Annual Wellness Exam EPSDT Early Periodic Screening Diagnosis Treatment

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Annual Wellness ExamEPSDTEarly Periodic
Screening Diagnosis Treatment

• Paula LeSueur MSN, CFNP
• Quality Improvement Consultant
• Presented for the SBHC-Quality Improvement
  Initiative

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EPSDT - Early Periodic Screening, Diagnosis and
Treatment

• Objectives
• Participants will be able to describe the main
  elements of the EPSDT exam.
• What are the Medicaid requirements for the EPSDT?
• How do you document all the elements?
• Participants will become more familiar with the
  use of the SHQ to assess behavioral and physical
  health risks.
• What role does the Student Health Questionnaire
  play in screening?
• Provision of Preventive health care is a quality
  marker for SBHC.

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EPSDT

• Early starting before problems worsen
• Periodic at regular intervals as needed
• Screening comprehensive well child exam
• Diagnosis as appropriate
• Treatment all medically necessary services for
  the patients condition, including referrals

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Components of Complete EPSDT Screen

• A comprehensive health and developmental history,
  including an assessment of both physical and
  mental health development
• A comprehensive unclothed physical exam
• Appropriate immunizations, according to age and
  health history, unless medically contraindicated
  at the time
• Laboratory tests, UA and Hgb, including an
  appropriate lead blood level assessment (at 1 and
  2 yrs of age)
• Health education, including anticipatory guidance

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Health and Developmental/ Behavioral Health

• The OSAH Student Health Questionnaire (SHQ) is
  based on the Guidelines for Adolescent Preventive
  Services.
• It is a comprehensive screening tool to
  assess/determine developmental, psycho-social and
  behavioral health risk and resiliency factors.
• Use the appropriate SHQ for elementary, middle or
  high school.

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Health and Developmental/Behavioral Health
Assessment

• The OSAH Student Health Questionnaire provides
  the required information. Use appropriate SHQ
  for Elementary School, Middle School or High
  School.

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SHQ

• Risk factors for each domain (section) of the SHQ
  need to be rated.
• Use rating scale of low, medium, high.
• Significant risks need to be listed on the Health
  Maintenance Record.
• The medical or behavioral health provider at the
  SBHC must review the SHQ with the student.

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Sensory Screening

• VisionSnellen eye chart
• at age 3 through age 12,15 18.
• Hearing/speech
• at age 4 through age 12, 15 18.
• use audiometer, under earphones, at 1000, 2000
  and 4000 Hertz at 20 decibels.

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Preventive Health Guidelines for Children and
Adolescents

• EPSDT recommended every year from birth through
  age 20
• Physical exam and developmental/behavioral health
  assessment
• Nutrition screening
• Measurements include ht, wt, BMI percentile, and
  blood pressure (from age 2 to 20)
• Dental screen- recommend routine visit every 6
  months, patient education and direct dental
  referral must be documented.

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Sensory Screening

• VisionSnellen eye chart
• at age 3 through age 12, 15 18.
• Hearing/speech
• at age 4 through age 12, 15 18
• use audiometer, under earphones, at 1000, 2000
  and 4000 Hertz at 20 decibels.

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Physical Exam includes

• Complete unclothed physical exam
• External genital exam and Tanner staging is
  required. Document in chart if student declines
  the exam e.g., (deferred at patient request).
  Tanner staging may be done by self report.
• Provide education re testicular and breast
  self-exam as appropriate.

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Lab Screenings

• Urinalysis to be performed preferably at age 5
  and 15 may be done between ages 10-20. May use
  Chemstrip 9 for testing.
• Hematocrit/hemoglobin - to be preformed
  preferably at 9 months and age 13 may be done
  between ages 10-20.
• If indicated, may repeat after menarche in
  females.

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High Risk Factor Screenings

• Pelvic exam -
• Medicaid regulations state that a pelvic exam is
  to be done with all sexually active females, with
  their consent, or initially at age 18-21.
• DOH Family Planning Division (Title X) recommends
  following National Guidelines (e.g., AAP, ACOG)
  which state for women younger than 21 years who
  have never been sexually active, no routine
  pelvic exam, PAP or STI test is needed. If the
  woman has ever been sexually active a PAP test
  should be performed 3 years after onset and
  yearly after that.
• May take 2 visits to complete the GYN exam and
  EPSDT.

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High Risk Factor Screenings

• Tuberculin Test -
• Screen for high-risk factors.
• Risk factors include immigration or travel to
  areas of high prevalence, IV drug use,
  incarceration, homelessness, HIV infection or
  living with person with HIV, working or
  volunteering in health care setting.

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High Risk Factor Screenings

• STI Screen all sexually active youth
• Urine chlamydia/gonorrhea
• HIV test if high risk- positive contact with
  known partner at risk, past STIs, multiple
  partners, IV drug use or sex in exchange for
  money or drugs
• For males sex with other males
• For syphilis only test if reside in areas of
  prevalence. NM is not in an area of prevalence.

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High Risk Factor Screenings

• Cholesterol -
• Perform or refer for the test if high risk
• Testing is based on individual risk,
• i.e. familial hyperlipidemia, family history of
  early onset of cardiovascular disease in parents
  or grandparents at age 55 or less, obesity,
  diabetes, high blood pressure or cigarette smoker.

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Immunizations

• Tetanus Booster - Tdap done between ages 12-15.
  Required for 7th grade entry for 2007-08.
• MMR, varicella and HepA - assess, give if
  indicated and not previously given.
• HepB - series should be completed in early
  childhood or by 7th grade.
• Influenza for all, unless contraindication
• HPV (3 doses).
• Immunizations should be given according to the
  most current Advisory Committee of Immunization
  Practice (ACIP) schedule. (www.cdc.gov/nip)

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Medical Chart Documentation

• No required state forms, but documentation must
  be an auditable form (a single sheet) in the
  medical chart
• Recommend use of Office of School and Adolescent
  Health Progress notes for elementary, middle or
  high school students.

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Encounter Form/ Billing Form
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Documentation to Support Billing

• ICD-9 code is V20.2 for youth to age 17
• ICD-9 code is V70.0 for youth 18 or older
• Use of Modifier 25 -
• When the principal reason for the visit is an
  EPSDT and during the visit another separate
  identifiable health condition requires additional
  evaluation and management above and beyond the
  other service, then a 25 modifier can be attached
  to the secondary CPT.

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Diagnosis and Treatment

• When there is indication for further evaluation
  of the patients health, diagnostic studies must
  be provided.
• Referrals for further diagnosis must occur.
• Follow-up is required to make sure the pt.
  receives a complete diagnostic evaluation.
• (Ref. US Department of Health and Human
  Services, Centers for Medicare and Medicaid
  Services, Region VI, Final Report NM Medicaid
  Review, Sept. 2009)

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Additional Diagnoses/Risks

• Include all diagnoses
• For example obesity (weight category dx),
  acanthosis, asthma, acne, adjustment disorder,
  substance use, depression
• Risk factors
• Refer to findings from the Student Health
  Questionnaire (SHQ), particularly high risk
  conditions.
• For example family disruption, poor academic
  performance, alcohol/drug use, pregnancy/STI
  risk, etc

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Medically Necessary Services

• Required by States Medicaid Provider Policies,
  as follows
• Clinical and rehabilitative physical or
  behavioral health services that prevent, diagnose
  or treat medical conditions or are essential to
  enable an eligible recipient to attain, maintain,
  or regain functional capacity with reasonable
  standards of service delivery and timeliness.
  (Ref. US Dept. of Health and Human Services,
  Center for Medicare and Medicaid Services Region
  VI, Final Report for NM Sept. 2009)

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Notification

• Inform parents of results of the exam, including
  any screening tests or lab results, except
  confidential information. Present results per
  phone or written report.
• Notify Primary Care Provider that Annual
  Exam/EPSDT was performed by use of the New Mexico
  SBHC Services Notification Form. Include any
  pertinent findings.
• Schedule follow-up appointments for confidential,
  behavioral health or other health care services.

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Thank you

• Eliminating the gap between what is and what can
  be in health care for all children

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