QUEST Integration – Early and Periodic Screening, Diagnostic and Treatment (EPSDT) Services

Original Effective Date:

08/01/1994

Current Effective Date:

01/01/2015

What is EPSDT?

EPSDT is a federally mandated program for QUEST Integration children emphasizing prevention, early detection of medical, dental and behavioral health conditions and timely treatment of conditions detected as a result of screening. Children include any member up to 21 years of age.

Early: Assessing a child’s health as early as possible in life to prevent or find potential diseases and disabilities in their early stages when they are most effectively treated.

Periodic: Assessing a child’s health at regularly scheduled intervals to assure that a condition, illness or injury is not incipient or present.

Screening: A comprehensive child health assessment to determine if a child has a condition, illness or injury that should be referred for more definitive evaluation and/or treatment.

Diagnostic: The definitive evaluation by appropriate medical practitioners to determine the nature, extent or cause of a condition, illness or injury.

Treatment: The medical and remedial services permitted under QUEST Integration and determined medically necessary for problems identified during screening or diagnostic procedures.

HMSA will cover all medically necessary diagnostic and treatment services or behavioral health problems discovered during an EPSDT screening. This includes timely immunizations and tuberculin screening, diagnosis and treatment of defects in vision and hearing, diagnosis and treatment of any issues found in general developmental and autism screening, and diagnosis and treatment of acute and chronic medical and behavioral health conditions, and medical-related dental services. Screening for developmental delays, autism, and behavioral health conditions should be done using standardized, validated screening tools as recommended by current national guidelines and the State’s EPSDT program.

EPSDT Components

Informing – EPSDT eligible members and their families are educated about the benefits of preventive health and given guidance on how to obtain timely EPSDT services.

Servicing – Providers screen and provide medically necessary diagnosis and treatment of conditions detected in a screening. All medically necessary medical, dental and behavioral health diagnostic and treatment services to correct conditions discovered during an EPSDT screening are covered. This includes personal care, private duty nursing services, certain non-experimental medical and surgical procedures, and chiropractic services.

Accountability of services – Medical records and health education documentation must be maintained.

Timeliness of services – Timely screening, diagnosis and treatment are essential in correcting or ameliorating defects of physical and mental illness during their early stages when conditions are easily treated.

Childhood Immunizations

Immunizations are an important part of EPSDT covered services. HMSA expects that the immunization status of the child will be assessed at each office visit, whether the visit is for EPSDT, chronic or acute care. If it is determined at the time of the screening that immunization is needed and appropriate, administer the immunization at that time. If it isn’t appropriate, please schedule a catch-up visit.

Administration of the immunization is left to the judgment of the physician and depends on the health status of the child at the time of the office visit. HMSA will not create any barriers to ensuring that immunizations are provided at the appropriate time. The administration is covered under the global EPSDT fee if provided during the EPSDT exam. All vaccines for members’ ages newborn through 18 years of age are provided through the Vaccines for Children (VFC) program. Immunizations for members age 19 and older are a covered benefit.

Additional information on the immunization requirement is in the section EPSDT Screening Component Requirements below.

Periodicity Schedule

• Seven exams from the member’s birth through the 12th month of age.
• Four exams from 13 months through 30 months of age.
• One exam each year starting at the age of 3 through 20 years old, spaced apart to yield meaningful results.

PCPs assigned a new EPSDT-eligible patient may do a “new member” EPSDT exam within 90 days of the assignment. This is an additional exam apart from the periodicity schedule to become familiar with the child’s health status.

When a routine physical exam is scheduled about the time an EPSDT exam is due, PCPs should consider providing all the EPSDT components, attaching both pages of a DHS 8015 Form (Pages 1 and 2, even if there is no information included on page 2) and submitting the visit as an EPSDT exam.

QUEST Integration generally covers only one professional visit each day per provider per patient. When a medical office visit and an EPSDT exam are billed for the same day, only the higher fee EPSDT visit will be accepted provided the required Clinical Information Form is completed and submitted with the claim. If the required form is not submitted, the claim will be denied with the message “Please submit EPSDT claim with Form 8015 or EPSDT catch up visit claim with Form 8016”.

EPSDT Screening Exams

PCPs may conduct the following EPSDT screenings:

• Periodic Screening: According to the EPSDT schedule and requirements of the State Medicaid Manual.
• Interperiodic Screenings: Interperiodic screenings are medically necessary screenings that occur between complete periodic screens. An interperiodic screen is a physical examination which is done more than 3 months after a complete examination has occurred. For example, an interperiodic screen may be required for school sports participation or as a new patient exam required by a new PCP.
• Partial Screenings: Partial screens occur when a screen for one or more specific conditions is needed, such as a vision or hearing screen.

HMSA covers all medically necessary diagnostic and treatment services to correct or ameliorate a medical, dental or behavioral health problem discovered during any of the EPSDT screenings (Periodic, interperiodic) or Partial), when provided by the PCP or a specialist.

EPSDT Screening Component Requirements

Health histories – Initial health history at the first assessment should include prenatal, delivery, neonatal, family, social, developmental, nutritional and medical information. Interval health history at subsequent screens should include medical, developmental (including school progress) and nutritional information. All must be recorded in the patient’s medical chart.

Measurements – Information must be plotted on the CDC’s National Center for Health Statistics (NCHS) charts. Individual growth charts are available from the CDC’s website http://www.cdc.gov/growthcharts/charts.htm.

Physical examination – A comprehensive physical examination, with positive findings, disposition and referrals recorded in the medical records. Head circumference, height and weight measurements must be plotted on a standard growth chart. Blood pressure readings are to be taken beginning at age 3.

Developmental/Behavioral Assessment – Obtain relevant developmental/behavioral/school history using age specific developmental screens and behavioral questionnaire/surveys (e.g., Eyberg). Examples of developmental screens include PEDS and ASQ. Other validated screening tools recommended by the AAP may also be used. A list of these tools can be found at the AAP website noted on the back of the DHS Forms 8015 and 8016. Appraisal of young child should include gross motor, fine motor, communication, self-help/self-care, socio-emotional, and cognitive skills development. Evaluation of school-age children should include attention skills, learning disabilities, peer relationship, psychological/psychiatric problems.

Vision Screening – Vision screening is required at each EPSDT exam. Gross screening is appropriate for young children.

Hearing/Language Screening – Screening is required at each EPSDT exam except when an audiogram is required. Gross screening is appropriate for young children

Audiogram – Audiogram testing is required at the 4, 5, 6, 8, and 10 year-old exams.

Dental Care – Inquire with the patient or parent whether the child has seen a dentist in the past year. Encourage parents of patients 12 months and older to have their child seen by their dentist every six months. If there are dental problems, children younger than 12 months may be referred to a dentist.

Hematocrit or Hemoglobin – Patients between the ages of 9-12 months and females 12-14 years should be screened for anemia. This may be ordered in conjunction with blood lead level testing for age-appropriate patients.

Verbal Lead Risk Assessment – A verbal risk assessment is required at each EPSDT exam for patients age 6 months to 72 months. Use the questions below as a guide to assess risk. If there are no risk factors, indicate “SLRA – negative” in the patient’s chart to denote that the State Lead Risk Assessment was negative. If any of the responses indicate positive risk factors, a blood lead level test must be done.

1. Did the child have an elevated blood lead level in the past?
2. Does the child have a sibling or playmate with lead poisoning?
3. Does the child live in or regularly visit a place built before 1978?
4. Does anyone close to the child have a job or hobby in:
   1. Painting/electrical/plumbing
   2. Ceramic, pottery using lead glaze
   3. Automotive repair/car batteries
   4. Fishing sinkers/fishing activities
   5. Boat repair
   6. Soldering/welding
   7. Remodeling/renovation
   8. Building/demolition

Blood Lead Level – Testing is required for the following children:

• All children in the 9-12 months age group even if not at risk
• All children 24 months of age even if not at risk
• All children with risk factors
• All children age 36-72 months who have not previously been tested

If lab results are within normal range, the blood test should be repeated in a year. If the results are borderline or elevated, a re-test should be accomplished according to the Centers for Disease Control and Prevention (CDC) guidelines.

Fluoride/Vitamin Prescription – Prescribe supplemental fluoride therapy according to the recommendations of the American Academy of Pediatric Dentistry and the American Academy of Pediatrics.

Autism Screening – Screening is required at the 18-month and 24-month exams. CHAT, or MCHAT, is the recommended screening tool. However, other validated screening tools recommended by the AAP may also be used. A list of these tools can be found at the AAP website listed on the back of the DHS Forms 8015 and 8016.

Other – Other tests as required. Sickle cell screen, which is optional, may be performed for highly ethnically susceptible individuals such as those of African-American descent. G6-PD screen may also be done for highly ethnically susceptible individuals such as those of Filipino or Chinese descent.

Immunizations – Immunizations should be provided according to the current recommendations of the Hawaii State Department of Health, Advisory Committee on Immunization Practices, Centers for Disease Control, and the American Academy of Pediatrics. Vaccines must be obtained through the Vaccines for Children (VFC) program for members through 18 years of age. For members age 19 and older, the vaccine may be billed separately using the applicable NDC number for the vaccine.

If a parent does not wish a child to be immunized, please note this on the Clinical Information Form so that we may assist with intervention on the importance of immunizations.

Health Education and Counseling – Provide age appropriate anticipatory guidance for general health, nutrition, developmental, behavioral, safety and parenting according to The American Academy of Pediatrics Bright Futures Guidelines. (Hagan JF, Shaw JS, Duncan P, eds. 2008. Bright Futures: Guidelines for Health Supervision of Infants, Children, and Adolescents, Third Edition. Pocket Guide. Elk Grove Village, IL: American Academy of Pediatrics).http://brightfutures.aap.org/3rd_Edition_Guidelines_and_Pocket_Guide.html.

Please note that substance abuse and sexuality counseling is required for adolescents ages 12 years and older.

Dental EPSDT Services to be Performed by the PCP

Generally, dental services for QUEST Integration members are the responsibility of the Medicaid fee-for-service program. However, there are some services that the PCP is expected to provide.

Birth to 11 months old

1. Oral Evaluation
   1. Check for presence of baby bottle tooth decay
      • Brown and/or while spots, or obvious destruction, on the maxillary
      • anterior teeth and back molars, as well as mandibular teeth
   2. Check for proper growth and development of the teeth and jaw
   3. Check for healthy gums
   4. Check for adequate oral hygiene

2. Recommendation of systemic fluoride or vitamins with fluoride for all children

   6 mos – 3 years

   0.25 mg daily*

   *This reflects the general experience in Hawaii. If the child's drinking water is fluoridated this schedule will not apply.

3. Anticipatory Guidance
   1. Teething
   2. Oral Habits – thumb sucking, pacifiers
   3. Injury prevention – use of walkers
   4. Oral Hygiene – wiping the teeth and gums with gauze or a wash cloth
   5. Nutrition – avoid fruit juices, formulas and soda in infant’s naptime and nighttime bottle; decrease foods high in refined sugar content
4. Dental Referral

   Refer the child for a dental visit if either of the following is present:

   1. Signs of baby bottle tooth decay
   2. Any evidence of problems with teeth, gums or jaw structure
5. Discourage
   1. Night ad lib breast feeding after the first primary teeth have erupted.
   2. Being put to bed with a bottle. If unable, use plain water only.

12 months and thereafter

1. Oral Evaluation
   1. Check for obvious tooth decay, including baby bottle tooth decay
   2. Check for proper growth and development of teeth and jaw
   3. Check for healthy gums
   4. Check for adequate oral hygiene

2. Recommendation of systemic fluoride or vitamins with fluoride for all children

   6 mos – 3 years	0.25 mg. daily*
   3 – 6 years	0.5 mg. daily*
   6 – 16 years	1.0 mg. daily*

   *This reflects the general experience in Hawaii. If the child’s drinking water is fluoridated this schedule will not apply.

3. Dental Referral
   1. Refer all children at 1 year old, especially if no teeth are present
   2. If no dental visit in the past six months (Ask)
   3. If any problems are found
   4. If the child has been seen by a dentist remind parent to keep appointment for their child’s six month checkup
   5. QUEST Integration dental services are provided by the Medicaid fee-for-service program. If the parent is not sure who the child’s dentist is, refer the parent to the Community Case Management Corporation at 808-792-1070 (Oahu) or 1-866-792-1070 (Neighbor Islands).
4. Encourage elimination of bottle feeding by 12-14 months of age
5. Anticipatory Guidance – Adapt to the child’s age
   1. Oral Habits - thumb sucking, nail biting, chewing ice
   2. Injury prevention – learning to walk, sport activities (mouth guards)
   3. Oral Hygiene – tooth brushing and flossing
   4. Nutrition – decrease of foods high in refined sugar content
   5. Substance Abuse (drugs, smoking and smokeless tobacco) – from ages 10-19
   6. Pregnancy – importance of oral hygiene to prevent gum problems
   7. Contact dentist if problems occur – broken tooth, swelling, bleeding

Provider Responsibility

Providers are critical to the program’s success. In order for this program to be a success, it is critical that parents and the child’s PCP are involved. HMSA makes every effort to effectively communicate with parents and PCPs. The EPSDT Coordinator is HMSA’s key liaison with providers and members to ensure the timely provision of routine well child and preventive health services. In addition, HMSA Care Coordinators are available to assist providers if they need any assistance with members.

• Provide health screening services, including immunizations, according to EPSDT guidelines and periodicity schedule.
• Provide appropriate information to enable patients or their families to make medically informed decisions about their healthcare practices and to foster patient compliance with the prescribed treatment program, with the assistance of HMSA’s care coordinators, if necessary.
• Promptly diagnose, treat or provide referral for problems identified during the screening process with services started within 6 months from the request for screening.
• Maintain a consolidated health record for each patient including information received from other providers and dates of contact regarding appointments (and rescheduling when necessary) for EPSDT screenings, recommended diagnostic or treatment services and follow-up referrals.

Payment

A global fee is paid for each screening examination billed with a CPT E&M codes 99381 – 99385 or 99391 – 99395 when billed with modifier EP and indicator Y in column 24H of paper CMS 1500 claims. A completed DHS Form 8015 must also be submitted with claims or visits will be denied with the message “Please submit EPSDT claim with Form 8015 or EPSDT catch up visit claim with Form 8016.”

The global fee includes payment for the mandatory and optional procedures and tests as well as administration of immunizations. The cost of vaccines for immunizations for children through age 18 years of age is not paid since these vaccines are available at no cost from the Department of Health’s Vaccines for Children Program. Laboratory screens for G6-PD and sickle cells are paid separately when billed by the laboratory.

A reduced global fee is paid for “catch-up” immunizations billed with CPT procedure codes 99211 – 99215 with modifier EP. This includes payment for a brief office visit to determine that the child does not have an acute illness, review of the immunization schedule, administration of the immunization and counseling as needed. If a child is immunized as part of a medical visit, only one visit fee is paid, either the medical visit using the applicable CPT-4 procedure code, or the “catch-up” reduced global fee. A completed DHS Form 8016 must be submitted with claims or the claims will be denied with the message “Please submit EPSDT claim with Form 8015 or EPSDT catch up visit claim with Form 8016.”

EPSDT Forms

EPSDT screening exams must be documented with one of the following forms.

• Hawaii Early and Periodic, Screening, Diagnostic, and Treatment (EPSDT) Exam form (DHS 8015) is used to report the findings of the EPSDT screens, any referrals made, care coordination needs, and immunization status.
• The EPSDT Catch up and Follow-Up Exam Form (DHS 8016) is used to report when a child is seen to bring immunizations up to date, including any referrals made.

For instructions how to obtain, complete and submit the DHS 8015 and DHS 8016 EPSDT forms please visit Training (hawaii.gov) or contact the EPSDT Help Desk:

• Phone: 808-900-8650
  • Hours of Operation: 8 a.m. to 5 p.m. (Monday to Friday)
• Email: epsdthelpdesk@dhsie.com

The appropriate version of the DHS Form 8015 must be completed and submitted with an EPSDT screening examination claim. The original version of the DHS Form 8016 must be completed and submitted with all EPSDT catch-up exams. The forms should be attached to the submitted paper claim or mailed before submitting electronic medical claims (EMC) so that HMSA has the form by the time the electronic claim is received. If the form is not submitted, the EPSDT screening exam will be denied with the message “Please submit EPSDT claim with Form 8015 or EPSDT catch up visit claim with Form 8016.” In addition, if a post-payment review of a submitted EPSDT form shows that all the required elements were not done, the EPSDT global fee that was paid for the visit will be recouped.

The DHS Form 8015 provides periodicity information to help you plan your EPSDT appointments and data you provide enables HMSA to provide reports to the state and federal governments. The form also provides information on patients’ health and immunization status, which helps to determine whether intervention by a care coordinator is needed to help a family keep their children healthy.

Form Completion Requirements-DHS 8015

Links to online videos on how to complete the forms are available at:

https://www.youtube.com/playlist?list=PL4642534463F4D328

Use black or blue ink. Completely fill in bubbles; do not use check marks, x’s or draw a line through one of more bubbles. If the age of the patient on the date of an exam is not listed at the top of the form under “Indicate the EPSDT period screening age being reported”, select the age immediately below the age of the child if the child has not yet received that exam. If the child already received the earlier exam, the next exam may be selected. For example, if the child is 8 months old, select the 6 month exam, or the 9 month exam if the 6-month exam was already completed.

If the EPSDT comprehensive exam was done, indicate the findings as either “Normal” or “Abnormal” in the Screening Done Today section of the form, complete, sign and submit the form with the EPSDT claim. It is not necessary to write further explanations related to normal findings and/or concerns.

Patient Information

Measurements

Screening Done Today

Referrals Made Today, Care Coordination Assistance Needed

Referrals Made Today (Note: If this section is left blank it denotes that no referrals were needed or made.)

Care Coordination Assistance Needed

Provider Information

Form Completion Requirements – DHS 8016

The purpose of the DHS 8016 is to provide a format for providers to report immunizations that were not administered on the date of an Early and Periodic, Screening, Diagnostic, and Treatment (EPSDT) Exam. Also, the form allows providers to report on results of specific screening tests performed or repeated and on follow-up treatment and referrals.

Use black or blue ink. Completely fill in circles; do not use check marks, x’s or draw a line through one or more circle.

Patient Information

Immunization Catch Up

Screening Done Today

Referrals Made Today

Provider Information

Revision History