screening by medical, dental, visual and other health care
				experts. The types of screening procedures performed and their frequency will
				depend on the child's age and health history. In Arkansas, the medical periodic
				screening schedule has been established following the recommendations of the
				American Academy of Pediatrics.
Screening
is the use of quick, simple
				procedures to sort out apparently well persons from those who may have a
				disease or abnormality and to identify those in need of a more definitive
				examination.
Diagnosis
is the determination of the
				nature or cause of a disease or abnormality through the combined use of health
				history, physical, developmental and psychological examination, laboratory
				tests and X-rays.
Treatment
means physician, hearing,
				visual or dental services or any other type of medical care and services
				recognized under state law to prevent, correct or ameliorate disease or
				abnormalities detected by screening or by diagnostic procedures. Treatment for
				conditions discovered through a screen may exceed limits of the Medicaid
				Program. Services not otherwise covered under the Medicaid Program will be
				considered for coverage if the services are prescribed by a physician as a
				result of an EPSDT screen. The services must be medically necessary and
				permitted under federal Medicaid regulations.
213.000
Provider's Role in the Child
			 Health Services (EPSDT) Program
The following steps are necessary in order to complete a Child
				Health Services (EPSDT) screen:
A.
			 When a child arrives for a Child Health Services (EPSDT) screening appointment,
			 ask to see the current Medical Assistance Identification Card (Medicaid Card).
			 Verify Medicaid eligibility electronically before services are
			 rendered.
B. Screen the child
			 according to the procedures outlined in Sections
			 215.000,
			 216.000,
			 217.000,
			 218.000 or
			 219.000 of this manual. All
			 elements of the screen must be completed and documented before the screen is
			 considered complete. This includes the evaluation of lab results and the
			 provision of or referral for immunizations.
A full medical screen must, at a minimum, include: a
				comprehensive health and developmental history (including assessment of both
				physical and mental health development); a comprehensive unclothed physical
				exam; appropriate immunizations according to age and health history; laboratory
				tests (including appropriate blood lead level assessment); and health education
				(including anticipatory guidance).
All parts of the screening package must be furnished to the
				Child Health Services (EPSDT) participant in order for the screening to qualify
				as a full medical Child Health Services (EPSDT) screening service.
I mmunizations that are
				appropriate based on age and health history, but which are contraindicated at
				the time of the screening, may be rescheduled at an appropriate time or
				referred to another provider.
C. Record the screening findings on the
			 DMS-694 or on the American Dental Association (ADA) form for dental screens.
View or print a DMS-694 sample form
.
The
			 DMS-694 screening form or the ADA (dental) form must be completed on each
			 individual screened for Child Health Services (EPSDT) in order to comply with
			 federal reporting and Child Health Services (EPSDT) requirements. The DMS-694
			 will record whether each of the recommended screening procedures required by
			 the periodicity schedule is performed, whether referral is necessary for health
			 problems discovered during the screen and the date of the required referral
			 appointment if one is made. Providers must be careful to complete Section
			 I of Form DMS-694 or the ADA
			 (dental) form using the beneficiary's name and Medicaid ID number exactly as
			 shown on the Medicaid card.
D. Talk
			 to the parent about the screening results, explaining in detail the findings
			 and any recommendations for diagnosis and treatment.
E. If the child needs further diagnosis
			 and/or treatment, complete the referral section of the DMS-694 by checking the
			 appropriate referral box.
F. Upon
			 completion of the EPSDT screening, mail the original DMS-694 form to the EDS
			 Claims Department, or file electronically using the 694 format. Retain copy 3
			 for the provider files.
View or print the EDS Claims
			 Department contact information.
G. If the screener provides treatment as a
			 result of the screening, the charges for the treatment procedures may be
			 submitted on the DMS-694 form. Do not submit charges for office visit services
			 on the DMS-694.
H. Treatment
			 services offered as a result of a Child Health Services (EPSDT) screen are not
			 limited to the Medicaid services specified under "Scope of Program" in Section
			 I of this manual. If a condition is diagnosed through a Child Health Services
			 (EPSDT) screen that requires treatment services not normally covered under the
			 Arkansas Medicaid Program, those treatment services will also be considered for
			 reimbursement.
I. When a provider
			 performs a Child Health Services (EPSDT) screen and/or refers the patient to
			 another provider for services not covered by Arkansas Medicaid, the referring
			 provider must give the beneficiary a prescription for the services. The
			 prescription must indicate the services being prescribed and state the services
			 are being prescribed due to a Child Health Services (EPSDT) screen.
The prescription for services must be dated by the provider
				referring the patient. The prescription for the non-covered service is
				acceptable if services were prescribed and the prescription is dated within the
				applicable periodicity schedule, not to exceed a maximum of 12 months.
J. The provider may verify whether
			 a periodic screen is due under the appropriate periodicity schedule by means of
			 an electronic eligibility verification transaction. The system's response
			 display will reveal each type of screen, e.g., medical, visual, dental and
			 hearing and the date of the last screen of each type indicated by the provider
			 initiating the eligibility verification transaction.
The Department of Health and Human Services (DHHS) county
				offices will continue to refer Medicaid beneficiaries to providers for Child
				Health Services (EPSDT) screens. However, a provider may initiate the health
				screen for an eligible beneficiary at the appropriate time without a referral
				from the DHHS county office.
An eligible child must be referred by the PCP, if the child is
				to be screened by a provider who is not the PCP.
242.100
Procedure Codes
See section
				212.000 for EPSDT screening
				terminology.
Claims for EPSDT medical screenings must be billed
				electronically or using the DMS-694 EPSDT paper claim form.
View or print a DMS-694 sample claim
				form.
Procedure Code
Modifier 1
Modifier 2
Description
99381-99385
EP
U1
EPSDT Periodic Complete Medical Screen (New
						  Patient)
99391-99395
EP
U2
EPSDT Periodic Complete Medical Screen (Established
						  Patient)
994311 994321
							 994351
EP
EP
EP
Initial Newborn Care/EPSDT screen in
						  hospital
991731
EP
EPSDT Periodic Vision Screen
V5008
EP
EPSDT Periodic Hearing Screen
D01201
CHS/EPSDT Oral Examination
D01401
EPSDT Interperiodic Dental Screen, with prior
						  authorization
99401
EP
EPSDT Health Education - Preventive Medical
						  Counseling
364152
Collection of venous blood by venipuncture
83655
Lead
1 Exempt from PCP
			 referral requirements
2 Covered
			 when specimen is referred to an independent lab
Immunizations and laboratory tests may be billed separately
				from comprehensive screens.
The verbal assessment of lead toxicity risk is part of the
				complete CHS/EPSDT screen. The cost for the administration of the risk
				assessment is included in the fee for the complete screen.
Laboratory/X-ray and immunizations associated with an EPSDT
				screen may be billed on the DMS-694 EPSDT claim form.
When billing on paper, the EPSDT screening services must be
				billed with a type of service code "6."
For billing on paper, immunizations must be billed with a type
				of service code "1."
242.130
Restrictions on Duplication of
			 Services
Services must be filed with the appropriate national procedure
				codes and applicable modifiers.
The following procedure codes with the applicable modifier
				represent an EPSDT Periodic Complete Medical Screen that includes both hearing
				and vision screens.
EPSDT Periodic Complete Medical Screen claims must be filed
				with the appropriate CPT-4 procedure codes and modifier. Procedure codes 99381
				through 99385 (New Patient), with modifiers EP and U1, and procedure codes
				99391 through 99395 (Established Patient), with modifiers EP and U2, will
				represent an EPSDT periodic complete medical screen, which includes both
				hearing and vision screens.
Immunizations and laboratory tests may be billed
				separately.
Example for EPSDT Periodic Complete Screen for an established
				patient:
99391, Modifiers EP and U2 = EPSDT Periodic Complete Medical
				Screen
242.150
Limitation for Laboratory Procedures Performed as Part of EPSDT Screens
Child Health Services (EPSDT) screens do not include laboratory
				procedures unless the screen is performed by the beneficiary's primary care
				physician (PCP) or is conducted in accordance with a referral from the
				PCP.
The following tests are exempt from this limitation and may
				continue to be billed in conjunction with an EPSDT Screen performed in
				accordance with existing Medicaid policy:
81000-
Urinalysis, by dip stick or tablet reagent for
						  bilirubin, glucose, hemoglobin, ketones, leukocytes, nitrite, pH, protein,
						  specific gravity, urobilinogen, any number of these constituents;
						  non-automated, with microscopy
81001 -
Urinalysis, by dip stick or tablet reagent for
						  bilirubin, glucose, hemoglobin, ketones, leukocytes, nitrite, pH, protein,
						  specific gravity, urobilinogen, any number of these constituents; automated,
						  with microscopy
81002-
Urinalysis, by dip stick or tablet reagent for
						  bilirubin, glucose, hemoglobin, ketones, leukocytes, nitrite, pH, protein,
						  specific gravity, urobilinogen, any number of these constituents;
						  non-automated, without microscopy
83020 -
Hemoglobin, electrophoresis (e.g., AZ, S,
						  C)
83655 -
Lead
85013-
Blood count; spun microhematocrit
85014-
Blood count; other than spun hematocrit
85018-
Blood count, hemoglobin
86580 -
Skin test; tuberculosis, intradermal
86585 -
Tuberculosis, tine test
Claims for laboratory tests, other than those specified above,
				performed in conjunction with an EPSDT screen will be denied, unless the screen
				is performed by the PCP or in accordance with a referral from the PCP.
The following screens will be affected by this policy:
Procedure Code
Modifier 1
Modifier 2
Description
99381-99385
EP
U1
EPSDT Periodic Complete Medical Screen (New
						  Patient)
99391-99395
EP
U2
EPSDT Periodic Complete Medical Screen (Established
						  Patient)