The primary reference for these questions and others that may arise is the EPSDT/PPHSD Billing Guidelines for MassHealth Physicians and Mid-level Providers (04/09), http://www.mass.gov/Eeohhs2/docs/masshealth/memlibrary/epsdt_billing-guide.pdf. 1. Well-Child-Care Provided During a Sick-Care Visit A 2 ˝ -year-old is brought in with a rash. The child’s existing physician notices that the child never had a two-year well-child visit. The provider has the time to perform the required range of screenings and does so. Q. How should this visit be billed? A. Since all of the screens as outlined in the EPSDT Services: Medical Protocol and Periodicity Schedule (Schedule) were provided, the visit can be billed as a completed well-child visit using the appropriate preventive medicine visit service code, and add-on code S0302, plus the diagnosis code appropriate for the condition for which the child was treated. • Line A: 99392 • Line B: S0302 On additional claim lines add any screenings or tests included in Appendix Z and, if Service Code 96110 is claimed for a behavioral health screen, add the appropriate modifier. However, if the provider had been unable to complete all of the required screens, and the child was scheduled to return at a later date, only the second visit could be billed as a well- child visit according to the Schedule. For example, bill the first visit as follows: • Line A: 99212 If the child is seen by the nurse practitioner who is providing service in collaboration with the physician during the return visit, and all of the required screens are completed, the second visit may be billed as follows: • Line A: 99392 SA • Line B: S0302 On additional claim lines add any screenings or tests included in Appendix Z and, if Service Code 96110 is claimed for a behavioral-health screen, add the appropriate modifier. 2. Well-Child Care Provided Over Multiple Visits A two-year old child comes in for a well-child-care visit and the physician is unable to complete the entire breadth of screenings as outlined in Appendix W, EPSDT Services: Medical Protocol and Periodicity Schedule of the all MassHealth provider manuals. Over a series of three visits, the provider is able to complete the screenings as outlined in the Schedule. Q. How should these visits be billed? Can the add-on code be claimed for one of the visits? A. Since all of the screens as outlined in the Schedule were eventually provided, the final visit can be billed as a completed well-child visit using the appropriate preventive medicine visit service code, and add-on code S0302. • Line A: 99392 • Line B: S0302 In addition, separate claims should be generated for the two previous visits. The appropriate evaluation and management service code should be billed to identify the type of visit that occurred. On additional claim lines add any screenings or tests included in Appendix Z and, if Service Code 96110 is claimed for a behavioral health screen, add the appropriate modifier. 3. Well-Child Care and Referrals A four-year-old comes to the office for a routine well-child care visit. The child is unable to cooperate for hearing and vision testing. To ensure that the child’s evaluation is complete, the physician makes a referral for purposes of performing these tests. Q. Since the physician did not perform the hearing and vision testing, but a referral was made, has the provider fulfilled the requirements for billing for a well-child-care visit provided in accordance with the Schedule? A. Yes. If the provider makes a good-faith effort to ensure that these tests are completed, the provider may bill for the well-child-care visit as provided in accordance with the Schedule. The primary care provider must coordinate with the testing provider, working together to ensure that all the required well-child service components are completed, and that the results are made part of the child’s medical record. The primary-care provider remains responsible for ensuring that all necessary screening and testing procedures are delivered to the child. 4. Sick Care Provided During a Well-Child-Care Visit An eight-year-old established patient comes in for a routine well-child visit. Upon examination the physician finds that the child has significant wheezing and a history suggestive of asthma. Although the child enters primarily for well-child care, a portion of the visit involves evaluation, intervention, and education about asthma. Q. How should this visit be billed? What diagnosis code should be used? A. The child entered for routine health maintenance. Therefore, this visit should be billed as a well-child visit. As long as all of the screens that are required according to the Schedule are completed, the provider may bill the S0302 visit code and receive the enhanced payment. Also, the provider should use the diagnosis code appropriate for asthma. • Line A: 99393 • Line B: S0302 • Line C: 96110, with modifier U1 or U2. • Line D: 99173 (Screening test of visual acuity, quantitative, bilateral) • Line E: 92552 Pure tone audiometry (threshold); air only 5. MassHealth Coverage of Behavioral Health Screening Code When Screening Tool Administered by Ancillary Staff in the Hospital Outpatient Department, Primary Care Setting An eight-year-old established patient comes into the hospital outpatient department for a routine well-child visit. An ancillary staff person, such as a medical assistant gives the behavioral health screening tool to the parent to complete. The parent gives the completed screening tool to the primary care provider during the examination. Q. Can the primary care provider bill for the professional component of the behavioral health screening code when the screening tool is administered by ancillary staff? A. Only a physician (or a Hospital for a hospital-based service) may bill for his/her professional services when provided in an OPD setting. When these services are provided by mid-level hospital based practitioners, the payment for their services is included in the Facility payment to the hospital and may not be billed separately. 6. Services Required to be completed during a Well-Child Visit A provider sees three MassHealth members in one day. One member is 8, one is 2 and one is 19. All three members receive an offer from the provider to receive EPSDT/PPHSD services and all three members (or parents/guardians) agree to the receipt of the services. The provider is unsure if all of the screens, as detailed in Appendix W, EPSDT Services: Medical Protocol and Periodicity Schedule for each age range are required to be administered, or if the provider can only provide a selection of the services. Q. Can the primary care provider only provide a subset of the required screens as detailed in Appendix W, or is the provider required to provide all the screens as listed, if the member agrees to the receipt of EPSDT/PPHSD services? If they only provide a subset, can they still bill for the add-on code? A. If all of the screens as outlined in the Schedule were provided appropriate to the child’s age, the visit can be billed as a completed well-child visit using the appropriate preventive medicine visit service code, and add-on code S0302. However, if the provider is unable to complete all of the required screens, the visit can not be billed as an EPSDT visit. If the child returns at a later date and the remainder of the screens are delivered, the second visit would be billed as a well-child visit according to the Schedule. If to ensure that the child’s evaluation is complete, the physician makes a referral for purposes of performing some of the screening tests such as the hearing and vision testing, the provider can bill for the well-child care visit as provided in accordance with the Schedule as long as the provider has made a good-faith effort to ensure that the screening tests are completed. The primary care provider must coordinate with the testing provider, working together to ensure that all the required well-child service components are completed, and that the results are made part of the child’s medical record. The primary-care provider remains responsible for ensuring that all necessary screening and testing procedures are delivered to the child. Q&As 4.25.08 Page 4