016.06.06 Ark. Code R. 009
The Child Health Services (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 up to their 21st birthday. The purpose of this program is to detect and treat health problems in the early stages and to provide preventive health care, including necessary immunizations. Child Health Services (EPSDT) combines case management and support services with screening, diagnostic and treatment services delivered on a periodic basis.
The Arkansas Medicaid Program requires that all eligible EPSDT participants under 21 years of age, must receive regularly scheduled examinations and evaluations of their general physical and mental health, growth, development and nutritional status.
These screenings must include, but are not limited to:
Screening services must be provided in accordance with reasonable standards of medical and dental practice, as soon as possible in a child's life and at intervals established for screening by medical, dental, visual and other health care experts.
An age appropriate screening may be performed when a child is being evaluated or treated for an acute or chronic condition.
The screening performed on the same date of service as an office visit for treatment of an acute or chronic condition may be billed as a periodic EPSDT screening, using the Form DMS-694. View a DMS-694 sample form.
Effective for dates of service on and after May 1, 2006, the office visit for treatment of an acute or chronic condition may be billed as a separate visit for the same date of service. The visit must be billed electronically, or on paper using form CMS-1500. View a form CMS-1500 sample form.
The primary care physician may provide the screening or refer the child to a qualified Medicaid provider for screening. Primary care physician referral for ESPDT screening is mandatory in the 75 counties in Arkansas. See Section I of this manual.
Diagnosis is the determination of the nature or cause of physical or mental 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 services, or dental services and any other type of medical care and services recognized under State law to prevent or correct disease or abnormalities detected by screening or by diagnostic procedures.
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 treatment. I f immunization is recommended at the time of screening, immunization(s) must be provided at that time, or a direct referral given.
I f a condition is diagnosed through a Child Health Services (EPSDT) screen that requires treatment services not normally covered under the Arkansas Medicaid Program, those treatment services will also be considered for reimbursement if the service is medically necessary and permitted under federal Medicaid regulations. The PCP must request consideration for reimbursement using the EPSDT Prescription/Referral for Medically Necessary Services/Items not specifically included in the Medicaid State Plan Form DMS-693. View or print form DMS-693.
Refer to Section I of this manual (Services Available through the Child Health Services (EPSDT) Program) for additional information.
Physicians interested in becoming a Child Health Services (EPSDT) provider should contact the central Child Health Services Office. View or print Child Health Services Office contact information.
The Child Health Services (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 until their 21st birthday. The purpose of this program is to detect and treat health problems in the early stages and to provide preventive health care, including necessary immunizations. Child Health Services (EPSDT) combines case management and support services with periodic screening, as well as diagnostic and treatment services delivered.
A primary care physician (PCP) may refer a child to a nurse practitioner to administer an EPSDT screen. A provider of nurse practitioner services may recommend to the PCP that an EPSDT screen could be necessary for any child that is thought to need one. If a nurse practitioner discovers a problem as a result of an EPSDT screen, or receives a referral as a result of an EPSDT screen, nurse practitioner services may be provided after consulting with the child's PCP.
View a form CMS-1500 sample form.
Refer to Section I of this manual for additional information. Providers of Child Health Services (EPSDT) should refer to the Child Health Services (EPSDT) provider manual.
See section 212.000 for EPSDT screening terminology.
Effective for dates of service on and after May 1, 2006, a primary care physician (PCP) may bill a sick visit and a Child Health Services (EPSDT) periodic screening for a patient on the same date of service if the screening is due to be performed.
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.
Procedure 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) |
994311 994321 994351 | EP EP EP | Initial Newborn Care/EPSDT screen in hospital | |
991731 | EP | EPSDT Periodic Vision Screen | |
V5008 | EP | EPSDT Periodic Hearing Screen | |
D01201 | CHS/EPSDT Oral Examination | ||
D01401 | EPSDT Interperiodic Dental Screen, with prior authorization | ||
99401 | EP | EPSDT Health Education - Preventive Medical Counseling | |
364152 | Collection of venous blood by venipuncture | ||
83655 | Lead |
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.
Electronic and paper claims require use of the above modifiers. When filing paper claims for an EPSDT screening service, type of service code "6" and the applicable modifier must be entered on the claim form.
For billing on paper, immunizations must be billed with a type of service code "1."
016.06.06 Ark. Code R. 009