A. INTRODUCTION This section explains the use of the State of Maryland Eligibility Verification System (EVS) and briefly summarizes the billing for services provided to MCO recipients, including newborn care. Although the section provides resource information on relevant MCO billing instructions, it is not intended to supplant the MCO’s billing instructions. MCO specific billing instructions can be found on each MCO’s web site or in their manual. Included in this section is also billing information about fluoride varnish application, Vaccines for Children program, and other services specific to child’s health that should be billed to Medicaid Fee-for-Service (FFS). In addition, the section instructs providers how to bill using the CMS-1500 Claim Form or 837P electronic format.
New patient 1 – 4 years 99382 32 New patient 5 – 11 99383 32 New patient 12 – 17 years 99384 32 New patient 18 – 39 years 99385 32 Comprehensive Preventive Medicine (Established Patient) Established patient 0 – 11 months 99391 32 Established patient 1 – 4 years 99392 32 Established patient 5 – 11 years 32 Established patient 12 – 17 years 99394 32 Established patient18 – 39 years 99395 32 Contact the staff specialist for Children’s Services for additional information at
Mental health/ behavioral assessment Annually beginning at 3 of age. Use of standardized screening tool is recommended. Pediatric Symptom Checklist (PSC-Y) Strengths and Difficulties Questionnaire (SDQ) Ages and Stages Questionnaire – Social Emotional (ASQ-SE) Early Childhood Screening Assessment 96127: Brief emotional/ behavioral assessment may be billed only when a standardized screening tool is used and results documented A maximum of 2 of 96127 will be reimbursed per visit; OR 96127 may be combined with other screening codes (ex. 96110) for a maximum of 2 units of screening per visit Depression screening Screening recommended annually beginning at 11 of age. If providers choose, they can “pre-screen” with PHQ-2 to determine if a longer standardized screening tool is needed. PHQ-9 Modified for Teens Pediatric Symptom Checklist (PSC-Y) Center for Epidemiological Studies Depression Scale for Children (CES-DC) Beck Depression Inventory (BDI) Brief emotional/ behavioral assessment may be billed only when a standardized screening tool is used and results documented. PHQ-2 may not be billed. A maximum of 2 units of 96127 will be reimbursed per visit; OR 96127 may be combined with other screening codes (ex. W7000) for a maximum of 2 units of screening per visit Substance use assessment Annually beginning at 11 years of age; use of brief screening tool is recommended. Positive screens should be followed by brief intervention and referral for treatment when indicated (SBIRT: Screening, Brief Intervention, and Referral to Treatment) CRAFFT CAGE-AID W7000: Alcohol and/or substance use disorder screening may be billed only when a standardized screening tool is used and results documented. W7020: Intervention; > 3 minutes up to 10 minutes Intervention; >10 minutes up to 20 minutes W7022: Intervention; >20 minutes A maximum of 1 unit of W7000 will be reimbursed annually for recipients age 11 and up may be combined with other screening codes (ex. 96127) for a maximum of 2 units of screening per visit A maximum 4 interventions will be reimbursed annually per recipient age 11 and up
Table 6. 2. Other Pediatric Mental Health Screening/Assessments Recommendation Examples of Acceptable Standardized Tools Billing Guidelines Limitations ADHD Assessment AAP clinical policy recommends use of parent and teacher ratings scales as a component of screening/diagnosis when there is concern Vanderbilt ADHD Diagnostic Rating Scales – Parent and Teacher Conners-3 Ratings Scales ADHD Rating for Children and Adolescents 96127: Brief emotional/ behavioral assessment may be billed only when a standardized screening tool is used and results documented. A maximum of 2 units of 96127 will be reimbursed per visit Other mental health screening/ assessment Disorder-focused mental health screening and assessment tools may be used when there is a specific concern, ex. anxiety Screen for Childhood Anxiety Related Disorders (SCARED) Spence Children’s Anxiety Scale Brief emotional/ behavioral assessment may be billed only when a standardized screening tool is used and results documented. A maximum of 2 units of 96127 will be reimbursed per visit ADHD Assessment AAP clinical policy recommends use of parent and teacher ratings scales as a component of screening/diagnosis when is concern Vanderbilt ADHD Diagnostic Rating Scales – Parent and Teacher Conners-3 Ratings Scales ADHD Rating Scale-5 for Children and Adolescents 96127: Brief emotional/ behavioral assessment may be billed only when a standardized screening tool is used and results documented. A maximum of 2 units of 96127 will be reimbursed per visit mental health screening/ assessment Disorder-focused mental health screening and assessment tools may be used when there is a specific concern, ex. anxiety Screen for Childhood Anxiety Related Disorders (SCARED) Spence Children’s Anxiety 96127: Brief emotional/ behavioral assessment may be billed only when a standardized screening tool is used and results documented. A maximum of 2 units of 96127 will be reimbursed per visit
5 –PATIENT’S ADDRESS – Enter the patient’s complete mailing address with zip code and telephone number (Optional). 6 – PATIENT’S RELATIONSHIP TO INSURED – Enter the appropriate relationship only when there is third party health insurance besides Medicare and Medicaid (No entry required when billing for a patient without third-party insurance). Block 7 – INSURED’S ADDRESS – When there is third party health insurance coverage besides Medicare and Medicaid, enter the insured’s address and telephone number (No entry required when billing for a patient without third-party insurance). 8 – RESERVED FOR NUCC USE. Block 9 – OTHER INSURED’S NAME – No entry required. 9a – OTHER INSURED’S POLICY OR GROUP NUMBER – Enter the patient's eleven digit Maryland medical assistance number exactly as it appears on the Medical Assistance card. Check for transposition of numbers. The MA number must appear here regardless of whether or not a patient has other insurance. A patient's Medicaid eligibility should be verified on each date of service, prior to rendering service, by calling the EVS. EVS is operational 24 hours a day, 365 days a year at the following number: 1-866-710-1447 or online at. Block 9b – RESERVED FOR NUCC USE – No entry required. Block 9c – RESERVED FOR NUCC USE – No entry required. Block 9d – INSURANCE PLAN OR PROGRAM NAME – Enter the insured's group name and group number if the patient has health insurance besides Medicare/Medicaid (No entry required when billing for a patient without third-party insurance). Block 10a thru 10c (Block 10d only for abortion-related billing) – IS PATIENT’S CONDITION RELATED TO – Check "Yes" or "No" to indicate whether employment, auto liability or other accident involvement applies to one or more of the services described in Item 24, if this information is known. If not known, leave blank. Block 11 – INSURED’S POLICY GROUP OR FECA NUMBER – If the patient has other third-party insurance and the claim has been rejected by that insurance, enter the appropriate rejection code listed below: For information regarding participant’s coverage, contact Third Party Liability Unit at 410-767-1765 . Code Rejection Reasons
24g. – DAYS OR UNITS OF SERVICE – Enter the total number of units or service for each procedure. Multiple, identical services rendered on different days should be billed on separate lines. Block 24h. – EPSDT FAMILY PLAN – No entry required. Block 24i. – ID. QUAL. – Enter the ID Qualifier 1D (Medicaid Provider Number) Block 24j. (gray shaded area) RENDERING PROVIDER ID # – Enter the 9-digit MA provider number of the practitioner rendering the service. In some instances, the rendering number may be the same as the payee provider number in Block #33. Enter the rendering provider’s NPI in the unshaded area. Block 25 – FEDERAL TAX ID NUMBER 26 – PATIENT’S ACCOUNT NUMBER – An alphabetic, alpha-numeric, or numeric patient account identifier (up to 13 characters) used by the provider’s office can be entered. If recipient’s MA number is incorrect, this number will be recorded on the Remittance Advice Block 27 – ACCEPT ASSIGNMENT? – For payment of Medicare coinsurance and/or deductibles, this Block must be checked “Yes”. Providers agree to accept Medicare and/or Medicaid assignment as a condition of participation. Note: Regulations that providers shall accept payment by the Program as payment in full for covered services rendered and make no additional charge to any participant for covered services. Block 28 – TOTAL CHARGE – Enter the sum of the charges shown on all lines of Block 24f. Block 29 – AMOUNT PAID – Enter the amount of any collections received from any third party payer, EXCEPT Medicare. If the recipient has third party insurance and the claim has been rejected, the appropriate rejection code shall be placed in Block # 11. Block 30 – RESERVED FOR NUCC USE – No entry required. Block 31 – SIGNATURE OF PHYSICIAN OR SUPPLIER INCLUDING DEGREE OR CREDENTIALS – Please write “Signature on File” and include the date of submission. Note: The date of submission must be in Block 31 in order for the claim to be reimbursed. Block 32 –SERVICE FACILITY LOCATION INFORMATION – Complete only if billing for medical laboratory services referred to another laboratory or the facility where trauma services were rendered. Enter the name and address of facility.