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Frequently Asked Questions
EPSDT FAQ's  

 
1.  For vision screening code, 99173 EP - what is the age appropriate code for comprehensive exam? We have been using 92012 and 92014
     Vision screening is a required component of the EPSDT program and must be billed in conjunction with an EPSDT comprehensive age appropriate screening (99382-99385 or 99392-99395 with an EP modifier) beginning at age 3. Only Medicaid providers who have an approved signed EPSDT agreement can provide and be reimbursed for these EPSDT screening services. The 99173 EP code is restricted to use by EPSDT providers.

2.  How do you become an EPSDT provider?
     You must first be enrolled as a Mississippi Medicaid provider. Then you can complete an additional provider agreement that will allow you to provide EPSDT services.

3.  Can a patient who is an established patient for routine health care but is new for screening be billed as a new patient for screening?
     No. You must bill the patient who is an established patient for routine health care as an established patient also for EPSDT screening in your clinic.

4.  Please define interperiodic screening.
     Interperiodic screens (medical, vision, and hearing) are visits outside of the EPSDT periodic standard scheduled screenings. They are visits for other medically necessary health care, screens, diagnostic, treatment and/or other measures to correct or ameliorate defects, physical and mental illnesses and conditions. These visits must be billed using the appropriate CPT Evaluation and Management codes without an EP modifier.

5.  Can we bill separately for adolescent counseling or is it a part of the EPSDT program?
     Adolescent counseling is a required component of the EPSDT program and must be billed in conjunction with an EPSDT comprehensive screen beginning at age 9. Only Medicaid providers who have an approved signed EPSDT agreement can provide these services. This code is restricted to use by EPSDT providers.

6.  Are IV infusions covered in the office through expanded EPSDT?
     Yes.

7.  Are Hgb/Hct done during EPSDT and U/H's code or not? If so are EP modifiers used or not?
     The laboratory tests (Hgb/Hct/U/H) are included in the EPSDT screening reimbursement rate and should not be billed separately.

8.  What is the EPSDT Program?
     EPSDT Program is the state's new name of Medicaid's comprehensive and preventive child health early and periodic screening, diagnostic, and treatment services for beneficiaries up to age 21. Early and Periodic Screening, Diagnostic, and treatment (EPSDT) was defined by law as part of the Omnibus Budget Reconciliation Act of 1989 (OBRA 89) legislation and includes periodic screening vision, hearing and dental services. These services were expanded in section 1905 (r) (5) of the Social Security Act (the Act) to require that any medically necessary health care service listed in section 1905 (a) of the Act be provided to an EPSDT beneficiary even if the service is not available under the State Plan.

9.  What services are covered under the Expanded EPSDT services?
     Expanded EPSDT services include any necessary Medicaid reimbursable health care to correct or ameliorate illnesses and conditions found on EPSDT screening. Services not covered, or exceeding the limits set forth in the Mississippi State Plan, must be prior authorized by DOM to ensure medical necessity. Expanded services are available to children from birth to 21 years of age. Eligibility extends through the last day of the child's birth month only.

10.  Who is eligible to participate in EPSDT?
     Children and youth (birth to twenty-one years) who are on Medicaid are eligible to participate in EPSDT.

11.  Who can provide EPSDT screenings?
     EPSDT screenings may be performed by physicians, physician assistants, nurse practitioners and registered nurses who are employed through the Mississippi Department of Education, who have met the certification requirement, and who meet the established protocols mandated by the Mississippi State Department of health, Mississippi Department of Education, Mississippi School of Nurse Association, and the Mississippi Board of Nursing.

12.  Do EPSDT screening providers need a separate Medicaid provider number?
     Physicians, physician assistants or nurse practitioners who wish to become EPSDT screening providers must complete the enrollment requirements and must sign a EPSDT specific provider agreement with DOM. If this is the first provider agreement entered into between the provider and DOM, a Medicaid provider number will be issued and a special EPSDT indicator will be added to the new Medicaid provider number. For current Medicaid providers, a special EPSDT indicator will be added to their existing Medicaid provider number. An onsite provider facility inspection must be conducted and approved prior to finalizing the EPSDT provider agreement with the effective begin date as the date the facility on-site review is completed and approved.

Note: A EPSDT provider agreement must be on file prior to providing EPSDT screening services, billing, and being reimbursed by Medicaid for services rendered. A EPSDT provider cannot have a retroactive effective date.

13.  How often can a EPSDT screening be performed?
     All providers must follow the periodicity schedule. The schedule is based on the American Academy of Pediatrics Recommendations for Preventive Pediatric Health Care. Frequency is as follows:
0-1month
2 months
4 months
6 months
9 months
12 months
15 months
18 months
Yearly beginning at age 2 years, up to age 21.
Yearly visits must occur once during the state fiscal year (July 1st- June30th)


14.  Where can a EPSDT screening be performed?
     
Local County Health Departments
Limited School Systems
Private and Public Clinics
Federally Qualified Health Clinics
Rural Health Clinics


15.  How do I know if a EPSDT screening has not already been done?
     All Medicaid providers can check Medicaid eligibility and see if the EPSDT screening is available through the Conduent Medicaid Web Portal. The web address is: www.ms-medicaid.com The providers that do not have internet service may call the Automated Voice Response System (AVRS). The number is: 1-800-884-3222.

16.  Why has Medicaid started sending our clinic EPSDT referrals?
     The Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) Program is a mandatory service under Medicaid. Each state is required to inform all Medicaid-eligible beneficiaries under age 21 that EPSDT services are available. Each state must also report annually to the Centers for Medicare and Medicaid Services (CMS) their performance and participation in the program. As part of our initiative to inform beneficiaries about the EPSDT program and increase participation in the program, the Medicaid Regional Offices are informing beneficiaries orally and in writing about the EPSDT program. A 315 referral form is completed for each beneficiary that chooses to participate. The 315 referral form is sent to the EPSDT participating provider to schedule the screen.

17.  Medicaid has sent me EPSDT 315 referrals on children that we have never seen before. What do I do with these referrals?
     Many of Medicaid-eligible beneficiaries do not have a Medical Home and have not received an EPSDT screening. This is reflected on our annual Federal report that shows a low participation rate for our state. EPSDT participating providers have entered into an agreement with the Division of Medicaid to provide this service to eligible beneficiaries. The Division of Medicaid policy is that participating providers contact the parent/schedule a screen for these beneficiaries within 60 days of receiving the referral.

18.  Will I be locked in to seeing only the beneficiaries that Medicaid sends referrals for?
     No. The Division of Medicaid wants every beneficiary to have a Medical Home and we encourage them to continue seeing their Medicaid provider of choice to establish a Medical Home.

19.  What do I do when we schedule the EPSDT screen and the beneficiary does not show up?
     Medicaid policy is that the EPSDT participating provider will make an appointment for the eligible beneficiary according to the periodicity schedule. If the family fails to keep the scheduled appointment, a second appointment letter will be sent providing the family another opportunity to participate in the EPSDT program within (30) days of the initial appointment. Failure of the family to keep the second appointment or to contact the clinic for a change in date and time will be considered a declination of services. Further attempts to contact the patient are not required for that periodic schedule.

After two appointment failures, the provider shall place the child for recall for the next EPSDT screening date on the periodicity schedule. It is the responsibility of the EPSDT screening provider to document efforts made to ensure the family an opportunity to participate in the EPSDT program. In no circumstances should the child be deleted from the system, unless the family refuses the service.

20.  Why is lead testing a requirement of the EPSDT program?
     Statistics show that the prevalence of lead poisoning is greater for children who are enrolled in Medicaid. Federal law mandates that all States screen all Medicaid-eligible children for lead poisoning as part of the EPSDT program requirements. A blood lead test must be used when screening Medicaid-eligible children.

21.  At what age is lead testing required?
     A screening blood lead test is required at 12 months and 24 months of age and anytime risk factors are identified by the risk assessment questionnaire. Additionally, children between the ages of 36 months and 72 months of age must receive a screening blood lead test if they have not been previously screened for lead poisoning. A blood lead test result equal to or greater than 10 mcg/dl obtained by a capillary specimen (finger stick) must be confirmed using a venous blood sample.

22.  The verbal lead risk questionnaire reveals no environmental risk factors at the 12 month screening visit. Is a blood lead test still required?
     Yes. A screening blood lead test is required at 12 months and 24 months regardless of the responses to the lead risk questionnaire. In addition, children over age 2 but less than age 6 should receive a screening blood lead test if not previously tested and at anytime a risk factor is identified.

23.  Will I receive Medicaid reimbursement for lead testing?
     Billing of lead analysis (83655) is appropriate only for the lab that analyzes the lead test and for those facilities that have purchased and utilize an in-house lead analyzer. Lab slips must contain accurate information including name, address, and current Medicaid number for appropriate billing by the independent lab. All labs must report weekly the results of all lead tests to the MSDH Lead Program. Those clinics with in-house lead analyzers must report all lead results to the MSDH Lead Program utilizing the reporting tool developed by the Lead Program.

A capillary specimen came back elevated requiring a confirmatory venous test. The venous test was elevated at 12 mcg/dl. What follow-up is required?

  1. All venous lead test results of 10mcg/dl or greater must be reported to the State Lead Program Coordinator at 601-576-7447.
  2. Provide family lead education; screen other children in the household under 6 years of age
  3. Provide nutritional counseling and check for iron deficiency (hct/hgb)
  4. Conduct a developmental assessment
  5. Repeat blood lead testing every 3 months until 2 venous results <10 mcg/dl. or 3 results <15 mcg/dl, then annually.

The Mississippi Childhood Lead Poisoning Prevention Guidance gives specifics on lead testing guidelines and recommended follow-up procedures. Download the guidance from the MSDH website at http://www.msdh.state.ms.us; click on preventive health services; click on environmental lead; scroll down to lead prevention guidance. For those without internet access, a copy can be obtained by calling 601-576-7447.

24.  Where might I get patient educational materials on lead poisoning and prevention?
     Contact the MSDH Childhood Lead Poisoning Prevention Program at 601-576-7447 for free literature on lead poisoning and prevention.

25.  What services are covered on the Plan of Care ?
     Only outpatient services should be requested on the prior authorization form through the Bureau of Maternal and Child Health . These are services such as physician office visits, outpatient visits and medical services that fall outside of the scope of regular Medicaid services .

26.  When should I submit an Addendum to the Plan of Care?
     You must have an approved Plan of Care on file with DOM -Maternal and Child Health before you can submit an Addendum and you have used all of the units on the original Plan of Care. Addendums should be submitted within the year the original PA request was submitted and with the original PA number.

27.  What is the EPSDT School Health-Related Services Program?
     The EPSDT School Health-Related Services Program provides reimbursement of medically necessary services for Medicaid-eligible children with disabilities or special needs as defined in the Individuals with Disabilities Education Act (IDEA) and identified through the Individualized Education Plan (IEP) or Individual Family Service Plan (IFSP) process. Schools may enroll as Medicaid providers, either by qualifying to provide services directly, or by contracting with independent practitioners to provide the services. The program is available to all Mississippi Department of Education school districts and Mississippi Department of Mental Health schools.

28.  Does each school require an individual provider number?
     The school district is issued one provider number for all schools within the district. All claim reimbursement will be provided using the district provider number.

29.  Are school districts required to obtain a National Provider Identifier (NPI) number?
     School districts are required to obtain and use a NPI number. The NPI is a unique 10-digit number used to identify health care providers and will be required on all electronic transactions.

30.  What services are available in the EPSDT School Health-Related Services Program?
     EPSDT School Health-Related Services include speech therapy, occupational therapy, physical therapy, and psychotherapy services. Evaluations conducted to determine a child's health-related needs for the purposes of the IEP/IFSP are also reimbursable. Therapy services must be prescribed by a physician and provided by a qualified licensed therapist.

31.  Does therapy performed in the EPSDT School Health-Related Services Program require prior authorization or a plan of care form?
     Medicaid deems prior authorization to be based on the IEP/IFSP and also uses the IEP/IFSP and the physician prescription/referral to establish medical necessity. The school district should submit a Services Checklist form before services are performed. The Services Checklist can be submitted electronically on the web portal.

32.  Is it mandatory that the Services Checklist form be submitted electronically?
     The Division of Medicaid strongly encourages electronic submission because providers are able to submit secure information in a timely fashion, thereby eliminating lost and/or misplaced paper transmittals.