Annual Wellness Exam EPSDT Paula LeSueur MSN, CFNP SBHC Medicaid Consultant Envision NM 2007

EPSDT Early Periodic Screening, Diagnosis and Treatment Objectives for our SBHCs: Provide comprehensive preventive health care. Identify student’s assets, risk behaviors and health risks.

Components of Complete EPSDT Screen A comprehensive health and developmental history, including an assessment of both physical and mental health development. A comprehensive, unclothed physical exam. Appropriate immunizations, according to age and health history, unless medically contraindicated at the time. Laboratory tests, including an appropriate lead blood level assessment (at 1 and 2 yrs of age). Health education, including anticipatory guidance.

Preventive Health Guidelines for Children and Adolescents EPSDT recommended every year from birth to age 20. Physical exam and developmental / behavioral health assessment. Nutrition screening. Measurements include; ht, wt, BMI percentile, and blood pressure (from age 2 to 20).

Developmental/Behavioral Health Assessment Utilize the Recommended Developmental and Behavioral Health Assessment for ages birth to 21 (HEADSS). The OSAH Student Health Questionnaire provides the required information. Use appropriate SHQ for Elementary School, Middle School or High School.

Sensory Screening Vision—Snellen eye chart Hearing/speech at age 3 through age 12,15 & 18. Hearing/speech at age 4 through age 12, 15 & 18. use audiometer, under earphones, at 1000, 2000 and 4000 Hertz at 20 decibels.

Physical Exam includes: Complete unclothed physical exam. External genital exam and Tanner staging is required. Document in chart if student declines the exam (e.g. deferred at patient request). Tanner staging may be done by self report. Provide education re: testicular and breast self-exam as appropriate.

Lab Screenings Urinalysis - to be performed at age 5 and 15. May use Chemstrip 9. Hematocrit/hemoglobin - to be done at 9 months and age 13. If indicated, may repeat after menarche in females.

High Risk Factor Screenings Tuberculin Test - Screen all teens for high-risk factors. Test if high individual risk. Risk factors include immigration or travel to areas of high prevalence, IV drug use, incarceration, homelessness, HIV infection or living with person with HIV, working or volunteering in health care setting.

High Risk Factor Screenings Pelvic exam - To be done with all sexually active females, with their consent, or initial exam at age 18 to 21. DOH Family Planning Division protocol states pelvic exam should be performed within 6 months of contraceptive use and PAP test should be performed after 3 years of sexual activity or age 21, whichever comes first. May complete the GYN or FP exam and schedule a return visit for the remainder of the EPSDT.

High Risk Factor Screenings STD Screen – all sexually active youth Urine chlamydia/gonorrhea . HIV test if high risk- positive contact with known partner at risk, past STDs, multiple partners, IV drug use or sex in exchange for money or drugs. For males: sex with other males. For syphilis only: test if reside in areas of prevalence. NM is not in an area of prevalence.

High Risk Factor Screenings Cholesterol - Perform or refer for the test if high risk. Testing is based on individual risk, i.e. familial hyperlipidemia, family history of early onset of cardiovascular disease in parents or grandparents at age 55 or less, obesity, diabetes, high blood pressure or cigarette smoker.

Immunizations Tetanus Booster - Tdap done between ages 12-15. Required for 7th grade entry for 2007-08. MMR, varicella and HepA - assess, give if indicated and not previously given. HepB - series should be completed in early childhood or by 7th grade. Influenza for high risk groups. HPV (3 doses). Immunizations should be given according to the most current Advisory Committee of Immunization Practice (ACIP) schedule. (www.cdc.gov/nip).

Procedure for SBHCs (how to make appointments) Who are the students served? Means test – what is the screening question? Do you have a PCP? Have you had a physical exam within the past year? Will you need a sports physical exam (SPE) some time this year?

Procedures, con’t. Who and when will EPSDTs be scheduled? Who will do vital signs, ht., wt., BMI % and lab tests? Who does the exam, the counseling and the education? Instruct student to be prepared for unclothed exam, come wearing t-shirt and gym shorts or boxers. Have gowns or drapes. Student to complete Student Health Question-naire for the Annual EPSDT and present the health history form for the SPE, if needed.

Procedures, con’t. Schedule annual exam (EPSDT) in SBHC for all students registered who have a signed parent consent form. Include components of Sports Physical and complete form, if needed. Complete EPSDT, submit claim to Salud if an approved Medicaid-SBHC provider. Provide referrals for lab tests or procedures as necessary. Document referral.

Encounter Form/ Billing form

Coding Schedule return visit for STD/Family Planning services. Use E&M code, as indicated. Reminder - If student refuses genital or any other part of the exam, including screening tests, document and state reason. Chaperone may be required for genital exam of the opposite sex, which should be allowed upon student request.

Notification Inform parents of results of the exam, including any screening tests or lab results, except confidential information. Present results per phone or written report. Notify Primary Care Provider that Annual Exam/EPSDT was performed by use of the New Mexico SBHC Services Notification Form. Include any pertinent findings. Schedule follow-up appointments for confidential, behavioral health or other health care services.

Documentation to support billing ICD-9 code is V20.2 for youth to age 17. ICD-9 code is V70.0 for youth 18 or older. Use of Modifier 25 – When the principal reason for the visit is an EPSDT and during the visit another separate identifiable health condition requires additional evaluation and management above and beyond the other service, then a 25 modifier can be attached to the secondary CPT.

Medical Chart Documentation No required state forms, but documentation must be an auditable form (a single sheet) in the medical chart. Recommend use of OSAH Progress notes for elementary, middle or high school students.

Strategies Perform Sports Physicals and then provide the remainder of the EPSDT during a scheduled appointment at the SBHC, in a timely manner. Perform Family Planning/STD screening exams and then reschedule for the remainder of the EPSDT visit.

Strategies Attend team/parent meetings to provide information about the annual exam and sports physicals. Meet with School Athletic Department to schedule appointments in conjunction with their needs. Routinely schedule EPSDTs - e.g., first appointment of the morning or the afternoon.