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HealthWatch/EPSDT
HP Provider Relations
October 2010
Agenda
– Objectives
– HealthWatch/Early and
Periodic Screening,
Diagnosis, and Treatment
(EPSDT) Program
– Covered Services
– Referrals
– Billing Guidelines
– Helpful Tools
– Questions
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HealthWatch/EPSDT
October 2010
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
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HealthWatch/EPSDT
October 2010
Understand
HealthWatch/EPSDT
Indiana Health Coverage Programs Overview
Hoosier Healthwise
Anthem, MDwise, and MHS
• Children
• Pregnant women
• Low-income families
Care Select
ADVANTAGE Health Solutions and MDwise
•
•
•
•
•
Aged, Blind, Physically and Mentally Disabled
Members in the HCBS Waiver Programs
M.E.D. Works participants
Out-of-home (wards) and foster children
Members receiving adoption assistance
Healthy Indiana Plan
Anthem, MDwise, and ESP
• Persons 19 to 64 years with income less than 200% federal poverty level (FPL)
• Preventive care and personal responsibility are strongly promoted
• Enhanced Services Plan (ESP) is available to individuals with high-risk conditions
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HealthWatch/EPSDT
October 2010
IHCP HealthWatch/EPSDT Provider Manual
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HealthWatch/EPSDT
October 2010
IHCP HealthWatch/EPSDT Provider Manual
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HealthWatch/EPSDT
October 2010
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
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HealthWatch/EPSDT
October 2010
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
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HealthWatch/EPSDT
October 2010
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
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HealthWatch/EPSDT
under 21 years
October 2010
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
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HealthWatch/EPSDT
or ADVANTAGE Health Solutions
October 2010
Learn
HealthWatch/EPSDT Covered Services
HealthWatch/EPSDT Covered Services
Screenings − 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
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HealthWatch/EPSDT
October 2010
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
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HealthWatch/EPSDT
October 2010
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-providerservices/manuals.aspx
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HealthWatch/EPSDT
October 2010
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 poisoning
CPT copyright 2009 American Medical Association. All rights reserved. CPT is a registered trademark of the American
Medical Association.
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HealthWatch/EPSDT
October 2010
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/generalprovider-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
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HealthWatch/EPSDT
October 2010
Hearing Screening
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
• *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
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HealthWatch/EPSDT
October 2010
Dental Screening
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
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HealthWatch/EPSDT
October 2010


Refer
HealthWatch/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-providerservices/manuals.aspx, and Appendix A: Periodicity and Screening Schedule
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HealthWatch/EPSDT
October 2010
Bill
HealthWatch/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/generalprovider-services/manuals.aspx
CPT copyright 2009 American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical
Association.
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HealthWatch/EPSDT
October 2010
HealthWatch/EPSDT Billing Guidelines
EPSDT
Screening
CPT® Code
ICD-9 Coding
Reimbursement
Fees
EPSDT Visit
(all components
documented)
Initial/New Patient:
99381-99385
Established Patient:
99391-99395
V20.2 - Routine infant or
child health check
EPSDT visits must be
billed with V20.2 and
one of the CPT codes
listed. These visits are
eligible for additional
reimbursement.
Evaluation and
Management:
New Patient:
99201-99205
Use additional ICD-9-CM
codes to identify special
screening examinations
performed
Reimbursement:
Initial/New Patient,
EPSDT
$75
Established Patient:
99211-99215
Sick Visit plus
EPSDT
(2 visit codes)
Preventive visit code
and
99203-99215 with
modifier 25
Established Patient,
EPSDT
$62
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
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HealthWatch/EPSDT
October 2010
Sick visits depend on
complexity and
doctor/patient
relationship
(new/established)
Reimbursement:
$19-65
HealthWatch/EPSDT Billing Guidelines
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–
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
HealthWatch/EPSDT
October 2010
HealthWatch/EPSDT Billing Guidelines
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–
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
HealthWatch/EPSDT
October 2010
Connect
HealthWatch/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
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October 2010
Find Help
Resources Available
Helpful Tools
Avenues 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
•
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Office of Medicaid Policy and Planning
[email protected]
HealthWatch/EPSDT
October 2010
Q&A