HP Provider Relations October 2010 HealthWatch/EPSDT

HealthWatch/EPSDTOctober Agenda – Objectives – HealthWatch/Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) Program – Covered Services – Referrals – Billing Guidelines – Helpful Tools – Questions

HealthWatch/EPSDTOctober 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

Understand HealthWatch/EPSDT

HealthWatch/EPSDTOctober 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

HealthWatch/EPSDTOctober IHCP HealthWatch/EPSDT Provider Manual

HealthWatch/EPSDTOctober IHCP HealthWatch/EPSDT Provider Manual

HealthWatch/EPSDTOctober 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

HealthWatch/EPSDTOctober 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

HealthWatch/EPSDTOctober HealthWatch/EPSDT Member Population Who is eligible for EPSDT services? – Medicaid enrolled children from birth to their 21 st birthday – EPSDT member population comes from three Medicaid programs: Hoosier Healthwise Care Select  Wards and foster children Healthy Indiana Plan (HIP)  Members under 21 years

HealthWatch/EPSDTOctober 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 or ADVANTAGE Health Solutions

Learn HealthWatch/EPSDT Covered Services

HealthWatch/EPSDTOctober 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 and Appendix A: Periodicity and Screening Schedulehttp://provider.indianamedicaid.com/general-provider-services/manuals.aspx

HealthWatch/EPSDTOctober 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 – CHIRP is the Statewide Immunization Registry provided by the Indiana State Department of Health For more information or to enroll, visit or call ISDH at

HealthWatch/EPSDTOctober 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 Detailed information can be found in Section 3 of the HealthWatch/EPSDT Provider Manual, located at services/manuals.aspxhttp://provider.indianamedicaid.com/general-provider- services/manuals.aspx

HealthWatch/EPSDTOctober 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 is expanded to include tests administered using filter paper and handheld testing devices in the office setting − Assay of lead (venous blood) U1 − Assay of lead, using filter paper 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.

HealthWatch/EPSDTOctober 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 provider-services/manuals.aspx, and Appendix A: Periodicity and Screening Schedulehttp://provider.indianamedicaid.com/general- provider-services/manuals.aspx 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

HealthWatch/EPSDTOctober Hearing Screening *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 AgeHearing Screening Schedule NewbornSubjective 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 visitObjective screening, by standard testing method 6 and 8 year visitsSubjective 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

HealthWatch/EPSDTOctober Dental Screening AAPD Recommendations6-12 months 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 

Refer HealthWatch/EPSDT referrals

HealthWatch/EPSDTOctober 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 ( – 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 services/manuals.aspx, and Appendix A: Periodicity and Screening Schedulehttp://provider.indianamedicaid.com/general-provider- services/manuals.aspx

Bill HealthWatch/EPSDT claims

HealthWatch/EPSDTOctober 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 and – 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 provider-services/manuals.aspxhttp://provider.indianamedicaid.com/general- provider-services/manuals.aspx CPT copyright 2009 American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association.

HealthWatch/EPSDTOctober HealthWatch/EPSDT Billing Guidelines EPSDT Screening CPT ® CodeICD-9 CodingReimbursement Fees EPSDT Visit (all components documented) Initial/New Patient: Established Patient: Evaluation and Management: New Patient: Established Patient: V Routine infant or child health check Use additional ICD-9-CM codes to identify special screening examinations performed EPSDT visits must be billed with V20.2 and one of the CPT codes listed. These visits are eligible for additional reimbursement. Reimbursement: Initial/New Patient, EPSDT $75 Established Patient, EPSDT $62 Sick Visit plus EPSDT (2 visit codes) Preventive visit code and with modifier 25 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 Sick visits depend on complexity and doctor/patient relationship (new/established) Reimbursement: $19-65

HealthWatch/EPSDTOctober HealthWatch/EPSDT Billing Guidelines – 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/EPSDTOctober HealthWatch/EPSDT Billing Guidelines – 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 for more information and specific reimbursement rates

Connect HealthWatch/EPSDT Partners

HealthWatch/EPSDTOctober HealthWatch/EPSDT Partners – Anthem – MDwise – Managed Health Services – ADVANTAGE Health Solutions

Find Help Resources Available

HealthWatch/EPSDTOctober Helpful Tools Avenues of resolution –IHCP Web site at –HealthWatch/EPSDT Provider Manual –IHCP Provider Manual (Web, CD-ROM, or paper) –Customer Assistance , or (317) in the Indianapolis local area –Written Correspondence P.O. Box 7263 Indianapolis, IN –Provider field consultant –EPSDT coordinator Office of Medicaid Policy and Planning

Q&A