EPSDT / HealthCheck
MCO Provider Training
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available at
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Total number of DC Medicaid EPSDT
eligible members (children under 21):
80,339
Total number of DC Medicaid Primary Care
Providers:
354
Medicaid EPSDT Services Benefit
Medicaid is a joint federal-state partnership program
administered by the Centers for Medicare &
Medicaid Services (CMS).
Congress enacted the Early and Periodic, Screening,
Diagnostic, and Treatment (EPSDT) services benefit
as part of the federal Medicaid Program.
• Defined the benefit in 1967 and expanded it in
1989
Medicaid EPSDT Services Benefit
EPSDT entitles all Medicaid enrolled children (birth –
21 years) to a comprehensive benefit package which
includes screenings, preventive health care, and
medically necessary diagnosis and treatment
• Assures availability and accessibility of required
health resources
• Helps Medicaid beneficiaries and their caregivers
effectively use these resources
EPSDT Services
EPSDT mandates the following Early and Periodic preventive health
services:
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Screening services
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


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Comprehensive health and developmental history (physical, mental, and developmental)
Comprehensive unclothed physical exam
Appropriate immunizations (per ACIP)
Laboratory tests, including mandatory lead screening
Vision screening
Hearing screening
Dental screening
Other necessary health care
cont. next slide
EPSDT Services, cont.
EPSDT mandates the following preventive health services:

Diagnostic services, if needed for further evaluation. If screenings indicate need for further
evaluation, diagnostic services must be provided. Referrals should be made without delay,
including follow-up to ensure that a diagnostic evaluation is received. If you have difficulty
finding information on where to refer, call the Office of the Ombudsman 877-685-6391.

Treatment (or referrals) to correct or improve health conditions. All Medicaid-enrolled
children should receive comprehensive EPSDT treatment services, including:
developmental services, eyeglasses, hearing aids, orthodontia, wheelchairs and prosthetic
devices, occupational and physical therapy, prescribed medical formula and nutritional
supplements, assistive communication devices, personal care, therapeutic behavioral services
(TBS), behavioral rehabilitation, home health, speech therapy, and substance abuse treatment.
For for the full scope of services covered under HealthCheck, see Medicaid's EPSDT Scope
of Benefits
Health Education
Required component of screening services – includes anticipatory guidance
Health education and counseling to both parents and children is required
– Assist in understanding age-appropriate developmental issues
– Provide information on benefits of healthy lifestyles and practices, including
regular dental care
– Accident and disease prevention
Additional Health Education resources, including anticipatory guidance cards, can be
found in the Resource section at www.dchealthcheck.net.
Blood Lead Testing
Childhood lead poisoning is the most common environmental disease in children
younger than 6 years of age in the United States.
Lead testing and prompt intervention in early childhood help reduce the risk of learning
disabilities, attention deficits, hyperactivity, and behavioral disorders caused by
elevated lead levels.
Only a small percentage of children in the District are documented to be receiving
blood lead tests at the appropriate intervals. In response to this, the District is
committed to improving this percentage.
cont. next slide
Blood Lead Testing, cont.
Lead screening periodicity and guidelines can be summarized on
the next slide.
For more information, contact the DC Lead Poisoning Prevention
Division at (202) 535-2634 or 535-1394.
Blood Lead Testing, cont.
All children covered under Medicaid should receive 2 blood lead tests.
District law requires all Medicaid-enrolled children receive a lead test at
least twice: first between ages 9 and 14 months, and a second time between
ages 22 and 26 months. This also complies with federal law that requires tests
at 12 and 24 months for all children covered under Medicaid.
In addition, if there is no documentation of previous lead screening, federal
law requires that all Medicaid-eligible children between the ages of 36 and
72 months of age also receive a screening blood lead test.
All other children 36-72 months require a test unless assessed as low lead risk.
Lead level of concern: greater than or equal to 10 ug/dL.
Vision and Hearing Services
Vision
Diagnosis and prescription for defects in vision including eyeglasses
Vision services must be provided according to DC’s periodicity
schedule
Hearing
Diagnosis and prescription for defects in hearing including hearing aids
Hearing services must be provided according to DC’s periodicity
schedule
Dental Services
Oral screening must be part of every well-child physical exam, but should not be seen
as a substitute for an exam by a dentist.
An oral assessment should be done by the primary care physician/pediatrician up to
age 3. Every Medicaid-enrolled infant should receive an oral health risk assessment
from his/her primary health care provider or qualified health care professional by 6
months of age that includes: (1) assessing the patient’s risk of developing oral disease
using the AAPD Caries-risk assessment tool; (2) providing education on infant oral
health; and (3) evaluating and optimizing fluoride exposure.
All Medicaid-enrolled children should be referred to a dentist for the establishment of
a dental home within 6 months after the first tooth erupts, or 12 months of age
(whichever comes first). Providers should encourage families to take their child to a
dentist every 6 months.
cont. next slide
Dental Services, cont.
The oral assessment done by the primary care physician/pediatrician
should not be in place to a visit to a dentist, and should include the
importance of oral care and a referral to a dentist.
For assistance in finding a dentist and scheduling an appointment,
caregivers should be encouraged to call the Dental Helpline: 866758-6807.
Other Necessary Health Care
Provide for other necessary health care, diagnostic services,
treatment, and other measures (as described further in the
Medicaid statute) to correct or ameliorate defects and physical
and mental illnesses and conditions discovered by the
screening services, whether or not such services are covered
by the State plan.
To learn more about services covered under
HealthCheck/EPSDT, see www.dchealthcheck.net.
EPSDT in DC = HealthCheck
EPSDT incorporated into MCO contracts with expectations and penalties
HealthCheck provides each Medicaid-enrolled child with a medical home in DC
Additional HealthCheck goals are to:
– Improve knowledge of the external review of DC's Medicaid managed care
program
– Help satisfy the requirements of the Salazar court mandates –Target goal of
80% EPSDT Compliance
• Required reporting and documentation of HealthCheck services
2009 EPSDT Compliance Ratio for DC: 68%
Why is EPSDT/HealthCheck
Important?
Collaboration: CMS, state Medicaid agencies, and EPSDT providers have a shared
obligation to ensure comprehensive pediatric preventive care for eligible children and
teens, and to support their families in accessing the health services available through
EPSDT.
Scheduling: Develop an approved schedule of preventive health visits at regular
intervals that meet reasonable standards of medical practice, including intervals for
vision, hearing, and dental screening services. See www.dchealthcheck.net for the most
up-to-date schedules of services.
Screening: Assess child health needs through initial and periodic examinations and
evaluations
Diagnose and Treat: Identify health problems for early diagnosis and treatment –
before the child’s health issues become more complex and treatment more costly.
Tools Required for
EPSDT/HealthCheck Visit
• Blood pressure cuffs (size appropriate)
• Eye vision screening tool available
• Audiometer
• Thermometer
• Scales appropriate for age to measure weight
• Device/tool to measure height
• Ophthalmoscope
• Otoscope
• Exam table with paper
• Percussion hammer
• Stethoscope
• Exam gown for older children
Providers will make available to patients health educational materials:
• Educational materials evident
• Education materials available in languages appropriate for patient population
• Explanation of EPSDT services provider orally and in writing to patients
All provider who immunize children shall participate in the Vaccines for Children Program
Keep VFC vaccines separate from private insurance vaccines
EPSDT Periodicity Schedule
DC is based on AAP and AAPD periodicity schedules, with
consultation….
These are available at:
www.dchealthcheck.net/resources/healthcheck/periodicity.html
HealthCheck follows CDC’s ACIP
Recommended Childhood and Adolescent
Immunization Schedules.
These are available at:
www.dchealthcheck.net/resources/pediatric/im
munizations.html
EPSDT Billing
Office Visit Codes
The following office visit codes are used to bill for EPSDT visits and are age
specific. There are also different codes to distinguish between new and
established patients.
Managed Care Organizations and DHCF use the data submitted on claims to
evaluate and monitor EPSDT care in the District, so it is especially important that
the claims are complete and accurate.
EPSDT Billing
Billing Codes are online at www.dchealthcheck.net/training/documentation/codes.html
New Patient
99381
99382
99383
99384
99385
Infant under 1 year of age
Early Childhood – age 1 to 4 years
Late Childhood – age 5 to 11 years
Adolescent – age 12 to 17 years
Age 18 to 22 years
Established Patient
99391
99392
99393
99394
99395
Infant under 1 year of age
Early Childhood – age 1 to 4 years
Late Childhood – age 5 to 11 years
Adolescent – age 12 to 17 years
Age 18 to 22 years
EPSDT Billing
Immunization codes
Administration of immunizations only
Codes for administration 90465-90474
Codes for vaccine rejected 90476-90749
90700
90701
90702
90703
90707
90712
90716
90718
90720
90744
Diphtheria, Tetanus Toxoids and Acellular Pertussis vaccine (DTap)
Diphtheria, Tetanus Toxoids and Pertussis vaccine (DTP)
Diphtheria and Tetanus Toxoids
Tetanus Toxoid
Measles, Mumps and Rubella virus vaccine, live (MMR)
Poliovirus vaccine, live, oral (any type)
Varicella (chicken pox) vaccine
Tetanus and Diphtheria Toxoids absorbed, for adult use (Td)
Diphtheria, Tetanus Toxoids and Pertussis (DTP) and Hemophilus Infuluenza B (HIB) vaccine
Immunization, active, Hepatitis B vaccine; newborn to 11 years
EPSDT Billing
Billing Codes are online at www.dchealthcheck.net/training/documentation/codes.html
Lab codes
85013
85014
85018
83655
81000
86580
Hemoglobin
Hemocrit
Hemoglobin
Lead screen
Urinalysis
TB Test, Intradermal
86585 TB Test, Tine Test
83718 Cholesterol, HDL
83719 Cholesterol, Direct
85660 Sickle Cell
99000-99001 Specimen Handling
EPSDT Billing
Provide well care during sick visit. Both visit codes can be billed
using modifier 25 with the regular office visit.
For example: 99213 with a modifier 25 and 99391.
Access Standards Required by MCO Contracts
Type of Appointment
Standard
Emergency care [life threatening]
Immediately at the nearest facility
Urgent care or Sick Care Appointments w/PCP
Within 24 hours of request
Urgent Care with a Specialist
Within 48 hours of referral
Routine Appointments [including Health Check and
IDEA appointments]
Within 30 days of request
Initial Appointments for pregnant women or persons
needing family planning
Within 10 days of request
Routine Physical Examination
Within 30 days of request
Waiting Time in Practitioner’s office
Not to exceed 1 hour
Use of free interpreter services
As needed during all appointments
Behavioral Health Access Standards
Type of Appointment
Standard
Behavioral Health Emergency care [life
threatening]
Immediately at the nearest facility
Behavioral Health Telephone Crisis Triage
Within 15 minutes over the telephone
Psychiatric Intervention or face-to-face Assessment
Within 90 minutes of completion of telephone assessment
[when needed] and available on a 24 hours basis 7 days a
week
Treatment for non-life threatening emergency
Treated as emergency care
Routine Behavioral Health Appointments
Within 10 days of request
Waiting Time in Practitioner’s office
Not to exceed 1 hour
Use of free interpreter services
As needed during all appointments
Access to After Hours Care
Type of Appointment
Standard
Emergency Care
Call 911 and/pr go to the nearest facility
immediately
Urgent non-medical emergency where care is needed
before business hours
Provide a telephone number for the covering
practitioner
Urgent non-medical emergency where care is not needed
until business hours
Advise member to call during business hours
Resources
Chartered Health Plan – EPSDT Manager, Christina Bristol (202) 216-2317
Unison Health Plan – EPSDT Manager, Jenine Woodward (202) 218-7884
Health Services for Children with Special Needs (HSCSN) – EPSDT Manager,
B.J. Wolf (202) 495-7538
DC Department of Health Care Finance – EPSDT Coordinator,
Colleen Sonosky (202) 442-5913
Web Sites
INCLUDE:
www.dchealthcheck.net Provider Education Site
www.aap.org
www.aapd.org
www.brightfutures.org
www.chartered-health.com
http://www.hscsn-net.org
www.unisonhealthplan.com
Provider Questions or Further
Training Requests
Chartered Health Plan – Director of Provider Network
Athena Cross-Edge (202) 552-3748
Health Services for Children with Special Needs – Director of Provider Services
Terri Hunt (202) 495-7587
Unison Health Plan – Director of Provider Network Management
Marci Jones (202) 218-7880
DC Department of Health Care Finance – Manager, Office of Provider Services
Laurie Rowe (202) 698-2044
Complete the extended
training and resources
available at
www.dchealthcheck.net
Your participation
counts!
Don’t forget to
REGISTER and
RECEIVE CMEs!