NC Department of Health and Human Services DMA Health Check Seminar September 2012 Presented by: HP Enterprise Services

DMA Health Check Resources DMA Website – Health Check Billing Guide EPSDT Policy Instructions (updated 1/11/2010) Request for Non-Covered Services Forms

DMA For Providers EPSDT and Health Check

DMA Fee Schedules

DMA Who’s Who in Medicaid Centers for Medicare and Medicaid Services –CMS Department of Health and Human Services –DHHS Division of Medical Assistance –DMA

DMA Who’s Who in Medicaid Department of Social Services –DSS HP Enterprise Services –HPES Computer Sciences Corporation –CSC

DMA EARLY AND PERIODIC SCREENING, DIAGNOSIS, AND TREATMENT (EPSDT) MEDICAID FOR CHILDREN Contact: EPSDT Nurse Consultant Division of Medical Assistance Telephone #: FAX #:

DMA EPSDT Websites  Basic Medicaid and N.C. Health Choice Billing Guide   Health Check Billing Guide   EPSDT Provider Page  hcheck.htm

DMA EPSDT Provider Website

DMA EPSDT Provider Website

DMA Provider Responsibility Verify Recipient Eligibility Carolina ACCESS Health Check Overview Maintain Medical Records Health Check Billing Requirements

DMA Eligibility Verification Methods NCECSWeb Tool –Free Service –Need Submitter ID & Password Automated Voice Response (AVR) System – EDI Vendor

DMA Verify Eligibility Use any of these methods to search Tips: Use MPN or NPI If no date is keyed it will reflect eligibility for the date of search Can not check future date until the first of that month Can search back 365 days

DMA Eligibility Results k Jane Doe k A 1/1/ /01/ /31/ /01/ /31/2012

DMA Carolina ACCESS (CA) Primary Care medical home for enrolled recipients Obtain referral from Primary Care Provider Referring NPI reported on claim More information: Basic Medicaid and N.C. Health Choice Billing Guide Section 6- Managed Care Programs

DMA CA Override Request Considered only for extenuating circumstances

DMA Carolina ACCESS Denial Codes –EOB 270 Billing provider is not the recipient’s Carolina ACCESS PCP. Authorization is missing or unresolved –EOB 286 Incorrect authorization number on claim form. Verify number and re-file claim

DMA Provider Responsibility Verify Recipient Eligibility Carolina ACCESS Health Check Overview Maintain Medical Records Health Check Billing Requirements

DMA Health Check/EPSDT Overview Important because… –Provides for early and regular medical, developmental, dental screenings and ongoing surveillance for all Medicaid recipients under the age of 21 –Part of the federal Medicaid EPSDT requirement to provide medically necessary health care

DMA Screening Assessments Health Check recommends regular medical screening assessments (well-child visits) for recipients Screening, diagnostic and treatment services are FREE of charge to the recipient

DMA Health Check/EPSDT Recommended Periodicity Schedule Within 1 st month9 or 15 months 2 months12 months 4 months18 months 6 monthsFor children ages 2 through 20, annual visits are recommended

DMA Periodic Health Check Screening Require all age-appropriate components –Developmental Screening –Vision Screening –Hearing Screening –Dental Screening –Immunizations

DMA Interperiodic Health Check Screening Require all age-appropriate components EXCEPT –Developmental Screening –Hearing Screening –Vision Screening Screening may be performed outside of the periodicity schedule All electronic claims should list referral code indicator “E” when a referral is made for follow-up

DMA Health Check Screening Assessment Components Comprehensive unclothed physical assessment Comprehensive health history Nutritional assessment Anticipatory guidance and health education Measurements, blood pressure and vital signs

DMA Health Check Screening Assessment Components Developmental surveillance Immunizations Vision screening Hearing screening Dental screening Laboratory procedures

DMA Developmental Screening Includes physical and mental development Required component of a Periodic Screening at the following ages: –6, 12, and 18 or 24 months old –3, 4, and 5 years old Must use a standardized and validated screening tool CPT code with EP modifier

DMA Developmental Screening Autism Screening CPT Code with EP modifier Screening at ages 18 and 24 months

DMA Developmental Screening Cont. Health Risk Assessments and Behavioral/Mental Health Screening –CPT Code EP modifier Smoking/Tobacco Use Cessation Counseling –CPT Codes EP modifier EP modifier Alcohol/Substance Abuse Structured Screening and Brief Intervention –CPT Codes EP modifier EP modifier

DMA Break Time….. See you back in 15 minutes!!

DMA Immunizations Same provider Same date of service as Health Check screening Same location as Health Check screening EP modifier appended to the immunization administration CPT code –Recipients from birth through age 20

DMA Immunizations The North Carolina Immunization Program (NCIP) Vaccines for Children (VFC) Birth through 18 years of age - no charge Reimbursement for the administration of vaccines EP modifier required

DMA Procedure CodeDescription Immunization administration (includes percutaneous, intradermal, subcutaneous, or intramuscular injections); one vaccine (single or combination vaccine/toxoid) (add-on-code) Immunization administration (includes percutaneous, intradermal, subcutaneous, or intramuscular injections); one vaccine (single or combination vaccine/toxoid) each additional vaccine (single or combination vaccine/toxoid) List separately in addition to code for primary procedure Immunization administration by intranasal or oral route; one vaccine (single or combination vaccine/toxoid) * (add-on-code) Immunization administration by intranasal or oral route; each additional vaccine (single or combination vaccine/toxoid) List separately in addition to code for primary procedure

DMA Vision Screening Required for Periodic Examinations beginning at age 3 through 10 years Age 11- screening needed only once every three years CPT code or with EP modifier

DMA Hearing Screening Objective screenings using an otoacoustic auditory emission (OAE) tool or audiometer Performed annually for ages 4-10 All other ages, selective screening based on assessment of risk CPT code 92551, 92552, or with EP modifier

DMA What if the hearing or vision component cannot be performed because…. Uncooperative, blind, deaf, or autistic Document the date of service and reason why unable to perform screening Submit claim without component CPT code

DMA Dental Screening An oral screening is to be performed at every Health Check visit Referral to a dentist is recommended for every child before age 1 and required at age of 3 Dental Varnishing allowed once every 60 calendar days –D1206 and D0145, no EP modifier

DMA Frequently Asked Questions Is Dental Varnishing a requirement of the Health Check program? Answer: No Is Dental Varnishing separately reimbursable in addition to a Health Check visit? Answer: Yes

DMA Laboratory Procedures Laboratory procedures include: –Hemoglobin or Hematocrit –Newborn Metabolic/Sickle Cell Screening –Tuberculin Test –Lead testing Included in Health Check fee when billed on same date of service

DMA Provider Responsibility Verify Recipient Eligibility Carolina ACCESS Health Check Overview Maintain Medical Records Health Check Billing Requirements

DMA Claim Submission Electronic submission Software Vendor or Clearinghouse NC Electronic Claims Submission (NCECSWeb Tool) Paper submission –For claims meeting exception criteria only

DMA Health Check Billing Requirements What are the six billing requirements specific to the Health Check Program?

DMA Requirement 1: Identify and record diagnosis code –CMS-1500, block 21 Primary diagnosis first –Periodic- V20.2 –Interperiodic V70.3 Medical diagnoses –Listed after primary, and before immunization diagnoses Immunization diagnosis code –Required when one or more immunizations are provided as the only service

DMA Requirement 2: Identify and record preventive medicine code and component codes Developmental screening CPT codes 96110, 99420, 99406, 99407, 99408, with EP modifier Vision CPT codes or with EP modifier Hearing CPT codes 92551, 92552, or with EP modifier

DMA Requirement 3: EP is a required modifier for all Health Check claim details –Screening assessments –Vision, Hearing, and Developmental screening –Immunization administration

DMA Requirement 4: Record Referrals: –List referral code indicator “E” for claims submitted via NCECSWeb Tool –List referral code indicator “F” when a referral is made for Family Planning services

DMA Requirement 5: Next Screening Date –Systematically entered according to the predetermined periodicity schedule –Provider-entered Next Screening Date –Systematically entered Next Screening Date

DMA Requirement 6: Identify and Record Immunization Administration CPT Code(s) and the EP Modifier Refer to immunization guidelines

DMA Preventive Medicine CPT Codes AgeNew Patient Established Patient Append EP Modifier Under age 1 year Yes 1 through 4 years Yes 5 through 11 years Yes 12 through 17 years Yes 18 through 20 years Yes

DMA Frequently Asked Question Can I get paid for a sick visit and a well visit on the same date of service? Answer: No If they are sick, treat the visit as a sick visit and reschedule the well check

DMA Billing Information Report CA Overrides on the NCECSWeb Tool using: –“Referring Physician Provider Number” (Carolina ACCESS Physician Number) Electronic Funds Transfer (EFT) Checkwrite schedule Cut-off date and time

DMA Billing Tips-All Providers Two Health Check screening assessments on different dates of service cannot be billed together Can be billed when performed during a periodic or interperiodic Health Check assessment for ages –CPT codes: 99406, 99407, 99408, 99409, Can be billed when performed during a periodic or interperiodic Health Check assessment for ages birth through 20 –CPT code: Immunizations and therapeutic injections may be billed on same claim/date of service

DMA Billing Tips - Private Sector Provider Health Check screening and office visit with different dates of service must be billed separately Health Check screening assessment and office visit cannot be paid initially on the same date of service For denied claim to be reconsidered –Submit an adjustment with medical documentation and EOB attached AVR and claim status

DMA Billing Tips - Local Health Department Two Health Check screenings on different dates of service cannot be billed on the same claim form An immunization administration fee may be billed if the immunization is provided in addition to a Health Check screening visit.

DMA Health Check Coordinators (HCCs) Assist parents and providers in assuring that Medicaid-eligible children have ACCESS to Health Check services Provide education and outreach services in 100 NC counties and the Qualla Boundary

DMA Health Check Common EOBs EOB 10 –Diagnosis or service invalid for recipient age EOB 1036 –Thank you for reporting vaccines EOB 1769 –No additional payment made for vision, hearing and/or developmental screening services EOB 1770 –Invalid procedure/modifier/ diagnosis

DMA Health Check References Billing reference sheet Immunization billing reference sheet Resource list Claim examples Local Health Department HSIS screens N.C. Periodicity Schedule and Coding Matrix

DMA Frequently Used Forms Medicaid Resolution Inquiry

DMA Medicaid Overrides Resolution Inquiry Form –Use only when requesting Time Limit Override Third Party Override Medicare Override HMOs Attached with Explanation of Benefits (EOB) and paper claim Mail to: HP Enterprise Services PO Box Raleigh, NC 27622

DMA Primary Insurance Private Insurance pays, submit electronic claim to Medicaid Non-payment indicated? Submit claim on paper –Attach Medicaid Resolution Inquiry Form, claim, and primary EOB Check “Third Party Override” box –Applied to the Deductible, Non-Covered Service, Policy Terminated –Exceeds maximum benefits for the year

DMA DMA-2057/Electronic Transmissions Update recipient’s commercial insurance information Transmit electronically via secured internet connection –New & preferred method Ability to send claim upon receipt of the confirmation from vendor HMS website

DMA Contact Information Automated Voice Response (AVR) System Billing questions HP Enterprise Services or , Option 3 Provider enrollment CSC EVC Call Center or

DMA Review A child comes in for a sports physical, outside of their periodicity schedule. Is this a periodic or interperiodic screening? Answer: Interperiodic What diagnosis code is required? Answer: V70.3

DMA Review True or False: An EP modifier is required when billing a health check visit code Answer: TRUE

DMA Provider Responsibility Verify Recipient Eligibility Carolina ACCESS Health Check Overview Maintain Medical Records Health Check Billing Requirements

DMA Review True or False: Although Medicaid ID cards are issued annually, eligibility information can still change on a monthly basis Answer: TRUE

ANY QUESTIONS? Thank You