016.06.05 Ark. Code R. 007
The Arkansas Division of IVIedical Services (DIVIS) recruits providers for medical, dental, visual, and hearing screenings and treatment services. All Child Health Services (EPSDT) providers are required to complete a provider application (DMS-652), a Medicaid contract (DMS-653) and a Request for Taxpayer Identification Number and Certification (W-9). View or print a provider application (form DMS-652), a Medicaid contract (form DMS-653) and a Request for Taxpayer Identification Number and Certification (Form W-9).
The Arkansas Medicaid Program must approve the provider application and the Medicaid contract as a condition of participation in the Medicaid Program. Persons and entities that are excluded or debarred under any state or federal law, regulation or rule are not eligible to enroll, or to remain enrolled, as Medicaid providers.
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 or 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 Services (EPSDT) Program.
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 application and contract, an eligible Child Health Services (EPSDT) provider must sign an agreement to participate as a Child Health Services (EPSDT) screening provider. View or print participatinq EPSDT provider aqreement.If interested, please contact the Central Child Health Services (EPSDT) Office. View or print the Central Child Health Services (EPSDT) contact information. Payment for screens performed by providers who have not signed an agreement will be denied.
When Child Health Services (EPSDT) medical screenings, 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 Child Health Services (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:
View or print Certification of Schools to Provide Comprehensive EPSDT Services form.
Schools or education service cooperatives enrolling as screeners for hearing and vision, hearing only or vision only must meet the following criteria:
View or print a provider application (form DMS-652), a Medicaid contract (form DMS-653) and a Request for Taxpayer Identification Number and Certification (Form W-9).
View or print participatinq EPSDT provider aqreement.
NOTE: School districts or education service cooperatives employing a qualified speech pathologist may complete an agreement to participate as a screening provider, using the speech pathology Medicaid provider number. The qualified speech pathologist may perform hearing screens and be reimbursed under the Medicaid provider number for speech pathology.
In situations where speech pathology services are provided by a qualified speech pathologist, who is contracted with a school district or an education service cooperative, the individual qualified speech pathologist may complete the agreement to participate as a CHS screening provider and perform hearing screens under the individual Medicaid number.
The Child Health Services (CHS) Early and Periodic Screening, Diagnosis and Treatment (EPSDT) Program is a federally mandated child health component of Medicaid. It is designed to bring comprehensive health care to individuals eligible for medical assistance from birth to age 21. Even if the person eligible for medical assistance is a parent, he or she is eligible for Child Health Services (EPSDT) if under age 21. Physicians and other health professionals who provide Child Health Services (EPSDT) screening may diagnose and treat health problems discovered during the EPSDT screening or may refer the child to other appropriate sources for such care.
The following is a broad definition of the components of the Child Health Services EPSDT program.
Early means as soon as possible in the child's life, or as soon as his or her 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.
Interperiodic means providing medically necessary screenings between the recommended age ranges for medical, visual, hearing and dental screenings in order to determine the existence of suspected illnesses or conditions.
Partial means a medical screen consisting of one or more of the Child Health Services (EPSDT) medical screening components, but not all components.
Screening is the use of quick, simple procedures to sort out apparently well persons from those who may have a disease or abnormality and to identify those in need of a more definitive examination.
Diagnosis is the determination of the nature or cause of a disease or abnormality through the combined use of health history, physical, developmental and psychological examination, laboratory tests and X-rays.
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 coverage if the services are prescribed by a physician as a result of an EPSDT screen. The services must be medically necessary and permitted under federal Medicaid regulations.
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, the immunization(s) will be administered as part of the screening process.
Immunizations for childhood diseases are exempt from primary care physician (PCP) referral requirements.
The Arkansas Medicaid program recommends that EPSDT providers follow the immunization schedule shown below as approved by the Advisory Committee on Immunization Practices (ACIP), the American Academy of Pediatrics (AAP) and the American Academy of Family Physicians (AAFP).
The current immunization schedule indicates the recommended ages for routine administration of currently licensed childhood vaccines, as of December 1, 2004, for children through age 18 years. More information about the current immunization schedule may be found on the AAP Web site at www.aap.org/policv/0212.html. View or print the Recommended Childhood Immunization Schedule.
Any dose not given at the recommended age should be given at any subsequent visit when indicated and feasible. Additional vaccines may be licensed and recommended during the year. Licensed combination vaccines may be used whenever any components of the combination are indicated and the vaccine's other components are not contraindicated. Providers should consult the manufacturers' package inserts for detailed recommendations.
Three Hib conjugate vaccines are licensed for infant use. If PRP-OMP [PedvaxHIB® or ComVax® (Merck)] is administered at ages 2 and 4 months, a dose at age 6 months is not required. DTaP/Hib combination products should not be used for primary immunization in infants at ages 2, 4 or 6 months, but they can be used as boosters following any Hib vaccine. The final dose in the series should be given at age 12 months or older.
The second dose of MMR is recommended routinely at age 4-6 years but may be administered during any visit, provided at least 4 weeks have elapsed since the first dose and that both doses are administered beginning at or after age 12 months. Those who have not previously received the second dose should complete the schedule by the visit at age 11 or 12 years.
Varicella vaccine is recommended at any visit at or after age 12 months for susceptible children (i.e., those who lack a reliable history of chickenpox). Susceptible persons > 13 years of age should receive 2 doses, given at least 4 weeks apart.
Hepatitis A vaccine is recommended for children and adolescents in selected states and regions and for certain high-risk groups; consult your local public health authority. Children and adolescents in these states and regions, and high-risk groups who have not been immunized against hepatitis A, can begin the hepatitis A immunization series during any visit. The two doses in the series should be administered at least 6 months apart. See MMWR 1999; 48 (RR-12); 1-37.
Note: Arkansas is not one of the selected states in which Hepatitis A immunizations are recommended. The recommendations could change, however, if there is an increase in the number of reported cases of Hepatitis A.
Influenza vaccine is recommended annually for children age > 6 months with certain risk factors (including but not limited to asthma, cardiac disease, sickle cell disease, HIV and diabetes) healthcare workers and other persons (including household members) in close contact with persons in groups at high risk (see MMWR 2004; 53(RR-6); 1-40) and can be administered to all others wishing to obtain immunity. In addition, healthy children, ages 6-23 months, and close contacts of healthy children aged 0-23 months are recommended to receive influenza vaccine because children in this age group are at substantially increased risk for influenza-related hospitalizations. For healthy persons aged 5 through 49 years (please note: EPSDT does not cover services provided to individuals age 21 and over), the intranasally administered live, attenuated influenza vaccine (LAIV) is an acceptable alternative to the intramuscular trivalent inactivated influenza vaccine (TIV). Children receiving TIV should be administered a dosage appropriate for their age (0.25 mL if age 6-35 months or 0.5 mL if [GREATER THAN]3 years). Children age [LESS THAN]8 years that are receiving influenza vaccine for the first time should receive two doses (separated by at least 4 weeks for TIV and at least 6 weeks for LAIV).
The Vaccines for Children (VFC) Program was established to enable free access to childhood immunizations for Medicaid-eligible children under nineteen years of age.
Arkansas Medicaid reimburses for the administrative fee for immunizations included in the Vaccines for Children (VFC) Program, which is administered by the Arkansas Department of Health (ADH). Providers may obtain the approved vaccines from the Department of Health.
To enroll in the VFC Program and obtain the vaccines, providers may contact the Arkansas Department of Health. View or print the Arkansas Department of Health contact information.
See section 212.000 for EPSDT screening terminology.
An EPSDT periodic complete medical screen includes both hearing and vision screens. Providers must not bill an EPSDT periodic or Interperiodic vision or hearing screen on the same day or within 7 days of an EPSDT complete medical screen by the same or different providers. The above billing combinations represent a duplication of services.
An EPSDT interperiodic full medical screen includes both hearing and vision screens. Providers must not bill an EPSDT periodic or Interperiodic vision screen on the same day or within 7 days of an EPSDT Interperiodic full medical screen by the same or different providers. The above billing combinations represent a duplication of services.
Claims for EPSDT medical screenings must be billed electronically or using the DMS-694 EPSDT paper claim form. View or print a DMS-694 sample claim form.
National Code | Modifier 1 | Modifier 2 | Description |
99381-99385 | EP | U1 | EPSDT Periodic Complete Medical Screen (New Patient) |
99391-99395 | EP | U2 | EPSDT Periodic Complete Medical Screen (Established Patient) |
99381-99385 | EP | EPSDT Interperiodic Full Medical Screen (New Patient) | |
99391-99395 | EP | EPSDT Interperiodic Full Medical Screen (Established Patient) | |
99391-99395 | EP | 52 | Partial Medical Screen/Reassessment EPSDT health and developmental history, including assessment of physical development (Established Patient) |
96151 | EP | Partial Medical Screen/Reassessment EPSDT health and developmental history, including assessment of mental development | |
99381-99385 | EP | 52 | Partial Medical Screen/Reassessment EPSDT unclothed physical assessment (New Patient) |
99391-99395 | EP | U1 | Partial Medical Screen/Reassessment EPSDT unclothed physical assessment (Established Patient) |
994311 994321 994351 | EP i | Initial Newborn Care/EPSDT screen in hospital | |
991731 | EP | EPSDT Periodic Vision Screen | |
V5008 | EP | EPSDT Periodic Hearing Screen | |
V5008 | EP | U1 | EPSDT Interperiodic Hearing Screen |
D01201 | CHS/EPSDT Oral Examination | ||
D01401 | EPSDT Interperiodic Dental Screen, with prior authorization | ||
920121 | EP | TS | EPSDT Interperiodic Vision Screen |
99401 | EP | EPSDT Health Education - Preventive IVIedical Counseling | |
364152 | Collection of venous blood by venipuncture | ||
83655 | Lead |
1 Exempt from PCP referral requirements
2 Covered when specimen is referred to an independent lab
Immunizations and laboratory tests may be billed separately from comprehensive screens.
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.
Laboratory/X-ray and immunizations associated with an EPSDT screen may be billed on the DMS-694 EPSDT claim form.
When billing on paper, the EPSDT screening services must be billed with a type of service code "6."
For billing on paper, immunizations must be billed with a type of service code "1."
For routine newborn care following a vaginal delivery or C-section, procedure code 99431, 99432 or 99435 should be used one time to cover all newborn care visits by the attending physician. Payment of these codes is considered a global rate and subsequent visits may not be billed in addition to codes 99431, 99432 and 99435. These procedure codes include the physical exam of the baby and the conference(s) with newborns parent(s) and is considered to be the initial newborn care/EPSDT screen in hospital. These procedure codes should not be used for illness care (e.g. neonatal jaundice). Providers may refer to the physician manual for necessary illness codes.
The procedure codes must be billed on the Centers for Medicaid and Medicare Services (CMS) billing form, titled the CMS-1500, or electronically. View or print a CMS-1500 sample form.
All EPSDT procedure codes must be billed on the DMS-694 EPSDT claim form with the following exceptions.
Services must be filed with the appropriate national procedure codes and applicable modifiers.
EPSDT Periodic Complete Medical Screen claims must be filed with the appropriate CPT-4 procedure codes and modifier. Procedure codes 99381 through 99385 (New Patient), with modifiers EP and U1, and procedure codes 99391 through 99395 (Established Patient), with modifiers EP and U2, will represent an EPSDT periodic complete medical screen, which includes both hearing and vision screens.
Immunizations and laboratory tests may be billed separately.
Example for EPSDT Periodic Complete Screen for an established patient:
99391, Modifiers EP and U2 = EPSDT Periodic Complete Medical Screen
EPSDT Interperiodic Full Medical Screen claims must be filed with the appropriate CPT-4 procedure codes and modifiers: procedure codes 99391 through 99395 (Established Patient) with modifier EP, and procedure codes 99381 through 99385 (New Patient) with modifier EP.
Immunizations and laboratory tests may be billed separately.
Example for EPSDT Interperiodic Full Medical Screen for an established patient:
99391, Modifier EP = Interperiodic Full Medical Screen (Established Patient)
*Procedure codes 99381 through 99385 (New Patient) with modifier EP should only be used to bill an EPSDT Interperiodic Full Medical Screen for new patients, ages 0 through 20 years of age, who have already received an EPSDT Periodic Complete Medical Screen by another provider within the current fiscal year.
Vaccines available through the VFC program are covered for Medicaid-eligible children. Only the administrative fee is reimbursed. When filing claims for administering VFC vaccines, providers must use the CPT procedure code for the vaccine administered. Electronic and paper claims require modifiers EP and TJ. When filing paper claims, type of service code "6" and the modifiers EP and TJ must be entered on form DMS-694. View or print a DMS-694 sample claim form.
Medicaid policy regarding immunizations for adults remains unchanged by the VFC program.
The following list contains the vaccines available through the VFC program.
Vaccine Description | Procedure Code | Modifier 1 | Modifier 2 |
Hemophilus influenza b (Hib) conjugate (4 dose schedule) for intramuscular use | 90645 | EP | TJ |
Hemophilus influenza b (Hib) PRP-D conjugate for booster use only, intramuscular use | 90646 | EP | TJ |
Hemophilus influenza b (Hib) PRP-OMP conjugate (3 dose schedule), for intramuscular use | 90647 | EP | TJ |
Influenza virus vaccine, split virus, preservative free, for children 6-35 months of age, for intramuscular use | 90655 | EP | TJ |
Influenza virus vaccine, split virus, for children 6-35 months of age, for intramuscular use | 90657 | EP | TJ |
Influenza virus vaccine, split virus, for use in individuals 3 years and above, for intramuscular use | 90658 | EP | TJ |
Pneumococcal conjugate vaccine polyvalent, for children under 5 years, for intramuscular use | 90669 | EP | TJ |
Diphtheria, tetanus toxoids and acellular pertussis vaccine (DtaP), for intramuscular use | 90700 | EP | TJ |
Diptheria and tetanus toxoids (DT) absorbed for use in individuals younger than 7 years, for intramuscular use | 90702 | EP | TJ |
Measles, mumps and rubella virus vaccine (MMR), live, for subcutaneous use | 90707 | EP | TJ |
Poliovirus vaccine, any type(s) (OPV), live, for oral use | 90712 | EP | TJ |
Poliovirus vaccine, inactivated (IPV), for subcutaneous use | 90713 | EP | TJ |
Varicella virus vaccine, live, for subcutaneous use | 90716 | EP | TJ |
Tetanus and diphtheria toxoids (Td) absorbed for use in individuals 7 years or older, for intramuscular use | 90718 | EP | TJ |
Diphtheria, tetanus toxoids and whole cell pertussis vaccine and Hemophilus influenza B vaccine (DTP-Hib) for intramuscular use | 90720 | EP | TJ |
Diphtheria, tetanus toxoids and acellular pertussis vaccine and Hemophilus influenza B vaccine (DtaP-Hib), for intramuscular use | 90721 | EP | TJ |
Diphtheria, tetanus toxoids and acellular pertussis vaccine and Hemophilus influenza B vaccine (DtaP-Hib), for intramuscular use | 90723 | EP | TJ |
Hepatitis B vaccine, adolescent (2 dose schedule), for intramuscular use | 90743 | EP | TJ |
Hepatitis B vaccine, pediatric/adolescent (3 dose schedule), for intramuscular use | 90744 | EP | TJ |
Screens
Child Health Services (EPSDT) screens do not include laboratory procedures unless the screen is performed by the recipient's primary care physician (PCP) or is conducted in accordance with 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, hemoglobin, ketones, leukocytes, nitrite, pH, protein, specific gravity, urobilinogen, any number of these constituents; non-automated, without microscopy |
83020 - | Hemoglobin, electrophoresis (e.g., 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 in accordance with a referral from the PCP.
The following screens will be affected by this policy:
National Code | Modifier 1 | Modifier 2 | Description |
99381-99385 | EP | U1 | EPSDT Periodic Complete Medical Screen (New Patient) |
99391-99395 | EP | U2 | EPSDT Periodic Complete Medical Screen (Established Patient) |
*99381-99385 | EP | EPSDT Interperiodic Full Medical Screen (New Patient) | |
99391-99395 | EP | EPSDT Interperiodic Full Medical Screen (Established Patient) | |
99391-99395 | EP | 52 | Partial Medical Screen/Reassessment EPSDT health and developmental history (including assessment of physical development) (Established Patient) |
99381-99385 | EP | 52 | Partial Medical Screen/Reassessment EPSDT unclothed physical assessment (New Patient) |
99391-99395 | EP | U1 | Partial Medical Screen/Reassessment EPSDT unclothed physical assessment (Established Patient) |
96151 | EP | Partial Medical Screen EPSDT health and development history including assessment of mental development |
*Procedure codes 99381 through 99385 (New Patient) with modifier EP should only be used to bill an EPSDT Interperiodic Full Medical Screen for new patients, ages 0 through 20 years of age, who have already received an EPSDT Periodic Complete Medical Screen by another PCP within the current fiscal year.
016.06.05 Ark. Code R. 007