Healthcare Services for Children Early and Periodic Screening, Diagnosis and Treatment (EPSDT) & Preventative Pediatric Healthcare Screening and Diagnosis (PPHSD) Agenda I. What are EPSDT and PPHSD? II. EPSDT and PPHSD Goals III. Appendix W: EPSDT/PPHSD Screening Procedures IV. EPSDT/PPHSD Diagnosis and Treatment Services V. Prior Authorization for a Covered Service VI. Prior Authorization for a Non-Covered Service VII. EPSDT and PPHSD Regulations – What’s New VIII. Behavioral Health Screening Tools IX. Behavioral Health Screens – Service Codes and Billing X. Billing for EPSDT and PPHSD Visits XI. EPSDT and PPHSD Resources XII. Questions and Answers What are EPSDT and PPHSD > What does EPSDT stand for? * Early * Periodic * Screening * Diagnosis * Treatment > Who gets EPSDT services? * MassHealth Standard and MassHealth CommonHealth members under the age of 21 > Who is not eligible for EPSDT/PPHSD? * MassHealth Limited > What does PPHSD stand for? * Preventative * Pediatric * Healthcare * Screening * Diagnosis > Who gets PPHSD services? * MassHealth Basic, Essential, Prenatal and Family Assistance members under the age of 21 Who provides EPSDT & PPHSD Services? Primary care providers must offer to conduct screens when they practice in an individual or group practice, in the outpatient department of a hospital or in a community health center. MassHealth is defining “primary care providers” as: * General Practitioners * Internal Medicine Physicians * Pediatricians * Independent Nurse Midwives * Family Physicians * Obstetrician/Gynecologists * Independent Nurse Practitioners MassHealth covers preventative care and treatment services for members under the age of 21 (except for MassHealth Limited members) > MassHealth pays for these members to see their primary care providers on a periodic schedule * Visits must occur at the following ages, at a minimum: one to two weeks, one month, two months, four months, six months, nine months, 12 months, 15 months, 18 months, two years, and then every year until the member’s 21st birthday > MassHealth also pays for these members to visit their primary care providers between periodic visits (inter-periodically) at any time the child might need to be seen by his/her primary care provider. * These visits may include the full range of components (as described in Appendix W) or just a portion of the components that are indicated by the suspected illness or condition. EPSDT and PPHSD Goals > Evaluate a child’s health early in life and continuously through the teen and young adult years in order to prevent and detect potential diseases and disabilities in the early stages, when they can be treated most effectively. > Educate members and their families about the availability and value of preventive well-child care, including the value of adhering to a regular and appropriate schedule of primary care visits. > Empower members and families with knowledge about the covered services and access methods. Appendix W: EPSDT/PPHSD Screening Procedures At these visits, primary care providers perform a series of health screens that include, but are not limited to: > Initial/Interval Health History > Comprehensive Physical Examination > Developmental and Behavioral Assessment > Vision and Hearing Screening > Cancer Screening and Examination > Immunization Assessment and Administration > Tuberculin Test > Cholesterol Screening > Hepatitis C and HIV > Nutritional Assessment > Dental Assessment and Referral > Health Education and Anticipatory Guidance > Lead Toxicity Screening > Hematocrit or Hemoglobin Test > Urinalysis > Sexually Transmitted Infections > Other Laboratory Testing Please refer to Appendix W of your provider manual for the intervals or age level at which each procedure is to be provided EPSDT/PPHSD Diagnosis and Treatment Services If any of the screens show that there might be a problem, the primary care provider must provide, or refer the member for further diagnosis and treatment. > Providers should refer to Subchapter 6 of their provider manual in order to determine if the additional diagnosis and treatment services are covered by MassHealth * Provider Manuals can be accessed online by visiting www.mass.gov/masshealthpubs and clicking on “Provider Library” and then “MassHealth Provider Manuals” > EPSDT covers any medically necessary diagnosis or treatment service that is included under federal Medicaid law even if it is not described in a MassHealth regulation, contract or procedure code covered for the member’s coverage type. > PPHSD covers any diagnosis or treatment service that is included in the member’s coverage type. Prior Authorization for a Covered Service > If a member needs a diagnosis or treatment service covered by his or her coverage type, you should check whether the service requires prior authorization (PA) and, if it does, submit a PA request according to normal processes > If you have questions, you may refer to MassHealth provider manual or contact MassHealth Customer Service at 800-841-2900 Prior Authorization for a Non-Covered Service > EPSDT (for MassHealth Standard and MassHealth CommonHealth members) covers any medically necessary diagnosis or treatment service that is included under federal Medicaid law, even if it is not described in a MassHealth regulation, contract, or procedure code covered for the member’s coverage type. * If a MassHealth Standard or MassHealth CommonHealth member needs such a diagnosis or treatment service you will need to submit a PA request according to the normal PA process. * Providers should consult current HCPC/CPT manuals in identifying an appropriate code for the service. * PA requests must be supported by a medical necessity letter from a MassHealth primary or specialty care provider. EPSDT and PPHSD Regulations – What’s New > In addition to MassHealth Standard members under 21, MassHealth CommonHealth members under 21 are now entitled to EPSDT services. * Prior to July 1, 2006, MassHealth CommonHealth members under 21 were entitled to PPHSD services, not EPSDT services. > An update to the description of the vision screening test covered during an EPSDT or PPHSD visit has occurred. > A mandate requiring primary care providers to offer* to conduct EPSDT and PPHSD screens according to Appendix W and provide or refer members for necessary follow-up has been implemented. *Note: Parents and guardians can choose not to have their children screened. Such refusal must be documented in members file. > The regulations now expressly include behavioral health (mental health and substance abuse) and developmental screens in the list of screening services covered during an EPSDT or PPHSD visit. > Primary care providers who conduct behavioral health screens according to Appendix W will now receive a separate payment for the screen, in addition to the rate for the visit. Behavioral Health Screening Tools On slide 13 there is a chart that shows the following information in four columns entitled: Screening Tool Name Behavioral Health Screening Tools Who completes the tool Appropriate age group for the tool ASQ:SE Ages and Stages Questionnaires: Social-Emotional http://www.brookespublishing.com/tools/asqse/index.htm Parent 4 - 60 Months BITSEA Brief Infant and Toddler Social and Emotional Assessment http://harcourtassessment.com/HAIWEB/Cultures/en-us/Productdetail.htm?Pid=015-8007-352&Mode=summary Parent 12 to 36 Months CBCL YSR ASR Achenbach System: Child Behavior Checklist Youth Self-Report Adult Self-Report http://www.ASEBA.org Parent, Youth,Young Adult 1.5 - 18 Years, 11 to 18 Years, 18 to 59 Years CRAFFT Car, Relax, Alone, Forget, Friends, Trouble http://www.ceasar-boston.org/clinicians/crafft.php Screening for substance abuse Youth 14 + M-CHAT Modified Checklist for Autism in Toddlers https://www.dbpeds.org/media/mchat.pdf (tool) http://www.dbpeds.org/articles/details.cfm?textID=377 (background) Screening for autism Parent 18 to 30 months PEDS Parents’ Evaluation of Developmental Status http://www.pedstest.com Parent Birth to 8 years PHQ-9 Patient Health Questionnaire-9 www.phqscreeners.com Screening for depression Young Adult 18 + PSC Pediatric Symptom Checklist Pediatric Symptom Checklist-Youth Report http://psc.partners.org/ Parent Youth 4 thru 16 Years 11 + years Behavioral Health Screens – Service Codes & Billing > Primary care providers who conduct behavioral health screens according to Appendix W (EPSDT Periodicity Schedule) will receive a separate payment for the screen in addition to the rate for the visit Primary care providers should bill using the following code: > CPT service code 96110 - Developmental testing; limited (e.g. Developmental Screening Test II, Early Language Milestone Screen), with interpretation and report * Listed in Appendix Z * Modifiers are required when billing CPT code 96110 and, effective July 1, 2008, failure to include them will result in a denial of the claim for 96110 * Refer to Subchapter 6 of the provider manual for information on the codes and modifiers > Division of Healthcare Finance and Policy (DHCFP) sets the reimbursement rates. The rates can be found at www.mass.gov/dhcfp by clicking on “DHCFP Regulations” in the What We Do box in the upper left corner. > The distinct modifiers that accompany 96110 allow MassHealth to track the disposition of the screen so that MassHealth will know the number of members with a behavioral health need identified. These modifiers vary by provider type. > Use one of the U3 – U8 series and make sure the modifier reflects the level of the servicing provider and whether a behavioral health need was identified or not. > Mid-level modifiers (SA, SB, HN) are not used when billing the behavioral health screen using CPT code 96110. > Billers, including billing intermediaries, need to verify with the medical record and/or the provider in order to determine that the correct modifier (designed to relay clinical information) is applied to procedure code 96110 Behavioral Health Screens – Service Codes & Billing On Slide 16, there is a table that displays the following information in 3 columns: Servicing Provider Modifier for Use When No Behavioral Health Need Is Identified* Modifier for Use When Behavioral Health Need Is Identified* Physician, Independent Nurse Midwife, Independent Nurse Practitioner, Community Health Center (CHC), Outpatient Hospital Department (OPD) U1 U2 Nurse Midwife employed by Physician or CHC U3 U4 Nurse Practitioner employed by Physician or CHC U5 U6 Physician Assistant employed by Physician or CHC U7 U8 *Behavioral health needs identified include those in the areas of behavioral health, socio-emotional well-being, or mental health. Behavioral Health Screens – Service Codes & Billing On Slide 17, there is a table that displays the following information in 2 columns: The following text explains the modifiers: Code/Modifier Text of Code/Modifier CPT 96110 Developmental testing; limited (e.g. Developmental Screening Test II, Early Language Milestone Screen), with interpretation and report U1 Physician, Independent Nurse Midwife, Independent Nurse Practitioner, Community Health Center (CHC), Outpatient Hospital Department (OPD), completed behavioral health screening with no behavioral health need identified U2 Physician, Independent Nurse Midwife, Independent Nurse Practitioner, Community Health Center (CHC), Outpatient Hospital Department (OPD), completed behavioral health screening and behavioral health need identified U3 Nurse Midwife (SB) employed by Physician or CHC, completed behavioral health screening with no behavioral health need identified U4 Nurse Midwife (SB) employed by Physician or CHC, completed behavioral health screening and behavioral health need identified U5 Nurse Practitioner (SA) employed by Physician or CHC, completed behavioral health screening with no behavioral health need identified U6 Nurse Practitioner (SA) employed by Physician or CHC, completed behavioral health screening and behavioral health need identified U7 Physician Assistant (HN) employed by Physician or CHC, completed behavioral health screening with no behavioral health need identified U8 Physician Assistant (HN) employed by Physician or CHC, completed behavioral health screening and behavioral health need identified Billing For EPSDT and PPHSD Visits Initial visit > First visit to a specific provider > A provider may bill for only one initial visit per member > CPT preventive medicine codes: 99381-99385, depending on the age of the member Periodic visits > A visit at one of the ages listed in Appendix W > Providers may bill for only one periodic visit per age level as listed in Appendix W per member, which means only one periodic visit each year after a member turns 2 years old > Visits are payable as periodic visits only if the full range of screening services required by Appendix W for the age level are delivered > CPT Preventive medicine codes: 99391-99395, depending on the age of the member Interperiodic visits > A visit that doesn’t occur at one of the ages listed in Appendix W > There is no limit on the number of medically necessary interperiodic visits that providers may bill per member > May include only some of the screening services listed in Appendix W and may be a visit to “catch up” with the recommended age visits * CPT Codes: Providers should use the appropriate CPT code for the services being delivered Newborn visits > To claim the periodic visit for a newborn, a provider generally must have visited the newborn at least twice before discharge from the hospital * The first visit is for an initial history and physical examination and is payable as an inpatient hospital visit using the appropriate CPT code, not as an initial EPSDT visit * The second visit is for a discharge history, physical examination, and all other screens required by Appendix W and is payable as a periodic visit for an established patient > If the newborn did not stay in the hospital long enough to be seen twice before discharge, the first visit at the provider’s office is payable as the newborn periodic visit > If more than two visits are provided, the additional hospital visits are payable as inpatient hospital visits EPSDT Add-on service code (for EPSDT and PPHSD): > Periodic visits delivered according to Appendix W, and interperiodic visits at which all the screenings required by Appendix W are delivered may be claimed with an add-on code to receive an enhanced payment > S0302: Completed Early and Periodic Screening, Diagnosis and Treatment (EPSDT) Service * List in addition to code for appropriate evaluation and management service. * The add-on code may be applied only to codes 99381-99385 and 99391-99395, and may be used for EPSDT services and PPHSD services. * List the preventive medicine evaluation and management code (99381-99385 or 99391-99395) on line A and the S0302 code on line B Sick visits > A visit for an illness or other health problem > If a member comes to an appointment for a sick visit and the provider notices the member missed a periodic visit, the provider can be paid for a periodic exam if he or she provides all screening services required by Appendix W, in addition to the sick care Mid-Level Practitioners > Visits delivered according to Appendix W by a non-independent nurse practitioner, non-independent nurse midwife, and physician assistant employed by a physician must be claimed using a modifier SA non-independent nurse practitioner SB non-independent nurse midwife HN physician assistant > List the preventive medicine evaluation and management CPT code (99381-99385 or 99391-99395) and the modifier on line A > Mid-level modifiers are not used when billing the behavioral health screen using CPT code 96110 (refer to details in slide 16) Payment Methodologies > Separate payment for laboratory services, vision screening, hearing screening, and behavioral health screening > The laboratory, behavioral health screening, vision screening, and hearing screening services required by Appendix W are payable in addition to, the initial, periodic, or interperiodic visit, when they are performed and interpreted in the office of the provider who provided the initial, periodic, or interperiodic visit > Codes for these services are listed in Appendix Z (EPSDT/PPHSD Screening Services Codes) of the MassHealth All Provider Regulations > DHCFP sets the reimbursement rates. The rates can be found at www.mass.gov/dhcfp by clicking on “DHCFP Regulations” in the What We Do box in the upper left corner. Claims may be billed to MassHealth electronically using the 837P or on the MassHealth Paper Claim form No. 4, 5, 9 or the UB-04 > For additional information on using the 837P transaction, please visit www.mass.gov/masshealth and click on “MassHealth and HIPAA” or email MassHealth HIPAA support at hipaasupport@mahealth.net > To order a supply of MassHealth proprietary claim forms (4, 5 or 9) access your customer service web account on www.mass.gov/masshealth or contact MassHealth Customer Service at 800-841-2900. * To obtain a customer service web account, access All Provider Bulletin 156 (August 2006) from the MassHealth Provider Library on www.mass.gov/masshealthpubs. Click on “MassHealth Provider Library” and then “MassHealth Provider Bulletins.” EPSDT and PPHSD Resources > You may refer to the following resources for more information: www.mass.gov/masshealth/childbehavioralhealth > Transmittal Letter All-155 that accompanied the EPSDT Regulations revision  > Appendix W – EPSDT Services: Medical Protocol and Periodicity Schedule & Appendix Z – EPSDT/PPHSD Screening Services Codes > MassHealth Early and Periodic Screening, Diagnosis and Treatment (EPSDT) Services and Preventive Pediatric Healthcare Screening and Diagnosis (PPHSD) Services Billing Guidelines for MassHealth Physicians and Mid-level Providers > MassHealth Provider Manuals, Subchapter 1 and Subchapter 6 > MassHealth Billing Guide for Paper Claim Form Nos. 4, 5, 9 and the UB-04 > MassHealth Companion Guide for electronic claim submission > MassHealth Customer Service at 800-841-2900 Questions and Answers……