Early Periodic Screening and Diagnostic Treatment EPSDT

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Early Periodic Screening and Diagnostic Treatment
(EPSDT)
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• Presented by EDS Provider Relations

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Agenda

• Session Objectives
• EPSDT Historical Overview
• Member Population
• Health Watch Program Covered Services
• Referrals
• Billing Guidelines
• EPSDT Well-Child Visits
• Prior Authorization
• Strategies for Outreach
• Immunizations
• Lead Poisoning Prevention
• Enrolling in the EPSDT Program
• Helpful Tools

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Objectives

• To have a general understanding of the following
• Basics of the EPSDT program
• Newborn and Well Child Screenings
• Awareness of prior authorization requirements
• How services are referred
• Specific billing guidelines
• Immunizations
• Lead poisoning prevention
• Who to contact if you have questions

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Early Periodic Screening, Diagnosis and Treatment

• The Indiana HealthWatch EPSDT program is a
  preventive health care program for members under
  age 21.
• Its purpose is to facilitate the introduction of
  young IHCP members to early and complete
  evaluations for the detection of abnormalities
  before such abnormalities become chronic or
  debilitating.
• EPSDT periodic medical screenings are conducted
  at regular intervals during the years of a
  childs life up to the 21st birthday for Medicaid
  eligible children and up to the 19th birthday for
  a child in Package C.

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EPSDT History

• 1965
• Medicaid is enacted, mandating coverage for
  children receiving AFDC (Aid to Families with
  Dependent Children) and making coverage available
  for other very poor children.
• 1967
• Early and Periodic Screening, Diagnostic, and
  Treatment (EPSDT) benefit is added to promote
  healthy child development and mitigate conditions
  that disable children.
• Evidence of widespread disability among military
  recruits and preschool children in Head Start.
• 1964 report One Third of a Nation
• showed pervasive health problems among young
  military draftees that could have been avoided
  had proper care been provided in childhood.

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Member Population

• Who can use EPSDT services?
• Medicaid Eligible children from birth to their
  21st birthday
• EPSDT member population comes largely from two
  Medicaid Programs
• Hoosier Healthwise
• Care Select
• Wards and Fosters
• Other members who are eligible for EPSDT
  services
• Healthy Indiana Plan (HIP) members
• Members aged 19 and 20

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Targeted Populations

• Medicaid Children who are not being screened
  according to the Periodicity Table
• Uninsured Children in Indiana
• October 1, 2008 Scheduled implementation of
  higher income eligibility threshold for the State
  Childrens Health Insurance Program (SCHIP)
• Raised from 200 of Federal Poverty Level (FPL)
  to 250 FPL
• This will allow coverage for approximately 10,000
  more children in Indiana

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Which Provider Specialties Can Be EPSDT PMPs?

• A Hoosier Healthwise PMP must be a physician
  licensed in one of the following specialties
• General Practice
• Family Practice
• General Pediatrics
• General Internal Medicine
• OB/GYN
• In Care Select, specialists may also serve as
  PMPs
• Specialist PMPs must be chosen by the member
• Do not receive auto-assignments

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Enrolling in the HealthWatch Program

• Primary specialty providers may enroll in the
  EPSDT program by doing the following
• Group Providers
• Print the IHCP Group and Clinic Provider
  Application and Maintenance Form
• Check Yes in box 8 on page 6 of the form
• Check Yes in box 17a on page 33 of the form for
  each rendering physician
• Billing Providers
• Print the IHCP Billing Provider Application and
  Maintenance Form
• Check Yes in box 8 on page 6 of the form
• Note Both forms are available on the Provider
  Enrollment page at www.indianamedicaid.com

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Enrolling in the HealthWatch Program

• 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)
• MDwise or,
• Sign a Care Select Addendum with one or both of
  the care management organizations (CMOs)
• MDwise
• Advantage Health Solutions

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Covered Services

• Newborn screening includes tests for eight
  conditions prior to discharge from the hospital
• Phenyleketonuria (PKU)
• Galactosemia
• Hypothyroidism
• Maple Syrup Urine Disease
• Hemoglobinopathies, including sickle cell anemia
• Homocystinuria
• Congenital adrenal hyperplasia
• Biotinidase deficiency

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Covered Services

• EPSDT periodic well child screenings include the
  following
• Comprehensive health and developmental history,
  including assessment of both physical and mental
  health development
• Comprehensive unclothed physical exam
• Nutritional assessment
• Blood lead level screen (required for well-child
  screen)
• Developmental assessment
• Simple vision and hearing assessment
• Simple dental and oral screening
• Health education, including anticipatory guidance
• Administration of or referral for any other test,
  procedure, or immunization that is clinically
  indicated

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Referrals

• Optometric referral when warranted by objective
  vision screening
• Audiology referral when indicated by a simple
  hearing evaluation in addition to an audiometric
  exam at age 4
• Dental referral when oral evaluation indicates or
  at the age of 24 months
• Primary medical provider should maintain
  documentation of all referrals and results in the
  members record
• Indicate an EPSDT referral on claims as follows
• CMS-1500 Mark Y in box 24H
• ADA2006 Mark X in box 1 (EPSDT/Title XIX)

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Billing Guidelines

• Use V20.2 as the primary diagnosis for EPSDT
  services
• Well child age appropriate and service related
  evaluation and management services using the CPT
  codes 99381-99385 (for new patients) and
  99391-99395 (for established patients)
• The use of V20.2 as the primary diagnosis allows
  bypass of third party liability when the primary
  insurance does not cover the service provided
• Initial evaluations reimburse at 75, or the
  billed amount if less
• Established exams reimburse at 62, or the billed
  amount if less

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Additional Billing Guidelines

• Other office visits without the full EPSDT
  components should be reported by using the other
  office visit evaluation and management CPT codes
  (99201-99205 and 99211-99215)
• Missed appointments should be reported to the
  appropriate MCO or CMO Member Services department
  for follow-up
• Refer to the Indiana Health Coverage Programs
  HealthWatch manual for required screenings,
  referrals and immunizations

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EPSDT Well Child Visit

• The components of the EPSDT HealthWatch exam are
  not separately billable
• Immunizations and 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 the T1015 CPT code
  for non-MCO members
• FQHC or RHC services provided to MCO members
  require appropriate physician billing
• Send cost reports to Myers Stauffer for review
  and reconciliation

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Prior Authorization

• EPSDT periodic well child screenings do not
  require prior authorization.
• Prior authorization may be required for
  additional treatments clinically indicated by the
  periodic EPSDT screening.
• There are also many other services that are
  provided to an EPSDT eligible child that qualify
  as diagnostic, screening, or treatments. Some of
  these services are identified in the recommended
  periodicity and screening schedule.
• Note Reference the periodicity and screening
  schedule and ACIP immunization guidelines at 405
  IAC 5-15-8

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Strategies for Outreach

• Members
• Letters
• Pamphlets
• Health Fairs
• Providers
• Provider seminars
• Quarterly workshops
• Newsletters
• Bulletins
• Banner Pages
• On-site visits
• Monthly conference calls with the CMOs and MCOs
  and the Office of Medicaid Policy and Planning
  (OMPP) to strategize and share information

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Current Statistics

• Immunizations
• More than 50 of adults 20 years of age and older
  in the U.S. do not have a protective level of
  antibody against tetanus and diphtheria
• Lead
• 2006 Reporting to CMS showed less than 1 of
  Medicaid Eligible children are being tested for
  Elevated Blood Lead Levels.
• Currently working on reporting

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• Immunization Program
• Indiana State Department of Health

800-701-0704 www.statehealth.in.gov/programs/immun
ization
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Immunizations / Vaccines

• Vaccinations are an important part of
  preventative health care and are considered part
  of the EPSDT Screenings
• Vaccines for Children Program (VFC)
• EPSDT covered vaccines include
• Tetanus Vaccine
• Diptheria Vaccine
• MMR Vaccine
• Polio Vaccine
• Hepatitis A and B vaccines
• Pneumococcal vaccine

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Immunizations / Vaccines

• EPSDT Covered vaccines include (cont)
• Influenza vaccine (shot and nasal spray)
• Meningococcal Vaccine
• Rotavirus Vaccine (RVV)
• HPV Vaccine
• Zoster Vaccine
• Varicella

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Vaccine Safety Reliable Resources

• Indiana State Department of Health
• http//www.in.gov/isdh/programs/
• immunization/VaccineSafety/index_vacc_safety.htm
• CDC Vaccine Safety
• http//www.cdc.gov/vaccines/vac-gen/safety/defau
  lt.htm
• Institute for Vaccine Safety http//www.vaccines
  afety.edu/
• Immunization Action Coalition
• http//www.immunize.org/safety/

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Vaccines for Children (VFC)

• The VFC Program supplies VFC enrolled healthcare
  providers with free vaccines to be administered
  to children 18 years old and younger who meet one
  or more of the following
• On Medicaid
• Without Health Insurance
• American Indian or Alaskan Native
• VFC program is federally funded
• VFC program started October 1994

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VFC in Indiana

• ISDH conducts annual assessment of vaccination
  rates via AFIX (Assessment, Feedback, Incentives
  Exchange) staff
• ISDH Vaccine E-letter provides immunization news
  in brief
• Approved RHCs and FQHCs can also utilize the VFC
  program

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VFC Provider Enrollment

• In order to participate in the VFC program,
  providers must have
• One-hour enrollment session for all clinic staff,
  provided by VFC staff to ensure complete
  understanding of the program
• Fax machine
• Proper refrigeration/freezer storage

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VFC Paperwork Requirements

• Vaccine Order Form
• Vaccine Tally Sheet (not needed if using CHIRP)
• Contact the ISDH Immunization Program at
  1-800-701-0704

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About CHIRP

• Statewide Immunization Registry provided by the
  Indiana State Department of Health
• No charge to providers to use CHIRP
• Internet Based Application that is secure and
  confidential
• Opt-Out Registry
• CHIRP data is not to be used for punitive
  purposes
• Used by several who serve children, including
  healthcare providers, state and local health
  departments, school nurses, licensed child-care
  centers, and other state immunization registries.
• Full training available
• For more information or to enroll, visit
  www.chirp.in.gov

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What are the Symptoms?

• Fatigue
• Crankiness
• Stomach aches
• Most commonly there are
• NO SIGNS

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How Much Is Too Much?

• In Children, CDC currently uses the Blood Lead
  Level (BLL) of 10 µg/dL (micrograms/deciliter) or
  higher to define Lead Poisoning
• The action level has been lowered through the
  years
• Marion County Health Department takes action at
  5µg/dL
• Negative effects have been found at very low
  levels (cognition, reduced IQ, and behavior)
• There is no safe exposure threshold

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Who is Most at Risk?

• Children regularly exposed to older dwellings
• Children with siblings or playmates with lead
  poisoning
• Children frequently in contact with people
  exposed to lead through work or hobbies
• Children who are recent immigrants
• Children in low-income families
• Children enrolled in Medicaid
• Children who are members of minorities
  particularly African American
• Children using Folk or Ethnic home remedies
• Children exposed to renovation and remodeling
  activities

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Where does the body store lead?

• 95 of lead is stored in bone
• Half-life in bone is 20 to 30 years
• Half-life in blood is 1 to 2 months (active
  portion, results in toxicity)
• Pregnancy lead crosses the placenta
• Breast-feeding lead is also transmitted
• Toxic effects of lead cannot be reversed!

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Blood Lead Level Screening

• Three basic ways to test
• Venous Testing
• Hand-held device testing
• Filter Paper
• Code 83655 has been expanded to include handheld
  testing devices and filter paper testing
• When using this code, utilize the diagnosis code
  to distinguish between the tests to rule out lead
  poisoning and the tests on those who already have
  been diagnosed as lead poisoned
• When a blood lead screening is performed, use
  primary diagnosis code V20.2 and the exposure
  diagnosis code (V15.86)

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Most Common Sources

• Lead Paint
• Dust

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Where is the Risk?

• Lead paint in homes built prior to 1978 places
  children at risk for lead poisoning.
• The older the home the higher the risk for lead
  hazards.
• Of the children poisoned, 80 of the exposures
  came from housing.
• 90 of the pre-1950 housing where the poisoned
  children lived had lead based paint hazards.

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Where Do Hazards Appear?

• Friction and impact surfaces including window
  sills and doors
• Surfaces with chipped, peeling or deteriorated
  paint
• Surfaces with alligator textures
• Porches, rails and fences
• Bare soilin particular around perimeter of house
  or play area
• Floors where dust can settle
• Play equipment

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EPSDT Partners
Anthem
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Helpful Tools Avenues of Resolution

• IHCP Web site at www.indianamedicaid.com
• HealthWatch Manual
• IHCP Provider Manual (Web, CD-ROM, or paper)
• Customer Assistance
• 1-800-577-1278, or
• [phone] in the Indianapolis local area
• Written Correspondence
• P.O. Box 7263Indianapolis, IN 46207-7263
• Provider Relations Field Consultant