HP Provider Relations October 2010 HealthWatch/EPSDT.

HP Provider Relations

October 2010

HealthWatch/EPSDT

HealthWatch/EPSDT October 20102

Agenda

– Objectives

– HealthWatch/Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) Program

– Covered Services

– Referrals

– Billing Guidelines

– Helpful Tools

– Questions


Session Objectives

To have a general understanding of the following:

– Basics of the IHCP HealthWatch/EPSDT Program

– EPSDT screenings

– EPSDT billing guidelines

– Who to contact if you have questions

UnderstandHealthWatch/EPSDT


Indiana Health Coverage Programs Overview


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 − Performing 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

– Treatment − Treating the problems found


HealthWatch/EPSDT

– 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 ensure that health problems are diagnosed and treated early, before they become more complex and their treatment more costly

– 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 enrolled children from birth to their 21st birthday

– EPSDT member population comes from three Medicaid programs:• Hoosier Healthwise

• Care Select

Wards and foster children

• Healthy Indiana Plan (HIP)

Members under 21 years


Which Provider Specialties Can Be HealthWatch/EPSDT PMPs?

– Hoosier Healthwise or Care Select primary medical provider (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 (MCEs) 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 (specialists are not auto-assigned), and

–Sign an Addendum with one or both of the care management organizations (CMOs)MDwise or ADVANTAGE Health Solutions

LearnHealthWatch/EPSDT Covered Services


HealthWatch/EPSDT Covered ServicesScreenings − foundation of the EPSDT program

Screening 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 http://provider.indianamedicaid.com/general-provider-services/manuals.aspx, and Appendix A: Periodicity and Screening Schedule


Immunizations

– Provide appropriate immunizations according to age and health history

– Vaccines for Children (VFC) is a federal program that makes vaccines available at no cost to providers• For more information about and to enroll in VFC,

contact the Indiana State Department of Health (ISDH) or visit http://www.in.gov/isdh/17203.htm

– CHIRP is the Statewide Immunization Registry provided by the Indiana State Department of Health• For more information or to enroll, visit

www.chirp.in.gov or call ISDH at 1-800-701-0704


Blood Lead Screening Tests

Lab tests are covered services as appropriate to an EPSDT examination

–EPSDT requires that...• Every Medicaid-enrolled child receive a blood lead screening test at 12 months

and 24 months

• 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

• Providers send blood samples for testing

–ISDH monitors lead poisoning in Hoosier children through the Indiana Childhood Lead Poisoning Prevention Program (ICLPPP)

–To find out where to send blood samples, contact the Family Helpline at 1-800-433-0746

Detailed information can be found in Section 3 of the HealthWatch/EPSDT Provider Manual, located at http://provider.indianamedicaid.com/general-provider-services/manuals.aspx


Blood Lead Screening Tests– Three basic ways to test for lead poisoning

• Venous testing

• Filter paper

• Handheld 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 poisoningCPT copyright 2009 American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association.


Vision Screening

Vision observation and screenings occur at these intervals:

– 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

Detailed information can be found in Section 4 of the HealthWatch/EPSDT Provider Manual, located at http://provider.indianamedicaid.com/general-provider-services/manuals.aspx, and Appendix A: Periodicity and Screening Schedule

• Vision screenings are given by the Department of Education in grades 1, 3, and 8

• Screening efforts should not be duplicated unless rescreening is necessary

• Confirmation of screening results may come from the child’s school or parents


Hearing Screening

• *Hearing tests are given by the Department of Education in grades 1, 4, 7, and 10

• 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, 2, 4, 6, and 9 month visits

Subjective screening, by history

12 month to 4 year 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 year visits

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

14, 16, and 20 year visits

Subjective screening, by history


Dental ScreeningAAPD 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

ReferHealthWatch/EPSDT referrals


Referrals– Referrals to a specialist may occur at times other than those

described by the periodicity schedule, when deemed medically necessary

– 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

– Refer 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 http://provider.indianamedicaid.com/general-provider-services/manuals.aspx, and Appendix A: Periodicity and Screening Schedule

BillHealthWatch/EPSDT claims


HealthWatch/EPSDT Billing Guidelines

– Indicate an EPSDT service on claims as follows:• CMS-1500: Mark “Y” in box 24H

• ADA 2006: 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/EPSDT Provider Manual for required screenings, referrals, and immunizations

Detailed information can be found in Section 3 of the HealthWatch/EPSDT Provider Manual, located at http://provider.indianamedicaid.com/general-provider-services/manuals.aspx

CPT copyright 2009 American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association.


HealthWatch/EPSDT Billing GuidelinesEPSDT 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: 99201-99205

Established 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

Sick Visit plus EPSDT(2 visit codes)

Preventive visit code and99203-99215 with 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



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

– Immunizations, blood draws, or other lab tests are separately billable

– 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 to guidelines established by the member’s MCE/CME



– EPSDT periodic well child screenings do not require prior authorization

– Prior authorization may be required for additional tests or treatments clinically indicated by the EPSDT screening

– Providers should contact the member's MCE/CME for prior authorization requirements

– Refer to the IHCP Fee Schedule at http://provider.indianamedicaid.com for more information and specific reimbursement rates

ConnectHealthWatch/EPSDT Partners


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

Find HelpResources Available


Helpful ToolsAvenues of resolution

– 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 7263

Indianapolis, IN 46207-7263

– Provider field consultant

– EPSDT coordinator• Office of Medicaid Policy and Planning

[email protected]

HP Provider Relations October 2010 HealthWatch/EPSDT.

Documents

Transcript of HP Provider Relations October 2010 HealthWatch/EPSDT.