Health Check Seminar

1

• Health Check Seminar

September 2012 Presented by HP Enterprise
Services
2
Health Check Resources

• DMA Website
• www.ncdhhs.gov/dma
• Health Check Billing Guide
• EPSDT Policy Instructions (updated 1/11/2010)
• Request for Non-Covered Services Forms

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For Providers
EPSDT and Health Check
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Fee Schedules
Fee Schedules
5
Whos Who in Medicaid

• Centers for Medicare and Medicaid Services
• CMS
• Department of Health and Human Services
• DHHS
• Division of Medical Assistance
• DMA

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Whos Who in Medicaid

• Department of Social Services
• DSS
• HP Enterprise Services
• HPES
• Computer Sciences Corporation
• CSC

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EARLY AND PERIODIC SCREENING, DIAGNOSIS, AND
TREATMENT (EPSDT)
MEDICAID FOR CHILDREN
Contact EPSDT Nurse Consultant
Division of Medical
Assistance Telephone
919-855-4260 FAX
919-715-7679
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EPSDT Websites

• Basic Medicaid and N.C. Health Choice Billing
  Guide
• http//www.ncdhhs.gov/dma/basicmed/
• Health Check Billing Guide
• http//www.ncdhhs.gov/dma/healthcheck/
• EPSDT Provider Page
• http//www.ncdhhs.gov/dma/provider/epsdthealthchec
  k.htm

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EPSDT Provider Website
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EPSDT Provider Website
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Provider Responsibility

• Verify Recipient Eligibility
• Carolina ACCESS
• Health Check Overview
• Maintain Medical Records
• Health Check Billing Requirements

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Eligibility Verification Methods

• NCECSWeb Tool
• Free Service
• Need Submitter ID Password
• Automated Voice Response (AVR) System
• 1-800-723-4337
• EDI Vendor

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Verify Eligibility
Use any of these methods to search
Tips Use MPN or NPI If no date is keyed it will
reflect eligibility for the date of search Can
not check future date until the first of that
month Can search back 365 days
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Eligibility Results
123456789k
08/01/2012
08/31/2012
123456789k
Jane Doe
1/1/1960
08/01/2012- 08/31/2012
987654321A
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Carolina ACCESS (CA)

• Primary Care medical home for enrolled recipients
• Obtain referral from Primary Care Provider
• Referring NPI reported on claim
• More information Basic Medicaid and N.C. Health
  Choice Billing Guide Section 6-Managed Care
  Programs

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CA Override Request

• Considered only for extenuating circumstances
• http//www.ncdhhs.gov/dma/ca/CAOverrideForm.pdf

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Carolina ACCESS Denial Codes

• EOB 270
• Billing provider is not the recipients Carolina
  ACCESS PCP. Authorization is missing or
  unresolved
• EOB 286
• Incorrect authorization number on claim form.
  Verify number and re-file claim

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Provider Responsibility

• Verify Recipient Eligibility
• Carolina ACCESS
• Health Check Overview
• Maintain Medical Records
• Health Check Billing Requirements

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Health Check/EPSDT Overview

• Important because
• Provides for early and regular medical,
  developmental, dental screenings and ongoing
  surveillance for all Medicaid recipients under
  the age of 21
• Part of the federal Medicaid EPSDT requirement to
  provide medically necessary health care

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Screening Assessments

• Health Check recommends regular medical screening
  assessments (well-child visits) for recipients
• Screening, diagnostic and treatment services are
  FREE of charge to the recipient

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Health Check/EPSDT Recommended Periodicity
Schedule
Within 1st month 9 or 15 months
2 months 12 months
4 months 18 months
6 months For children ages 2 through 20, annual visits are recommended
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Periodic Health Check Screening

• Require all age-appropriate components
• Developmental Screening
• Vision Screening
• Hearing Screening
• Dental Screening
• Immunizations

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Interperiodic Health Check Screening

• Require all age-appropriate components EXCEPT
• Developmental Screening
• Hearing Screening
• Vision Screening
• Screening may be performed outside of the
  periodicity schedule
• All electronic claims should list referral code
  indicator E when a referral is made for
  follow-up

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Health Check Screening Assessment Components

• Comprehensive unclothed physical assessment
• Comprehensive health history
• Nutritional assessment
• Anticipatory guidance and health education
• Measurements, blood pressure and vital signs

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Health Check Screening Assessment Components

• Developmental surveillance
• Immunizations
• Vision screening
• Hearing screening
• Dental screening
• Laboratory procedures

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Developmental Screening

• Includes physical and mental development
• Required component of a Periodic Screening at the
  following ages
• 6, 12, and 18 or 24 months old
• 3, 4, and 5 years old
• Must use a standardized and validated screening
  tool
• CPT code 96110 with EP modifier

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Developmental Screening

• Autism Screening CPT Code 99420 with EP modifier
• Screening at ages 18 and 24 months

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Developmental Screening Cont.

• Health Risk Assessments and Behavioral/Mental
  Health Screening
• CPT Code
• 99420 EP modifier
• Smoking/Tobacco Use Cessation Counseling
• CPT Codes
• 99406 EP modifier
• 99407 EP modifier
• Alcohol/Substance Abuse Structured Screening and
  Brief Intervention
• CPT Codes
• 99408 EP modifier
• 99409 EP modifier

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Break Time..See you back in 15
minutes!!
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Immunizations

• Same provider
• Same date of service as Health Check screening
• Same location as Health Check screening
• EP modifier appended to the immunization
  administration CPT code
• Recipients from birth through age 20

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Immunizations

• The North Carolina Immunization Program (NCIP)
• Vaccines for Children (VFC)
• Birth through 18 years of age - no charge
• Reimbursement for the administration of vaccines
• EP modifier required

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Procedure Code Description
90471 Immunization administration (includes percutaneous, intradermal, subcutaneous, or intramuscular injections) one vaccine (single or combination vaccine/toxoid)
90472 (add-on-code) Immunization administration (includes percutaneous, intradermal, subcutaneous, or intramuscular injections) one vaccine (single or combination vaccine/toxoid) each additional vaccine (single or combination vaccine/toxoid) List separately in addition to code for primary procedure
90473 Immunization administration by intranasal or oral route one vaccine (single or combination vaccine/toxoid)
90474 (add-on-code) Immunization administration by intranasal or oral route each additional vaccine (single or combination vaccine/toxoid) List separately in addition to code for primary procedure
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Vision Screening

• Required for Periodic Examinations beginning at
  age 3 through 10 years
• Age 11- screening needed only once every three
  years
• CPT code 99172 or 99173 with EP modifier

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Hearing Screening

• Objective screenings using an otoacoustic
  auditory emission (OAE) tool or audiometer
• Performed annually for ages 4-10
• All other ages, selective screening based on
  assessment of risk
• CPT code 92551, 92552, or 92587 with EP modifier

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What if the hearing or vision component cannot be
performed because.

• Uncooperative, blind, deaf, or autistic
• Document the date of service and reason why
  unable to perform screening
• Submit claim without component CPT code

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Dental Screening

• An oral screening is to be performed at every
  Health Check visit
• Referral to a dentist is recommended for every
  child before age 1 and required at age of 3
• Dental Varnishing allowed once every 60 calendar
  days
• D1206 and D0145, no EP modifier

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Frequently Asked Questions

• Is Dental Varnishing a requirement of the Health
  Check program?
• Answer No
• Is Dental Varnishing separately reimbursable in
  addition to a Health Check visit?
• Answer Yes

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Laboratory Procedures

• Laboratory procedures include
• Hemoglobin or Hematocrit
• Newborn Metabolic/Sickle Cell Screening
• Tuberculin Test
• Lead testing
• Included in Health Check fee when billed on same
  date of service

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Provider Responsibility

• Verify Recipient Eligibility
• Carolina ACCESS
• Health Check Overview
• Maintain Medical Records
• Health Check Billing Requirements

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Claim Submission

• Electronic submission
• Software Vendor or Clearinghouse
• NC Electronic Claims Submission (NCECSWeb Tool)
• Paper submission
• For claims meeting exception criteria only

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Health Check Billing Requirements

• What are the six billing requirements specific to
  the Health Check Program?

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Requirement 1

• Medical diagnoses
• Listed after primary, and before immunization
  diagnoses
• Immunization diagnosis code
• Required when one or more immunizations are
  provided as the only service

• Identify and record diagnosis code
• CMS-1500, block 21
• Primary diagnosis first
• Periodic- V20.2
• Interperiodic V70.3

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Requirement 2

• Vision CPT codes 99172 or 99173 with EP modifier
• Hearing CPT codes 92551, 92552, or 92587 with EP
  modifier

• Identify and record preventive medicine code and
  component codes
• Developmental screening CPT codes 96110, 99420,
  99406, 99407, 99408, 99409 with EP modifier

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Requirement 3

• EP is a required modifier for all Health Check
  claim details
• Screening assessments
• Vision, Hearing, and Developmental screening
• Immunization administration

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Requirement 4

• Record Referrals
• List referral code indicator E for claims
  submitted via NCECSWeb Tool
• List referral code indicator F when a referral
  is made for Family Planning services

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Requirement 5

• Next Screening Date
• Systematically entered according to the
  predetermined periodicity schedule
• Provider-entered Next Screening Date
• Systematically entered Next Screening Date

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Requirement 6

• Identify and Record Immunization Administration
  CPT Code(s) and the EP Modifier
• Refer to immunization guidelines

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Preventive Medicine CPT Codes
Age New Patient Established Patient Append EP Modifier
Under age 1 year 99381 99391 Yes
1 through 4 years 99382 99392 Yes
5 through 11 years 99383 99393 Yes
12 through 17 years 99384 99394 Yes
18 through 20 years 99385 99395 Yes
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Frequently Asked Question

• Can I get paid for a sick visit and a well visit
  on the same date of service?
• Answer No
• If they are sick, treat the visit as a sick visit
  and reschedule the well check

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Billing Information

• Report CA Overrides on the NCECSWeb Tool using
• Referring Physician Provider Number
• (Carolina ACCESS Physician Number)
• Electronic Funds Transfer (EFT)
• Checkwrite schedule
• Cut-off date and time
• http//www.ncdhhs.gov/dma/provider/calendar.htm

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Billing Tips-All Providers

• Two Health Check screening assessments on
  different dates of service cannot be billed
  together
• Can be billed when performed during a periodic or
  interperiodic Health Check assessment for ages
  11-20
• CPT codes 99406, 99407, 99408, 99409,
• Can be billed when performed during a periodic or
  interperiodic Health Check assessment for ages
  birth through 20
• CPT code 99420
• Immunizations and therapeutic injections may be
  billed on same claim/date of service

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Billing Tips - Private Sector Provider

• Health Check screening and office visit with
  different dates of service must be billed
  separately
• Health Check screening assessment and office
  visit cannot be paid initially on the same date
  of service
• For denied claim to be reconsidered
• Submit an adjustment with medical documentation
  and EOB attached
• AVR and claim status

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Billing Tips - Local Health Department

• Two Health Check screenings on different dates of
  service cannot be billed on the same claim form
• An immunization administration fee may be billed
  if the immunization is provided in addition to a
  Health Check screening visit.

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Health Check Coordinators (HCCs)

• Assist parents and providers in assuring that
  Medicaid-eligible children have ACCESS to Health
  Check services
• Provide education and outreach services in 100 NC
  counties and the Qualla Boundary

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Health Check Common EOBs

• EOB 1769
• No additional payment made for vision, hearing
  and/or developmental screening services
• EOB 1770
• Invalid procedure/modifier/
• diagnosis

• EOB 10
• Diagnosis or service invalid for recipient age
• EOB 1036
• Thank you for reporting vaccines

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Health Check References

• Claim examples
• Local Health Department HSIS screens
• N.C. Periodicity Schedule and Coding Matrix

• Billing reference sheet
• Immunization billing reference sheet
• Resource list

http//www.ncdhhs.gov/dma/healthcheck/coding_matri
x.pdf
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Frequently Used Forms
Medicaid Resolution Inquiry
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Medicaid Overrides

• Resolution Inquiry Form
• Use only when requesting
• Time Limit Override
• Third Party Override
• Medicare Override
• HMOs
• Attached with Explanation of Benefits (EOB) and
  paper claim
• Mail to HP Enterprise Services
• PO Box 300009
• Raleigh, NC 27622

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Primary Insurance

• Private Insurance pays, submit electronic claim
  to Medicaid
• Non-payment indicated? Submit claim on paper
• Attach Medicaid Resolution Inquiry Form, claim,
  and primary EOB
• Check Third Party Override box
• Applied to the Deductible, Non-Covered Service,
  Policy Terminated
• Exceeds maximum benefits for the year

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DMA-2057/Electronic Transmissions

• Update recipients commercial insurance
  information
• Transmit electronically via secured internet
  connection
• New preferred method
• Ability to send claim upon receipt of the
  confirmation e-mail from vendor
• HMS website http//ncprovider.hms.com

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Contact Information

• Automated Voice Response (AVR) System
• 1-800-723-4337
• Billing questions HP Enterprise Services
• 1-800-688-6696 or 919-851-8888, Option 3
• Provider enrollment CSC EVC Call Center
• 1-866-844-1113 or email NCMedicaid_at_csc.com

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Review

• A child comes in for a sports physical, outside
  of their periodicity schedule. Is this a
  periodic or interperiodic screening?
• Answer Interperiodic
• What diagnosis code is required?
• Answer V70.3

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Review

• True or False An EP modifier is required when
  billing a health check visit code
• Answer TRUE

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Provider Responsibility

• Verify Recipient Eligibility
• Carolina ACCESS
• Health Check Overview
• Maintain Medical Records
• Health Check Billing Requirements

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Review

• True or False Although Medicaid ID cards are
  issued annually, eligibility information can
  still change on a monthly basis
• Answer TRUE

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Thank You

• Any Questions?