016.06.98 Ark. Code R. § 048 - Child Health Services (EPSDT) Update Transmittal #37 - To replace the outdated childhood immunization charts and tables with the 1998 Immunization Schedule approved by the Advisory Committee on Immunization Practices, the American Academy of Pediatrics, and the American Academy of Family Physicians
The Arkansas Division of Medical Services recruits providers for medical, dental, visual and hearing screenings, and treatment services. All Child Health Services (EPSDT) providers are required to sign an appropriate provider contract with the Arkansas Division of Medical Services. The providers must consider the screening fee designated by the Arkansas Medical Assistance Program as payment in full and are prohibited by law from requesting or receiving additional payment from the recipient or his/her responsible relatives.
Any licensed physician, family practitioner, obstetrician, pediatrician, optometrist, etc., or any outpatient hospital, community or public health clinic supervised by a licensed physician that is enrolled in the Arkansas Medical Assistance Program and offers the screening package as outlined in the Recommended Screening Procedures is eligible to participate in the Child Health -SeFviees-(EPSDT-)-Pr0gram^-------------------------------------------------------------------------------------------------------
In addition, providers offering screening components, including vision,:hearing and .dental screens may enroll as Child Health Services (EPSDT) providers. . Such providers may include optometrists, licensed audiologists and others.
In addition to signing the Medicaid contract, an eligible Child Health Services (EPSDT) provider must sign an agreement to participate as a Child Health Services (EPSDT) screening provider. (See page II-2 of this manual.) If interested, please contact the Central Child Health Services (EPSDT) Office at 682-8298 or In-State WATS Line 1-800-482 -1141. Payment for screens performed by providers who have not signed an agreement will be denied.
When Child Health Services (EPSDT) medical screenings or medical screening components or immunizations are not performed by a physician provider, the screening provider must have a written agreement with a physician who assumes the responsibility for the provision of Child Health Services (EPSDT) screenings and immunizations and agrees:
The physician does not have to be physically present in the clinic at all times during the hours of operation. However, the physician must assume responsibility for the clinic's operation. All screenings and immunizations must be performed by personnel meeting, at a minimum, registered nurse status.
School districts and education service cooperatives may provide all CHS/EPSDT screening services. A school district or cooperative may participate at one of two levels, as either a comprehensive screening provider who will provide all EPSDT screening components, or as a provider for vision and/or hearing screens.____________________________________._,^,^__________________
Schools enrolling as comprehensive screening providers must meet the following criteria:
* Provider must complete an application and contract with the Arkansas Medicaid Program. (See Section I of this manual.)
+ The application and contract must be approved by the Arkansas Medicaid
Program.
+ The Provider must sign an agreement to participate as a CHS screening provider per Section 201 of this manual.
* The Provider must be certified as a comprehensive CHS/EPSDT Provider by the Superintendent of schools (See Section 240).
Schools or education service cooperatives enrolling as screeners for hearing and vision, hearing only or vision only must meet the following criteria:
* The Provider must complete an application and contract with the" Arkansas Medicaid Program. (See Section I of this manual.) _'
+ The application and contract must be approved by the Arkansas Medicaid
Program.
* The Provider must sign an agreement to participate as a CHS screening provider per Section 201 of this manual.
A comprehensive medical screening program for all eligible Medicaid children requires the medical provider to assume overall responsibility for detection and treatment of conditions found among these young patients. This means the provider should have knowledge of specialized referral services available within the community and should maintain continuing relationships with physician specialists. It also requires the provider to work closely with the Human Services office staff in ensuring that eligible children in need of medical attention take full advantage of the medical services available to them.
The screening procedures outlined in Sections 213 and 215 of this manual are considered the minimal elements of a comprehensive screening. Other procedures may be included depending upon the child's age and health history. Each of the screening procedures is based on recommendations from the Federal Department of Health and Human Services and the American Academy of Pediatric Each screening should be billed separately providing-the appropriate information for each of the;:,applicable screening ..components.- ; Other specific procedures may be used at the screener's discretion as long as the following federally mandated components are included in the complete medical screening procedure: observe and measure growth and development, give nutritional advice, immunize, counsel and give health education and perform laboratory procedures applicable for age.
Periodic visual, hearing and dental screens, medically necessary interperiodic screens and screens not covering all medical screening components (partial screens) should not duplicate prior services. A partial screen, if medically necessary, may be performed by a health, developmental or educational professional who comes into contact with the child outside of the form,al health care system.
Requirements for Periodic Medical. Visual, Hearing and Dental Screenings. Distinct periodicity schedules have been established for medical screening services, vision services, hearing services and dental services (i.e., each of these services has its own periodicity schedule).
The determination of whether an interperiodic or partial medical screen is medically necessary may be made by a health, developmental or educational professional who comes into contact with the child outside of the formal health care system (e.g., including State early intervention or special education programs, Head Start and day care programs, the Special Supplemental Food Program for Women, Infants and Children (WIC) and other nutritional, assistance programs.) For example, a child is screened at age 7 according to the periodicity schedule for visual screening services and is found to have no abnormalities. At age 8, the child is referred to the school nurse by a teacher who suspects the child may have a vision problem. The visual screening confirms that a problem exists. The screening services will be covered even though screening services are not required by the visual periodicity schedule until the child reaches age 10.
The Child Health Services/Early and Periodic Screening, Diagnosis and Treatment (EPSDT) Program is a mandatory child health component of Medicaid and is designed to bring comprehensive health care to individuals (age 0 through 20) eligible for medical assistance. Even if the person eligible for medical assistance is a parent, he/she is eligible for Child Health Services (EPSDT) if he/she is under 21 years of age.
Early means as soon as possible in the child's life; or as soon as a family's eligibility for assistance has been established.
Periodic means at intervals established for screening by medical, dental, visual and other health care experts. The types of screening procedures performed and their frequency will depend on the child's age and health history. In Arkansas, the medical periodic screening schedule has been established following the recommendations of the American Academy of
Pediatrics. The age schedule recommended for Child Health Services (EPSDT) medical_________
screening and immunizations is shown in Section 215 of this manual. The age schedule recommended for Child Health Services (EPSDT) visual screening is found in Section 216 of this manual, the schedule for hearing screening is found in Section 217 and the schedule for dental screening is found in Section 218.
Interperiodic means providing medical necessary screenings in between the recommended age ranges for medical, visual, hearing and dental screenings in order to determine the existence of suspected physical or mental illnesses or conditions.
Partial means a medical screen consisting of one or more of the Child Health Services (EPSDT) medical screening components, but not each component.
Screening is the use of quick, simple procedures to sort out apparently well persons from those who have a disease or abnormality and to identify those in need of more definitive study of their physical or mental problems.
Diagnosis is the determination of the nature or cause of physical or mental disease or abnormality through the combined use of health history, physical, develppmental and psychological examination, laboratory tests and X-rays. Physicians and other health professionals who do Child Health Services (EPSDT) screening may diagnose and treat health problems discovered during the screening or may refer the child to other appropriate sources for such care.
Treatment means physician, hearing, visual or dental services or any other type of medical care and services recognized under State law to prevent, correct or ameliorate disease or abnormalities detected by screening or by diagnostic procedures. Treatment for conditions discovered through a screen may exceed limits of the Medicaid program. Services not otherwise covered under the Medicaid program will be considered for payment if the services are prescribed by a physician as a result of an (EPSDT) screen.
For example, a physician performs a Child Health Services (EPSDT) screen on September 1, 1990 and refers the recipient for prosthetics services. The recipient is 16 years old. According to the Medical Periodicity Schedule, the recipient had the age appropriate (16-18) EPSDT screen at the age of 16. He is not due for another Child Health Services (EPSDT) screen until the age of 18. However, because the prescription for the non-covered service may not exceed a maximum of 12 months from the date of the screen, the prescription for prosthetics services is valid until September 1, 1991. Another recipient is screened on September 1, 1990 and referred to a Prosthetics provider. The recipient is 12 months old. According to the Medical Periodicity Schedule, the patient is due to be screened again at 15 months old. Therefore, the prescription for the services which are to be provided by the Prosthetics provider is valid until December 1, 1990. The current periodicity schedules may be found in this manual.
Department of Human Services (DHS) County Offices will continue to refer Medicaid recipients to providers for Child Health Services (EPSDT) screens. However, a provider, except for recipients residing in the counties listed in Section 214.1, may initiate the health screen for an eligible recipient at the ! appropriate time without a referral from the DHS County Office.
An eligible child who lives in one of the twenty-five (25) counties listed in Section 214.1 must be referred by the PCP if the child is to be screened by a provider who is not the PCP.
The Medical Assistance Program provides recipients freedom of choice of local participating Medicaid Child Health Services (EPSDT) providers. The local Human Services office is responsible for showing recipients a list of participating Child Health Services providers when the recipient expresses an interest in Child Health Services (EPSDT) except in those counties that require a Primary Care Physician (PCP) referral prior to screening. See Section 214.1. Recipients have freedom of choice in their selection of a PCP.
Effective for dates of service on or after April 1, 1998, Medicaid eligible recipients residing in the following counties are subject to Primary Care Physician (PCP) referral requirements with regard to Child Health Services (EPSDT) medical and hearing screens. Medical and hearing screens, except routine newborn care, require a referral if performed by any health care provider other than the PCP. Dental screens, Visual screens and immunizations for childhood diseases are exempt from this requirement.
|
BENTON |
LONOKE |
|
BOONE |
MADISON |
|
CARROLL |
MARION |
|
CLARK |
OUACHITA |
|
CLAY |
PERRY |
|
CRAIGHEAD |
POINSETT |
|
CRAWFORD |
POPE |
|
FAULKNER |
PULASKI |
|
FRANKLIN |
RANDOLPH |
|
GARLAND |
SALINE |
|
GRANT |
, SEBASTIAN |
|
JOHNSON |
WASHINGTON |
|
LAWRENCE |
|
AGE |
PREPARATION AND EXAMINATION |
|
Birth to 1 month |
CHS (EPSDT) Screen, Immunizations |
|
1 to 2 months |
CHS (EPSDT) Screen, Immunizations & Oral Assessment |
|
2 to 4 months |
CHS (EPSDT) Screen, Immunizations & Oral Assessment |
|
4 to 6 months |
CHS (EPSDT) Screen, Immunizations & Oral Assessment |
|
6 to 9 months |
CHS (EPSDT) Screen, Immunizations 85 Oral Assessment |
|
9 to 12 months |
CHS (EPSDT) Screen, Immunizations 85 Oral Assessment |
|
12 to 15 months |
CHS (EPSDT) Screen, Immunizations 85 Oral Assessment |
|
15 to 18 months |
CHS (EPSDT) Screen, Immunizations 8g Oral Assessment |
|
18 months to 2 years |
CHS (EPSDT) Screen, Immunizations 8g Oral Assessment |
|
2 to 3 years - |
CHS (EPSDT) Screen, Immunizations 8& Oral AssessnieuL |
|
3 to 4 years |
CHS (EPSDT) Screen, Immunizations & Oral Assessment |
|
4 to 5 years |
CHS (EPSDT) Screen, Immunizations** and Oral Assessment |
|
5 to 6 years |
CHS (EPSDT) Screen, Immunizations & Oral Assessment |
|
6 to 8 years |
CHS (EPSDT) Screen, Oral Assessment |
|
8 to 10 years |
CHS (EPSDT) Screen, Oral Assessment |
|
10 to 12 years |
CHS {EPSDT) Screen, Immunizations & Oral Assessment |
|
12 to 14 years |
CHS (EPSDT) Screen, Immunizations & Oral Assessment |
|
14 to 16 years |
CHS (EPSDT) Screen, Immunizations 65 Oral Assessment |
|
16 to 18 years |
CHS (EPSDT) Screen, Oral Assessment |
|
18 to 21 years |
CHS (EPSDT) Screen, Oral Assessment |
** Arkansas state law requires the last dose of polio vaccine, DPT, DT, or TD to be administered after the child's 4th birthday.
Immunizations for childhood diseases do not require PCP referral.
Most medical and hearing screens for children residing in the counties listed in Section 214.1 require a PCP referral before the screens may occur. Routine newborn care, vision screens and dental screens do not require PCP referral. See Section 313.
Effective for dates of service on or after September 1, 1998, Child Health Services (EPSDT) Screens will not include laboratory procedures unless the screen is performed by the recipient's PCP or is conducted pursuant to a referral from the PCP.
The following tests are exempt from this limitation and may continue to be billed in conjunction with an EPSDT Screen performed in accordance with existing Medicaid policy:
81000 - Urinalysis, by dip stick or tablet reagent for bilirubin, glucose, hemoglobin, ketones, leukocytes, nitrite, pH, protein, specific gravity, urobilinogen, any number of these constituents; non-automated, with microscopy
81001 - Urinalysis, by dip stick or tablet reagent for bilirubin, glucose, hemoglobin,
ketones, leukocytes, nitrite, pH, protein, specific gravity, urobilinogen, any number of these constituents; automated, with microscopy
81002 - Urinalysis, by dip stick or tablet reagent for bilirubin, glucose,Iiemoglobin, ketones, leukocytes, nitrite, pH, protein, specific gravity, urobilinogen, any number of these constituents;non-automated, without microscopy
83020 - Hemoglobin, electrophoresis (eg, AZ, S, C)
83655 - Lead
85013 - Blood count; spun microhematocrit
85014 ~ Blood count; other than spun hematocrit
85018 - Blood count, hemoglobin
86580 - Skin test; tuberculosis, intradermal
86585 - Tuberculosis, tine test
Claims for laboratory tests, other than those specified above, performed in conjunction with an EPSDT Screen will be denied unless the screen is performed by the PCP or pursuant to a referral from the PCP.
The following screens will be affected by this policy:
Z0612 - EPSDT Screen, 0 through 20 years of age '
Z1652 - EPSDT Interperiodic Full Medical Screen
Z1638 - EPSDT Comprehensive health and developmental history (including Assessment of physical development) (Partial Medical Screen)
Z1640 - EPSDT Comprehensive Unclothed Physical Assessment (Partial Medical Screen)
Z1752 - Newborn 6-weeks check-up (Nurse Midwife)
Z1639 EPSDT Comprehensive health and development history (including Assessment of mental development) (Partial Medical Screen)
The child's immunization status should be assessed from the child's health record. If the child needs any immunization at the time of the screening, this should be performed as part of the screening process.
Recommended Childhood Immunization Schedule United States, January - December 1998
Click here to view image
NOTE: Tuberculin testing ^riust be performed at age 1 % years.
NOTE: Arltansas state law requires the last dose of polio vaccine, DPT, DT or TD to be after the child's 4'" birthday.
Arkansas Medicaid will only pay for the administration of immunizations included in the Vaccines for Childr6n (VFC) Program administered by the Arkansas Department of Health (ADH).
To enroll in the VFQ Program, providers may contact the Arkansas Department of Heklth at 1-800-574 -4040 toll-free or locally at 501-661-2723.
Recommended Childhood I mmunization Schedule Explanation
Infants born to HBsAg-positive mothers should receive 0.5 mL of hepatitis B immune globulin (HBIG)-W-ithin-l-2-hrs-ot-birth,-and-either-5-^g-of-Merck-vaccine-(Recombivax-,HB)-or-
10 fig of SB vaccine (Engerix-B) at a separate site. The 2"*^ dose is recommiended at 1-2 mos of age and the 3'"'^ dose at 6 mos of age.Infants born to mothers whose HBsAg status is unknown should receive either 5 )ag of Merck vaccine (Recombivax HB) or 10 (ig of SB vaccine (Engerix-B) within 12 hours of birth. The 2"'^ dose of vaccine is recommended at 1 mo of age and the 3^'^ dose at 6 mos of age. Blood should be drawn at the time of delivery to determine the mother's HBsAg status; if it is positive, the infant should receive HBIG as soon as possible (no later than 1 wk of age). The dosage and timing of subsequent vaccine doses should be based upon the mother's HBsAg status.
The ACIP recommends 2 doses of IPV at 2 and 4 mos of age followed by 2 doses of OPV .at 12-18 mos and 4-6 years of age. IPV is the only poliovirus vaccine'recommended for immunocompromised persons and"theii"household cont^rt^T" '.
A health and developmental history should be obtained from the parent or other responsible adult who is familiar with the child's health history. The child's height and weight should also be recorded and compared with the ranges considered normal for children of that age.
An unclothed physical examination should be performed to note obvious physical defects including orthopedic, genital, skin, and other observable deviations. If there is evidence that the child has been physically abused, this should be reported to the authorities according to state law requirements.
A developmental assessment should be obtained by history and observation of the qhild, or by , ^
one of the developmental tests. This portion of the screening could include assessriient of eye- Z
hand coordination, gross motor function (walking, hopping, climbing), fine motor skills (use of finger dexterity and hand usage), speech development, daily living personal skills such as dressing, feeding and grooming oneself, behavioral development, and proofs of mind with body integration.
A visual evaluation is required for all children receiving Child Health Services (EPSDT) screening. The age specific procedures (Section 215) may be helpful to determine the necessary procedures according to the child's age. This screening does not require Titmus machine or other opthalmological testing. Subjective testing may be provided as part of a vision screening.
A hearing evaluation is required for all children receiving a Child Health Services (EPSDT) screening. The age specific procedures (Section 217) may be helpful to determine the "necessary procedures according to the child's age. This screening does not require machine audiology testing. Subjective testing may be provided as part of a hearing screening.
An oral assessment is considered part of the full Child Health Services (EPSDT) screening, procedure codes Z0612 or Z1652. A referral to a dentist for an oral screen is offered beginning at birth of child.
Blood lead level testing should be performed for all children ages 1-5 and on older children as risk factors indicate (See Section 219). Children found to have lead poisoning must be diagnosed and treated. Treatment will include environmental evaluation to identify the source(s} of the lead and periodic reevaluation.
Laboratory procedures should be performed as appropriate for the child's age and population group. A hematocrit or hemoglobin test is recommended for children five (5) years of age and older. Urinalysis is recommended at intervals beginning at age 6 months. AH children between the ages of 6 months and 6 years are required to receive blood lead tests (see Section 219). Other laboratory procedures are to be performed when deemed appropriate by the child's age and/or health history (i.e., sickle cell, anemia, tuberculin, pap smear).
-^Physical-and-laboratory-^determinations-eairied-GUt-in-the-sereening-proeess-will-usually-jdeld-^---^-----
information useful in assessing nutritional status. A child having any detectable nutritional deficiencies should be treated or referred to the proper resource for counseling. : This component of the medical screen is included in the full Child Health Services (EPSDT) screening, procedure codes Z0612 or Z1652.
Health education is a required component of screening services and includes anticipatory guidance. The developmental assessment, comprehensive physical examination, visual, hearing or dental screening provides the initial opportunity for providing health education. Health education and counseling to parents (or guardians) and children are required. Health education and counseling are designed to assist in understanding what to expect in^ terms of the child's development and to provide information about the benefits of healthy lifestyles and practices, as well as accident and disease prevention.
NOTE: The four components designating a partial screen (Z1638, Z1639, Z1640, Z1644) constitute a full Child Health Services screen and are never billed in conjunction with complete screening services. (Periodic = Z0612, Interperiodic = Z1652, Newborn = Z1209)
The exemplary age specific Child Health Services (EPSDT) medical screening procedures are to indicate the scope and depth of the Child Health Services (EPSDT) screening components and the frequency in which these services should be performed. These guidelines are not to be substituted for the physician's or other screener's judgment as to the kinds of services required for individual circumstances. The following are suggested screening schedule components for specific age ranges. If a child comes under care for the first time at any point on the schedule or if any items are not completed by the suggested age, the schedule should be brought up to date at the earliest possible time.
HISTORY (Initial/Interval) to be performed (Ages 1, 2, 4, 6, 9, 12 months) -MEASUREMENTS-to-be-perfor-med------------------------------------------------------------------------------------------------
* Height & Weight (Ages 1, 2, 4, 6, 9, 12 months) ,,;^
* Head Circumference (Ages 1, 2, 4, 6, 9, 12 months)
SENSORY SCREENING subjective, by history
* Vision (Ages 1, 2, 4, 6, 9, 12 months)
* Hearing (Ages 1, 2, 4, 6, 9, 12 months)
DEVEL. /BEHAV. ASSESSMENT to be performed (Ages 1, 2, 4, 6, 9, 12 months)
By history and appropriate physical examination: if suspicious, by specific objective developmental testing.
PHYSICAL EXAMINATION to be performed (Ages 1, 2, 4, 6, 9, 12 months). At each visit, a complete physical examination is essential with the infant totally unclothed.
PROCEDURES - These may be modified depending upon entry point into schedule and individual need.
* Hered. /Metabolic Screening to be performed (Age 1 month). Metabolic screening (e.g., thyroid, PKU, galactosemia) should be done according to state law.
* Immunization(s) to be performed (Ages 2, 4, 6 months). See Section 215.12.
* Tuberculin Test to be performed (Age 12 months). For low risk groups the following options are recommended:
For high risk groups, annual TB skin testing is recommended.
* Hematocrit or Hemoglobin to be performed (Age 9 months). Present medical evidence suggests the need for reevaluation of the frequency and timing of hemoglobin or hematocrit tests. One determination is therefore suggested during each time period. Performance of additional tests is left to the individual practice experience.
* Blood lead level testing should be performed according to the criteria found in Section 215.27 and Section 219.
* Urinalysis to be performed (Age 6 months). Present medical evidence suggests the need for reevaluation of the frequency and timing of urinalysis. One determination is therefore suggested during each time period. Performance of additional tests is left to the individual practice experience.
-HE-AtT-H-E-DUGATIQN-(ANT-ieiPAT0RY-GUIDANGE-)-to-be-per-formed-(Ages-l-2^4^6 -------------
months). Appropriate discussion and counseling should be an integral part of each visit......
HISTORY (Initial/Interval) to be performed (Ages 15, 18, 24 months; 3, 4 years) MEASUREMENTS to be performed
* Height and Weight (Ages 15, 18, 24 months; 3, 4 years)
* Blood Pressure (Ages 3, 4 years)
SENSORY SCREENING
* Vision-subjective, by history, ages 15, 18, 24 months. Objective, by a standard testing method, age 3 years (Refer to Section 216).
+ Hearing-subjective, by history, ages 15, 18, 24 months. Objective, by a standard testing method, age 3 years (Refer to Section 217).
DEVEL. /BEHAV. ASSESSMENT to be performed (Ages 15, 18, 24 months; 3, 4 years). By history and appropriate physical examinations: if suspicious, by specific objective developmental testing.
PHYSICAL EXAMINATION to be performed (Ages 15, 18, 24 months; 3, 4 years). At each visit, a complete physical examination is essential, with infant totally unclothed, older child undressed and suitably draped.
PROCEDURES - These may be modified, depending upon entry point into schedule and individual need.
* Immunization(s) to be performed (Ages 15, 18, 24 months). See Section 215.12.
* Tuberculin Test to be performed (Age 24 months). For low risk groups the following options are recommended
For high risk groups, annual TB skin testing is recommended.
* Hematocrit or Hemoglobin to be performed (Age 24 months). Present medical eyidence suggests the need for reevaluation of the frequency and timing of hemoglobin or hematocrit tests. One determination is therefore suggested during each time period. Performance of additional tests is left to the individual practice experience.
*Blood-lead-level-testing-should-be-per-formed-according-to-the-criteria-found-in Section 215.27 and Section 219. : ,.
* Urinalysis to be performed (Age 24 months). Present medical eyidence suggests the need for reeyaluation of the frequency and timing of urinalysis. One determination is therefore suggested during each time period. Performance of additional tests is left to the individual practice experience.
HEALTH EDUCATION (ANTICIPATORY GUIDANCE) to be performed (Ages 15, 18, 24 months; 3, 4 years). Appropriate discussion and counseling should be an integral part of each visit.
INITIAL DENTAL REFERRAL to be performed (during the first year). Subsequent examinations as prescribed by dentist and recommended by the Child Health Services (EPSDT) dental schedule. (Refer to Section 218)
* Height and Weight (Ages 5, 6, 8, 10, 12 years)
* Blood Pressure (Ages 5, 6, 8, 10, 12 years)
SENSORY SCREENING
* Vision-objective, by a standard testing method (Ages 5, 6, 10, 12 years). (Refer to Section 216)
* Hearing-objective, by a standard testing method (Ages 5, 6, 7, 8, 12 years), (Refer to Section 217)
DEVEL. /BEHAV. ASSESSMENT to be performed (Ages 5, 6, 8, 10, 12 years). By history and appropriate physical examinations: if suspicious, by specific objective developmental testing.
PHYSICAL EXAMINATION to be performed {Ages 5, 6, 8, 10, 12 years). At each visit, a complete physical examination is essential with child undressed and suitably draped.
PROCEDURES - These may be modified, depending upon entry point into schedule and individual need.
* Immunization(s) to be performed (Age 5 years). See Section 215.12.
* Hematocrit or Hemoglobin to be performed (Age 8 years). Present medical evidence suggests the need for reevaluation of the frequency and timing of hemoglobin or hematocrit tests. One determination is therefore suggested during each time period. Performance of additional tests is left to the individual practice experience.
------------^---------^Blood-lead"level testing-should-be-performed-as-indicated-by-risk-factorsat-------------
higher ages.
* Urinalysis to be performed (Age 8 years). Present medical evidence suggests the need for reevaluation of the frequency and timing of urinalysis. One determination is therefore suggested during each time period. Performance of additional tests is left to the individual practice experience.
DENTAL REFERRAL to be performed once per State Fiscal Year (SFY). (Refer to Section 218)
HEALTH EDUCATION/ANTICIPATORY GUIDANCE to be performed (Ages 5, 6, 8, 10, 12 years). Appropriate discussion and counseling should be an integral part of each visit for care.
Adolescent related issues (e.g., psychosocial, emotional, substance usage, and reproductive health) may necessitate more frequent health supervision.
MEASUREMENTS to be performed
* Height and Weight (Ages 14,16, 18 years)
* Blood Pressure (Ages 14, 16, 18 years)
SENSORY SCREENING
* Vision-objective by a standard testing method (ages 16, 18 years). (Refer to Section 216)
+ Hearing-objective by a standard testing method (ages 16, 18 years). (Refer to Section 217)
DEVEL. /BEHAV. ASSESSMENT to be performed (Ages 14, 16, 18 years). By history and appropriate physical examinations: if suspicious, by specific objective developmental testing.
PHYSICAL EXAMINATION to be performed (Ages 14, 16, 18, 20 years). At each visit, a complete physical examination is essential, with child undressed and suitably draped.
PROCEDURES - These may be modified, depending upon entry point into schedule and individual need.
* Immunization(s) to be performed (Ages 14 years). See Section 215.12.
* Tuberculin Test to be performed (Age 18 years). For lovtr risk groups the following options are recommended:
For high risk groups, annual TB skin testing is recommended.
* Hematocrit or Hemoglobin to be performed (Age 18 years). Present medical evidence suggests the need for reevaluation of the frequency and timing of hemoglobin or hematocrit tests. One determination is therefore suggested during each time period. Performance of additional tests is left to the individual practice experience.
* Urinalysis to be performed (Age 18 years). Present medical evidence suggests the need for reevaluation of the frequency and timing of urinalysis. One determination is therefore suggested during each time period. Performance of additional tests is left to the individual practice experience.
HEALTH EDUCATION/ANTICIPATORY GUIDANCE to be performed (Ages 14, 16, 18,..20 years). Appropriate discussion and counseling should be an integral part of each visit. , "_
Administer an age-appropriate vision assessment. (Periodic = Z1636, Interperiodic = Z1642)
Vision services are subject to their own periodicity schedule. However, where the periodicity schedule coincides with the schedule for medical screening services, you may include vision screens as a part of the required minimum medical screening services. Vision screens are exempt from the PCP referral requirement.
Vision Periodicily Schedule:
|
Newborn - 5 |
One vision screen |
|
Age 5-6 |
One vision screen |
|
Age 6 - 10 |
One vision screen |
|
Age 10 - 12 |
One vision screen |
|
Age 12 - 16 |
One vision screen |
|
Age 16 - 18 |
One vision screen |
|
Age 18-21 |
One vision screen |
Vision Services
At a minimum, includes diagnosis and treatment for defects in vision, including eyeglasses.
Administer an age-appropriate hearing assessment. Consult with audiologists or the Department of Health or Department of Education to obtain appropriate procedures to use for screening and methods of administrating the screens. {Periodic = Z1637, Interperiodic = Z1643). This includes, at a minimum, diagnosis and treatment for defects in. hearing, including hearing aids.
Hearing services are subject to their own periodicity schedule. However, where the periodicity schedule coincides with the schedule for medical screening services, you may include hearing screens as a part of the required m.inimum medical screening services. A PCP referral must be obtained before initiating a hearing screen in the 25 counties listed in Section 214.1.
Hearing Periodicity Schedule:
|
Newborn - 5 |
One hearing screen |
|
Age 5-6 |
One hearing screen |
|
Age 6 - 7 |
One hearing screen |
|
Age 7 - 8 |
One hearing screen |
|
Age 8 - 12 |
One hearing screen |
|
Age 12 - 16 |
One hearing screen |
|
Age 16 - 18 |
One hearing screen |
|
Age 18-21 |
One hearing screen |
Although an oral assessment may be part of a medical screen, it does not substitute for examination through direct referral to a dentist. A direct dental referral is required for every child once per State Fiscal Year (July 1 through June 30). This visit will be billed as Procedure Code 00110 EPSDT Dental Screen (formerly known as EPSDT Initial Dental Screen-a.k.a. Initial Oral Exam.
Effective September 1, 1998, Procedure Code 00120 (EPSDT Periodic Dental Screen) is non-payable.
A Child Health Services (EPSDT) Interperiodic Dental Screen may be completed as often as medically necessary. However, eifective September 1, 1998, this procedure code (Z1641) must be prior authorized in order for the claim to be paid. Refer to Section 220 for an explanation of the prior authorization process.
Dental screens are exempt from the Primary Care Provider (PCPl referral requirement-Dental Services - At a minimum, include relief of pain and infections, restoration of teeth and maintenance of dental health. Dental services may not be limited to emergency services. The periodicity schedule for other EPSDT services may not govern the schedule for dental services.
A child should receive his/her first dental screen examination within 6 months after eruption of the first primary tooth but no later than 12 months of age.
All children from age six (6) months to six (6) years of age are considered to be at risk and must be screened for blood lead poisoning. Blood lead tests are required for all children at twelve (12) months of age and again at twenty-four (24) months of age, regardless of the child's risk assessment level. A screening blood test also is required for any Medicaid-eligible child 36 to 72 months of age who has not previously been screened for lead poisoning. The blood lead test is required when screening children for lead poisoning (Section 215.27).
NOTE: The erythrocyte protoporphryn test is no longer acceptable as a screening test.
Risk Assessment
Beginning at six (6) months of age and at each visit thereafter, the CHS/EPSDT provider must discuss childhood lead poisoning interventions with the child's parents or guardian and must verbally ask the following questions as part of an EPSDT screen:
^ j^_____,,__j_.j_j_j.,,__.__^
your child's daycare, preschool, headstart center or babysitter's home built before 1960? Does the house or building have peeling or chipping paint?
* Does your child live in a house built before 1960 with recent, on-going or planned renovation or remodeling?
* Have any of your children or their playmates had lead poisoning?
* Does your child frequently come in contact with an adult who works with lead, i.e., construction, welding, pottery or other trades practiced in the child's community where lead is used?
* Does your child live near a lead smelter, battery recycling plant or other industry " likely to release lead, such as ... (give any examples in your community)?
* Do you give your child any home or folk remedies which may contain lead?
* Does your child live near a heavily traveled major highway where soil and dust may be contaminated with lead?
* Does your home's plumbing have lead pipes or copper with lead solder joints?
* Ask any additional questions which may be specific to situations that exist in a particular community.
The child's EPSDT record must be documented to reflect that these questions were verbally asked at each complete periodic screen between ages six (6) months and six (6) years.
Determining Risk
Risk is determined from the response to the questions on the verbal risk assessment.
If the answers to all questions are negative, a child is considered low-risk for high doses of lead exposure. Children considered as low-risk must receive blood lead screenings at twelve (12) months and twenty-four (24) months of age.
If the answers to any question is positive, a child is considered high-risk for high doses of lead exposure. A blood test m.ust be obtained at the time the child is determined to be high-risk.
Subsequent verbal risk assessments may redetermine a child's risk category. In the event a child previously categorized as low-risk is redetermined as high-risk; the child must be given a blood lead test._________________________________________________________________________________
Screening Blood Tests
Screening blood tests are blood tests for children who have not previously been tested for lead poisoning with a blood lead test or who have previously been tested and found not to have an elevated blood level.
Children determined to be low-risk must be given screening blood tests at twelve (12) months and twenty-four (24) months of age.
Children determined to be high-risk must be given screening blood tests beginning at six (6) months of age. A screening blood test is required at every visit prescribed in the CHS/EPSDT periodicity schedule through 72 months of age (unless the child received a blood lead test within the last six (6) months of the periodic visit) when initial blood lead test results are less than 10 micrograms per deciliter (ug/dl). Blood lead test results equal to or greater than 10 ug/dl obtained by a capillary specimen must be confirmed by a venous blood sample.
Children between the ages of twenty-four (24) months and six (6) years who have not received a screening blood lead test, must receive one im.mediately regardless of their risk level.
Diagnosis, Treatment and Follow-up
In the event a child is found to have blood lead levels equal to or greater than 10 ug/dl, providers are to use their professional judgement with reference to Centers for Disease Control recommendations for preventing lead poisoning in young children.
Billing
I See Section 313 for specific billing instructions.
Prior authorization is required for procedure code Z1641, interperiodic dental screen. Prior authorization for procedure code Z1641 must be requested on the ADA claim form. Refer to the Dental provider manual for details regarding the prior authorization process.
Reimbursement for Child Health Services (EPSDT) screens, immunizations, and lab procedures is based on the lesser of the billed amount or the Medicaid maximum.
A provider may request reconsideration of a Program decision by writing to the Assistant Director, Division of Medical Services. This request must be received within 20 calendar days following the application of policy and/or procedure or the notification of the provider of its rate. Upon receipt of the request for review, the Assistant Director will determine the need for a Program/Provider conference and will contact the provider to arrange a conference if needed. Regardless of the Program decision, the provider will be afforded the opportunity for a conference, if he/she so wishes, for a full explanation of the factors involved and the Program decision. Following review of the matter, the Assistant Director will notify the provider of the action to be taken by the Division within 20 calendar days of receipt of the request for review or the date of the Program/Provider conference.
If the decision of the Assistant Director, Division of Medical Services is unsatisfactory, the provider may then appeal the question to a standing Rate Review Panel established by the Director of the Division of Medical Services which will include one member of the Division of Medical Services, a representative of the provider association and a member of the Department of Human Services (DHS) Management Staff who will serve as chairman.
The request for review by the Rate Review Panel must be postmarked within 15 calendar days following the notification of the initial decision by the Assistant Director, Division of Medical Services. The Rate Review Panel will meet to consider the question(s) within 15 calendar days after receipt of a request for such appeal. The questiori(s) will be heard by the panel and a recommendation will be submitted to the Director of the Division of Medical Services.
Click here to view image
Steps For Obtaining Provider Number
For school districts who wish to become Arkansas Medicaid Providers, and be reimbursed for Medicaid-eligible children receiving EPSDT {Early, Periodic, Screening, Diagnosis, and Treatment) screens, the steps for applying for a provider number are as follows:
Department of Human Services Provider Enrollment Number
-----------------------------------------P.G^^O5^443^Slol^W04------------------------------------------------------------------------
Little Rock, AR 72203
Phone: (501) 682-8323
Health and Nursing Services Specialist Arkansas Department of Education 2020 West Third, Suite 320 Little Rock, AR 72205
Phone: (501) 324-9740
Click here to view image
Claims for EPSDT medical screenings must be billed on claim SS-694, or through the Automated Eligibility Verification and Claims Submission (AEVCS) system.
Z0612 EPSDT Screen, 0 through 20 years of age
Z1209* Newborn Care/EPSDT Screen in hospital including physical examination of baby and conferences with parents - global fee. Z1636* EPSDT Periodic Vision Screen
Z1637 EPSDT Periodic Hearing Screen
Z1638 EPSDT Comprehensive health and developmental history (including assessment of physical development) (Partial Medical Screen) Z1639 EPSDT Comprehensive health and developmental history (including assessment of mental development) (Partial Medical Screen).
Z1640 EPSDT Comprehensive Unclothed Physical Assessment (Partial Medical Screen)
Z1641* EPSDT Interperiodic Dental Screen, with prior authorization
Z1642* EPSDT Interperiodic Vision Screen
Z1643 EPSDT Interperiodic Hearing Screen
Z1644 EPSDT Health Education (Partial Medical Screen)
Z1652 EPSDT Interperiodic Full Medical Screen
Z1913 Venipuncture, when required for Venous Blood Lead Test
83655 Blood Lead Test (billed by lab perform.ing the test)
99432* Newborn care, in other than hospital setting, including physical examination of baby and conference(s) with parent(s)
00110* EPSDT Dental Screen
Z1751* Routine Newborn care (Nurse-Midwife)
Z1752 Newborn 6-weeks check-up (Nurse-Midwife)
Effective for dates of service on or after April 1, 1998, Medicaid eligible recipients residing in the counties listed in Section 214.1 are subject to the Primary Care Physician (PCP) referral requirement.
* Exempt from PCP referral requirements.
Immunizations for childhood diseases are exempt from PCP referral requirements.
Procedure codes Z0612, Z1209, Z1652 and 99432 represent a full medical screen. Immunizations and laboratory tests may be billed separately. See NOTE on page III-32.
The verbal assessment of lead toxicity risk is part of the complete CHS/EPSDT screen. The cost for the administration of the risk assessment is included in the fee for the complete screen.
NOTE:' Lab/X-ray and immunizations (not subject to Vaccines For Children [VFC] requirements) associated with Child Health Services (EPSDT) screen may be billed on the SS-694. Child Health Services fEPSDTl screening services must be billed with a tvpe of service "6." Immunizations must be billed with a type of service " 1". All Child Health Services (EPSDT) procedure codes must be billed on the SS-694 claim form with the following exceptions:
Immunizations subject to the VFC requirements must be billed on the Automated Eligibility Verification and Claims Submission (AEVCS) system. These charges cannot be billed on the SS-694.
Procedure codes Z1636, Z1642 and Z1644 may be billed on either the SS-694 or the SS-26V. Procedure codes 00110 and Z1644 may be billed on either the SS-694 or the ADA claim form.
-^ior-authorization-for-proGedure--Gode-Zi641--rnust-be-requested-on-the-ADA-elairn-forih^-------------
Procedure code Z1641 for a Dental Screen must be billed on the ADA claim form.
Procedure codes 99201 through 99215 (Office Medical Services), 99341-99353 (home medical services) and 99221-99223 (hospital inpatient medical services) are non-allowable procedure codes on the SS-694. These codes must be billed in the HCFA-1500 format.
Providers are not limited to diagnosis codes V20.0, V20.1, V20.2 and V79.3 when billing EPSDT screening codes.
Providers billing the Arkansas Medicaid Program for immunizations should bill the appropriate CPT-4 or locally assigned procedure code for the specific immunization. The immunization procedure codes and descriptions may be found in the CPT-4 book. Providers may bill the immunization procedure codes on either the Child Health Service (EPSDT) claim form, 85-694, the HCFA-1500, or electronically through the Automated Eligibility Verification and Claims Submission (AEVCS) system.
Notes
State regulations are updated quarterly; we currently have two versions available. Below is a comparison between our most recent version and the prior quarterly release. More comparison features will be added as we have more versions to compare.