October 2009 Healthwatch/Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) Presented by EDS Provider Relations.

October 2009

Healthwatch/Early and Periodic Screening, Diagnosis, and Treatment (EPSDT)

Presented by EDS Provider Relations

2 / October 2009HealthWatch/EPSDT

Objectives

To have a general understanding of the following:

•HealthWatch/EPSDT are used interchangeably

•Basics of the IHCP HealthWatch/Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) Program

•EPSDT Screenings

•When to refer members for treatment

•EPSDT billing guidelines

• Immunizations and Vaccine for Children Program

•Lead poisoning prevention and testing

•Who to contact if you have questions


Overview of Indiana Health Coverage Programs


IHCP HealthWatch/EPSDT Provider Manual


HealthWatch/EPSDT

•Early - Identifying problems early, starting at birth

•Periodic - Checking children's health at periodic, age-appropriate intervals

•Screening - Doing physical, mental, developmental, dental, hearing, vision, and other screening tests to detect potential problems

•Diagnosis - Performing diagnostic tests to follow up when a risk is identified, and

•Treatment - Treating the problems found


HealthWatch/EPSDT

•Early and Periodic Screening, Diagnosis and Treatment, (EPSDT) is also referred to as “HealthWatch” in Indiana

•HealthWatch/EPSDT service is Indiana Medicaid's comprehensive and preventive child health program for individuals under the age of 21

•The EPSDT program is expected to assure that health problems are diagnosed and treated early, before they become more complex and their treatment more costly


HealthWatch/EPSDT

•The EPSDT program consists of two main components:

(1) assuring the availability and accessibility of required health care resources; and

(2) helping Medicaid recipients and their parents or guardians effectively use these resources

•The EPSDT program is designed to enhance primary care with an emphasis on prevention and early intervention


HealthWatch/EPSDT Member Population

Who is eligible for EPSDT services?

•Medicaid Eligible children from birth to their 21st birthday

•EPSDT member population comes from three Medicaid Programs:– Hoosier Healthwise– Care Select

• Wards and Fosters– Healthy Indiana Plan (HIP)

• Members under 21 years


Which Provider Specialties Can Be HealthWatch/EPSDT PMPs?

A Hoosier Healthwise or Care Select PMP must be a physician licensed in one of the following specialties: – General Practice, Family Practice, General Pediatrics, General

Internal Medicine, or OB/GYN

Physicians interested in becoming PMPs are also required to contract with one or more of the following managed care organizations (MCOs) to participate in the risk-based managed care network:

Anthem, Managed Health Services (MHS), or MDwise

Specialists may also serve as PMPs in Care Select, if• Chosen by the member (Specialist are not auto-assigned) , and

• Sign an Addendum with one or both of the care management organizations (CMOs):

MDwise or ADVANTAGE Health Solutions


HealthWatch/EPSDT Covered Services



The periodic schedule for EPSDT screenings, adopted from the American Academy of Pediatrics (AAP), is as follows:

– Newborn– 2 to 4 days, if the newborns left the hospital < 48 hours after

delivery– by 1 month of age– 2 months of age– 4 months of age– 6 months of age– 9 months of age– 12 months of age– 15 months of age– 18 months of age– Once every year from ages 2 to 20 yearsDetailed information can be found in the HealthWatch/EPSDT Provider Manual, located at

www.indianamedicaid.com/ihcp/Publications/manuals.htm

– Appendix A: Periodicity and Screening Schedule

Periodicity Recommendations


HealthWatch/EPSDT Covered Services Screenings are the foundation of the EPSDT program

Screenings must include the following:

• Comprehensive health and developmental history, including review of both physical and mental health development

• Comprehensive unclothed physical exam

• Appropriate immunizations according to age and health history

• Laboratory tests including a lead toxicity screening, as appropriate

• Nutritional assessment

• Health education, including anticipatory guidance

• Vision screens

• Hearing screens

• Dental screens– Detailed information can be found in the HealthWatch/EPSDT Provider

Manual, located at www.indianamedicaid.com/ihcp/Publications/manuals.htm



HealthWatch/EPSDT Covered Services Immunizations: Consult the CDC/ACIP or AAP Web sites for the

current immunization schedule.

•CDC National Immunization Program (NIP): http://www.cdc.gov/vaccines

•American Academy of Pediatrics Red Book: http://www.aapredbook.org

• The Vaccines for Children (VFC) is a federally funded program that makes certain vaccines available, at no cost to providers, for administration to children age 18 years and younger, who meet one or more of the following: – On Medicaid– Without health insurance– American Indian or Alaskan Native

VFC in IndianaComplete enrollment materials, attend an orientation, and meet

requirements to participate in the program

Contact the ISDH Immunization Program at 1-800-701-0704 for more information



To participate in the VFC program, providers must:

•Meet refrigerator/freezer storage requirements – Freezer only needed if carrying varicella

•Follow all VFC storage and handling requirements

•Have working fax machine

•Properly maintain a vaccine inventory

•Screen for VFC Eligibility

Anyone who provides medical care to eligible children can be a VFC provider: Private physicians, local health departments, RHCs, FQHCs


About CHIRP

•Statewide Immunization Registry provided by the Indiana State Department of Health

•Secure, no-cost, Internet-based application

•Training available at no cost

•For more information or to enroll, visit www.chirp.in.gov or call ISDH at 1-800-701-0704


EPSDT Vaccine Safety: Reliable Resources

• Indiana State Department of Healthhttp://www.in.gov/isdh/17204.htm

•CDC: Vaccine Safetyhttp://www.cdc.gov/vaccines/vac-gen/safety/default.htm

• Institute for Vaccine Safety http://www.vaccinesafety.edu/

• Immunization Action Coalitionhttp://www.immunize.org/safety/



Laboratory tests including a lead toxicity screening,as appropriate

•EPSDT requires that every Medicaid eligible child receive a blood test at 12 months and 24 months

•Testing should be done in conjunction with an EPSDT visit

• If both blood lead tests are below the action level of 10 μg/dL (micrograms/deciliter), no additional testing is required, unless the child’s environment changes

ISDH, through the Indiana Childhood Lead Poisoning Prevention Program (ICLPPP), monitors lead poisoning in Hoosier children who receive screening

Detailed information can be found in Section 3 of the HealthWatch/EPSDT Provider Manual, located at www.indianamedicaid.com/ihcp/Publications/manuals.htm


HealthWatch/EPSDT Blood Lead Level Testing

• Three basic ways to test

– Venous testing

– Filter paper

– Hand-held device testing

• The coverage and reimbursement rate for code 83655 is expanded to include tests administered using filter paper and handheld testing devices in the office setting

– 83655 - Assay of lead (venous blood)

– 83655 U1 - Assay of lead, using filter paper

– 83655 U2 - Assay of lead, using handheld testing device

• When using 83655, utilize the correct diagnosis code depending on the basis of the test

– V20.2 = tests to rule out lead poisoning

– V15.86 = those who already have been diagnosed as having lead poisoning


HealthWatch/EPSDT Covered Services Nutritional Assessment

Evaluate the patient for normal health and growth

Offer information about Special Supplemental Program for Women, Infants, and Children (WIC)

• The purpose of WIC is to improve participants’ health and quality of life by providing nutrition education and counseling, medical and social referrals, and supplemental food to eligible women and children. To qualify for WIC, participants must meet the following three criteria:

– Be an Indiana resident

– Have an income at or below 185 percent of the FPL

– Be at medical or nutritional risk

• Participants are limited to pregnant women, breastfeeding women up to one year after delivery, postpartum women up to six months after delivery, infants, and children younger than 5 years old

• For more information, visit the Web site at http://www.in.gov/isdh/19691.htm



Health Education and Anticipatory Guidance

•Health education that is appropriate for the age of the children in the home

– Injury prevention

– When to call the doctor/visit the ER

– Home hazards – weapons, poison, lighter/matches

•Anticipatory guidance for the family should be geared to questions, issues, or concerns for that particular child and family

– Auto Safety – Car seat installation, seatbelt use, backseat safety

– Sleep patterns – “Back to Sleep”, appropriate bedtime

– Use of smoke detector



Vision observation and screenings:•Up to 3 years and at 6, 8, 14, 16, and 18 years

– Visual observation with an external eye examination

– Subjective screening by history

•3 to 5 years and at 10, 12, and 20 years

– Annual objective screening test by standard testing method

– If warranted, refer child to an appropriate specialist

•Consult the IHCP HealthWatch/Early and Periodic Screening, Diagnosis and Treatment Provider Manual for more information

– Detailed information can be found in Section 4 of the HealthWatch/EPSDT Provider Manual, located at www.indianamedicaid.com/ihcp/Publications/manuals.htm




*Hearing tests are given by the Dept. of Education in grades one, four, seven, and 10th. Screening efforts should not be duplicated unless rescreening is necessary. Confirmation of screening results may come from the child’s school or parents.

Age Hearing Screening Schedule

Newborn Subjective screening, by history; to be performed on patients at risk

2-4 days, by 1 month, 2, 4, 6 and 9 months visits

Subjective screening, by history

12 months to 4 years visit

Range during which an objective screening may be provided, with objective screening, by standard testing method is recommended at age 4 years.

5 year visit Objective screening, by standard testing method

6 and 8 year visits Subjective screening, by history

10, 12, and 18 years visits

Objective screening, by standard testing method, not to be duplicated if screened within the school system.*

14, 16, and 20 years visits

Subjective screening, by history



AAPD Recommendations 6-12 months

12-24 months

2-6 years

6-12 years

>12 years

• Clinical oral examination.• Assess oral growth and development by clinical exam.• Caries-risk assessment. • Anticipatory guidance/counseling• Injury prevention counseling• Counseling for nonnutritive habits

• Radiographic assessment, and • Prophylaxis and topical fluoride ► Must be repeated regularly and frequently to maximize effectiveness; and ►Timing, selection, and frequency determined by child’s history, clinical findings, and susceptibility to oral disease.

• Counseling for speech/language development.

• Assessment for pit and fissure sealants• Transition to adult dental care• Assessment and treatment of developing malocclusion

• Assessment and/or removal of third molars• Counseling for intraoral/peri-oral piercing• Substance abuse counseling

Dental Screening


HealthWatch/EPSDTReferrals


Refer to a licensed vision care provider when objective vision screening methods indicate a need

Refer newborns identified under the universal newborn hearing screening (UNHS) program to First Steps www.indianafirststeps.com

Refer older children for testing and treatment to an Audiologist when screening results identify possible deficiency.

The dental referral must be for an encounter with a licensed dentist for diagnosis and, if necessary, treatment

– Detailed information can be found in Section 4 of the HealthWatch/EPSDT Provider Manual, located at www.indianamedicaid.com/ihcp/Publications/manuals.htm


ReferralsHealthWatch/EPSDT Covered Services


Referrals to a specialist may also occur at times other than those described by the periodicity schedule, when deemed medically necessary

Specialist would include, but are not limited to:

Vision Care Specialist, Licensed Audiologist, or Dentist

PMP should maintain documentation of all referrals, along with results in the member’s record

Additional common referral sources:

Indiana State Department of Health www.in.gov/isdh

Indiana Family Helpline 1-800-433-0746

Indiana Quitline 1-800-QUIT- NOW (1-800-784-8669)

Indiana First Steps www.indianafirststeps.com

HealthWatch/EPSDT Covered Services Referrals


HealthWatch/EPSDTBilling


HealthWatch/EPSDT EPSDT Billing Guidelines

EPSDT Screening

CPT® Code ICD-9 Coding

ReimbursementFees

EPSDT Visit (all components documented)

Initial/New Patient: 99381-99385Established Patient: 99391-99395

Evaluation and Management:New Patient: 99201-99205Established Patient: 99211-99215

V20.2 - Routine infant or child health check Use additional ICD-9-CM codes to identify: special screening examinations performed.

EPSDT visits must be billed with V20.2 and one of the CPT codes listed. These visits are eligible for additional reimbursement. Reimbursement: Initial/New Patient, EPSDT $75 Established Patient, EPSDT $62

Well-Child VisitProvide and document preventive care at any visit.Include age appropriate medical history, physical exam, and health education. A comprehensive prenatal visit can also meet the requirements for a well-child visit.

Preventive Visits: Initial/New Patient 99381 – 99385Established Patient 99391-99395 Prenatal Care:59425 and 59426

V70.0 or V70.3 – V70.9 or V20.2 (see EPSDT Visit above)

Additional reimbursement is available only if the ICD-9 code is V20.2 – refer to the EPSDT Visit explanation. Reimbursement (if billed with V70.0 or V70.3-V70.9): Initial/New Patient, Well-child $63-$69 Established Patient, Well-child $50-$56 Prenatal Care Visit: $40-$43


HealthWatch/EPSDT EPSDT Billing Guidelines

EPSDT Screening

CPT® Code ICD-9 Coding Fees

Sick Visit plus EPSDT (2 visit codes)

Preventive visit code and99203-99215 w/ modifier -25

V20.2 must be used as the primary diagnosis for the appropriate preventive visit. The appropriate presenting diagnosis must also be included with the CPT code for the sick visit

Sick visits depend on complexity and Doctor/Patient relationship(new/established) Reimbursement: $19-65


HealthWatch/EPSDT Billing Guidelines

• Indicate an EPSDT service on claims as follows:

– CMS-1500: Mark “Y” in box 24H

– ADA2006: Mark “X” in box 1 (EPSDT/Title XIX)

• Office visits without all the EPSDT components should be reported by using CPT® codes 99201-99205 and 99211-99215

• When an EPSDT visit and an established sick visit are provided on the same day, providers can bill for reimbursement of both services

• Refer to the IHCP HealthWatch/Early and Periodic Screening, Diagnosis, and Treatment Provider Manual for required screenings, referrals, and immunizations

Detailed information can be found in Section 3 of the HealthWatch/EPSDT Provider Manual, located at www.indianamedicaid.com/ ihcp/Publications/manuals.htm



• The individual components of the EPSDT exam are not separately billable

• Immunizations, blood draws or other lab tests are separately billable with the exception of the blood level testing

• Services provided at a Federally Qualified Health Center (FQHC) or Rural Health Clinic (RHC) must be billed appropriately using T1015 for non-RBMC members

• FQHC or RHC services provided to RBMC members must be billed according guidelines established by the member’s MCO/CMO



•EPSDT periodic well child screenings do not require prior authorization

•Prior authorization may be required for additional treatments clinically indicated by the EPSDT screening

•Providers should contact the members MCO/CMO for prior authorization requirements

• Refer to the IHCP Fee Schedule at www.indianamedicaid.com for more information and specific reimbursement rates


HealthWatch/EPSDT Immunizations/VFC

•EPSDT providers are encouraged to participate in the Vaccines for Children (VFC) Program

•The VFC Program reduces cost as a barrier to vaccination and enables better access to healthcare

• If a member is VFC eligible, the administrative fee must be billed to Medicaid, not to exceed $8

Detailed information can be found in Section 3 of the HealthWatch/EPSDT Provider Manual, located at www.indianamedicaid.com/ihcp/Publications/manuals.htm


HealthWatch/EPSDT Partners

•Anthem

– http://www.anthem.com

– 1-866-408-6132

•MDwise

– http://www.mdwise.com

– 1-800-356-1204

•Managed Health Services

– http://www.managedhealthservices.com

– 1-877-647-4848

•ADVANTAGE Health Solutions

– http://www.advantageplan.com

– 1-866-504-6708


Helpful Tools

• IHCP Web site at www.indianamedicaid.com

• HealthWatch/EPSDT Provider Manual

• IHCP Provider Manual (Web, CD-ROM, or paper)

• Customer Assistance– 1-800-577-1278, or

– (317) 655-3240 in the Indianapolis local area

• Written Correspondence

– P.O. Box 7263Indianapolis, IN 46207-7263

• Provider Relations field consultant

• EPSDT coordinator Office of Medicaid Policy and Planning [email protected]

Avenues of Resolution


Questions

October 2009

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Office of Medicaid Policy and Planning (OMPP)

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950 N. Meridian St., Suite 1150

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October 2009 Healthwatch/Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) Presented by EDS Provider Relations.

Documents

healthwatchepsdt pmps

healthwatchepsdt objectives

services slide

months of age

epsdt services

epsdt program screenings

screening schedule slide

health problems