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Health Check Seminar

Health Check Seminar . September 2012 Presented by: HP Enterprise Services. 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. For Providers. EPSDT and Health Check.

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Health Check Seminar

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  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

  3. For Providers EPSDT and Health Check

  4. Fee Schedules Fee Schedules

  5. Centers for Medicare and Medicaid Services CMS Department of Health and Human Services DHHS Division of Medical Assistance DMA Who’s Who in Medicaid

  6. Department of Social Services DSS HP Enterprise Services HPES Computer Sciences Corporation CSC Who’s Who in Medicaid

  7. 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

  8. 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/epsdthealthcheck.htm

  9. EPSDT Provider Website

  10. EPSDT Provider Website

  11. Verify Recipient Eligibility Carolina ACCESS Health Check Overview Maintain Medical Records Health Check Billing Requirements Provider Responsibility

  12. NCECSWeb Tool Free Service Need Submitter ID & Password Automated Voice Response (AVR) System 1-800-723-4337 EDI Vendor Eligibility Verification Methods

  13. 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

  14. Eligibility Results 123456789k 08/01/2012 08/31/2012 123456789k Jane Doe 1/1/1960 08/01/2012- 08/31/2012 987654321A

  15. 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 Carolina ACCESS (CA)

  16. Considered only for extenuating circumstances http://www.ncdhhs.gov/dma/ca/CAOverrideForm.pdf CA Override Request

  17. EOB 270 Billing provider is not the recipient’s Carolina ACCESS PCP. Authorization is missing or unresolved EOB 286 Incorrect authorization number on claim form. Verify number and re-file claim Carolina ACCESS Denial Codes

  18. Verify Recipient Eligibility Carolina ACCESS Health Check Overview Maintain Medical Records Health Check Billing Requirements Provider Responsibility

  19. 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

  20. 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

  21. Health Check/EPSDT Recommended Periodicity Schedule

  22. Periodic Health Check Screening • Require all age-appropriate components • Developmental Screening • Vision Screening • Hearing Screening • Dental Screening • Immunizations

  23. 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

  24. 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

  25. Health Check Screening Assessment Components • Developmental surveillance • Immunizations • Vision screening • Hearing screening • Dental screening • Laboratory procedures

  26. 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

  27. Autism Screening CPT Code 99420 with EP modifier Screening at ages 18 and 24 months Developmental Screening

  28. 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 Developmental Screening Cont.

  29. Break Time…..See you back in 15 minutes!!

  30. 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

  31. 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

  32. 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

  33. 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

  34. 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

  35. 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

  36. 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 Frequently Asked Questions

  37. 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

  38. Verify Recipient Eligibility Carolina ACCESS Health Check Overview Maintain Medical Records Health Check Billing Requirements Provider Responsibility

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

  40. What are the six billing requirements specific to the Health Check Program? Health Check Billing Requirements

  41. Identify and record diagnosis code CMS-1500, block 21 Primary diagnosis first Periodic- V20.2 Interperiodic V70.3 Medical diagnoses Listed after primary, and before immunization diagnoses Immunization diagnosis code Required when one or more immunizations are provided as the only service Requirement 1:

  42. Requirement 2: • Identify and record preventive medicine code and component codes • Developmental screening CPT codes 96110, 99420, 99406, 99407, 99408, 99409 with EP modifier • Vision CPT codes 99172 or 99173 with EP modifier • Hearing CPT codes 92551, 92552, or 92587 with EP modifier

  43. EP is a required modifier for all Health Check claim details Screening assessments Vision, Hearing, and Developmental screening Immunization administration Requirement 3:

  44. 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 Requirement 4:

  45. Next Screening Date Systematically entered according to the predetermined periodicity schedule Provider-entered Next Screening Date Systematically entered Next Screening Date Requirement 5:

  46. Identify and Record Immunization Administration CPT Code(s) and the EP Modifier Refer to immunization guidelines Requirement 6:

  47. Preventive Medicine CPT Codes

  48. 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 Frequently Asked Question

  49. 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 Billing Information

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