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

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

3. DMA For Providers EPSDT and Health Check

4. DMA Fee Schedules

5. 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

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

7. DMA EARLY AND PERIODIC SCREENING, DIAGNOSIS, AND TREATMENT (EPSDT) MEDICAID FOR CHILDREN Contact: EPSDT Nurse Consultant Division of Medical Assistance Telephone #: 919-855-4260 FAX #: 919-715-7679

8. DMA EPSDT Websites  Basic Medicaid and N.C. Health Choice Billing Guide  http://www.ncdhhs.gov/dma/basicmed/  Health Check Billing Guide  http://www.ncdhhs.gov/dma/healthcheck/  EPSDT Provider Page  http://www.ncdhhs.gov/dma/provider/epsdthealt hcheck.htm

9. DMA EPSDT Provider Website

10. DMA EPSDT Provider Website

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

12. DMA Eligibility Verification Methods NCECSWeb Tool –Free Service –Need Submitter ID & Password Automated Voice Response (AVR) System –1-800-723-4337 EDI Vendor

13. 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

14. DMA Eligibility Results 123456789k Jane Doe 123456789k 987654321A 1/1/1960 08/01/2012- 08/31/2012 08/01/2012 08/31/2012

15. 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

16. DMA CA Override Request Considered only for extenuating circumstances http://www.ncdhhs.gov/dma/ca/CAOverrideForm.pdf

17. 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

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

19. 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

20. 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

21. 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

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

23. 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

24. 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

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

26. 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 96110 with EP modifier

27. DMA Developmental Screening Autism Screening CPT Code 99420 with EP modifier Screening at ages 18 and 24 months

28. DMA Developmental Screening Cont. Health Risk Assessments and Behavioral/Mental Health Screening –CPT Code 99420 EP modifier Smoking/Tobacco Use Cessation Counseling –CPT Codes 99406 EP modifier 99407 EP modifier Alcohol/Substance Abuse Structured Screening and Brief Intervention –CPT Codes 99408 EP modifier 99409 EP modifier

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

30. 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

31. 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

32. DMA Procedure CodeDescription 90471 Immunization administration (includes percutaneous, intradermal, subcutaneous, or intramuscular injections); one vaccine (single or combination vaccine/toxoid) 90472+ (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 90473 Immunization administration by intranasal or oral route; one vaccine (single or combination vaccine/toxoid) 90474+* (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

33. 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 99172 or 99173 with EP modifier

34. 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 92587 with EP modifier

35. 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

36. 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

37. 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

38. 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

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

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

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

42. 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

43. DMA Requirement 2: Identify and record preventive medicine code and component codes Developmental screening CPT codes 96110, 99420, 99406, 99407, 99408, 99409 with EP modifier Vision CPT codes 99172 or 99173 with EP modifier Hearing CPT codes 92551, 92552, or 92587 with EP modifier

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

45. 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

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

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

48. DMA Preventive Medicine CPT Codes AgeNew Patient Established Patient Append EP Modifier Under age 1 year9938199391Yes 1 through 4 years9938299392Yes 5 through 11 years9938399393Yes 12 through 17 years9938499394Yes 18 through 20 years9938599395Yes

49. 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

50. 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 http://www.ncdhhs.gov/dma/provider/calendar.htm

51. 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 11-20 –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: 99420 Immunizations and therapeutic injections may be billed on same claim/date of service

52. 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

53. 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.

54. 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

55. 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

56. 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 http://www.ncdhhs.gov/dma/healthcheck/coding_matrix.pdf

57. DMA Frequently Used Forms Medicaid Resolution Inquiry

58. 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 300009 Raleigh, NC 27622

59. 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

60. 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 e-mail from vendor HMS website http://ncprovider.hms.comhttp://ncprovider.hms.com

61. DMA Contact Information Automated Voice Response (AVR) System 1-800-723-4337 Billing questions HP Enterprise Services 1-800-688-6696 or 919-851-8888, Option 3 Provider enrollment CSC EVC Call Center 1-866-844-1113 or email NCMedicaid@csc.comNCMedicaid@csc.com

62. 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

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

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

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

66. ANY QUESTIONS? Thank You