23 Miss. Code. R. 223-1.6 - Documentation Requirements for Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) Screenings

A. The medical record must include, at a minimum, documentation of the specific age appropriate screening requirements according to the American Academy of Pediatrics (AAP) Bright Futures Periodicity Schedule including the date the test or procedure was performed, the specific tests or procedures performed, the results of the tests or procedures or an explanation of the clinical decision to not perform a test or procedure in accordance with the AAP Bright Futures Periodicity Schedule, and documentation of the following:

1. Consent for screening with the beneficiary's and/or legal guardian/representative's signature,

2. Beneficiary and family history with appropriate updates at each screening visit, including, but not limited to, the following:

a) Psychosocial/behavioral history,

b) Developmental history, and

c) Immunization history,

3. Measurements, including, but not limited to:

a) Length/height and weight,

b) Head circumference,

c) Weight for length percentiles,

d) Body mass index (BMI), and

e) Blood pressure,

4. Sensory screenings, subjective and/or objective:

a) Vision, and

b) Hearing,

5. Developmental/behavioral assessment, as appropriate, including:

a) Developmental screening to include, but not limited to:

1) A note indicating the date the test was performed,

2) The standardized tool used which must have:

(a) Motor, language, cognitive, and social-emotional developmental domains,

(b) Established reliability scores of approximately 0.70 or above,

(c) Established validity scores of approximately 0.70 or above for the tool conducted on a significant amount of children and using an appropriate standardized developmental or social-emotional assessment instrument, and

(d) Established sensitivity/specificity scores of approximately 0.70 or above, and

3) Evidence of a screening result or screening score,

b) Autism screening,

c) Developmental surveillance,

d) Psychosocial/behavioral assessment,

e) Tobacco, alcohol and drug use assessment,

f) Depression screening, and

g) Maternal depression screening.

6. Unclothed physical examination,

7. Procedures, as appropriate, including, but not limited to:

a) Newborn blood screening,

b) Vaccine administration, if indicated,

c) Anemia testing,

d) Lead screening and testing,

e) Tuberculin test, if indicated,

f) Dyslipidemia screening,

g) Sexually transmitted infection screening,

h) Human immunodeficiency virus (HIV) testing,

i) Cervical dysplasia screening, and

j) Other pertinent lab and/or medical tests, as indicated,

8. Oral health, including:

a) Dental assessment,

b) Dental counseling, and

c) Referral to a dental home at the eruption of the first tooth or twelve (12) months of age,

9. Anticipatory guidance, including, but not limited to:

a) Safety,

b) Risk reduction,

c) Nutritional assessment, and

d) Supplemental Nutrition Assistant Program (SNAP) and Women, Infants and Children (WIC) status,

10. Appropriate referral(s) to other enrolled Mississippi Medicaid providers for diagnosis and treatment,

11. Follow-up on referral(s) made to other enrolled Mississippi Medicaid providers for diagnosis and treatment,

12. Next scheduled EPSDT screening appointments, and

13. Missed appointments and any contacts or attempted contacts for rescheduling of EPSDT screening appointments.

B. Medical records must be available to the Division of Medicaid and/or designated entity upon request. [Refer to Maintenance of Records Miss. Admin. Code Part 200, Rule 1.3]

Notes

23 Miss. Code. R. 223-1.6

Miss. Code Ann. §§ 43-13-117, 43-13-118, 43-13-121, 43-13-129.

Revised to correspond with SPA 2015-017 (eff. 11/01/2015) Amended 10/1/2016 Amended 12/1/2018