Arkansas Administrative Code
Agency 016 - DEPARTMENT OF HUMAN SERVICES
Division 06 - Medical Services
Rule 016.06.05-092 - Child Health Services / Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) Provider Manual Update Transmittal #69; Ventilator Equipment Provider Manual Update Transmittal #55; Division of Youth Services (DYS) and Division of Children and Family Services (DCFS) Targeted Case Management Provider Manual Update Transmittal #9; Children's Services Targeted Case Management Provider Manual Update Transmittal #17; DDS Alternative Community Services (ACS) Waiver Program Provider Manual Update Transmittal #57; Prosthetics Provider Manual Update Transmittal #74

See section 212.000 for EPSDT screening terminology.

An EPSDT periodic complete medical screen includes both hearing and vision screens. Providers must not bill an EPSDT periodic or interperiodic vision or hearing screen on the same day or within 7 days of an EPSDT complete medical screen by the same or different providers. The above billing combinations represent a duplication of services.

An EPSDT interperiodic full medical screen includes both hearing and vision screens. Providers must not bill an EPSDT periodic or interperiodic vision screen on the same day or within 7 days of an EPSDT interperiodic full medical screen by the same or different providers. The above billing combinations represent a duplication of services.

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.

1 Exempt from PCP referral requirements

2Covered when specimen is referred to an independent lab

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.

When billing on paper, the EPSDT screening services must be billed with a type of service code "6."

For billing on paper, immunizations must be billed with a type of service code "1."

Screens

Child Health Services (EPSDT) screens do not include laboratory procedures unless the screen is performed by the recipient's primary care physician (PCP) or is conducted in accordance with a referral from the PCP.

The following tests are exempt from this limitation and may continue to be billed in conjunction with an EPSDT Screen performed in accordance with existing Medicaid policy:

Claims for laboratory tests, other than those specified above, performed in conjunction with an EPSDT screen will be denied, unless the screen is performed by the PCP or in accordance with a referral from the PCP.

The following screens will be affected by this policy:

* Procedure codes 99381 through 99385 (New Patient) with modifier EP should only be used to bill an EPSDT Interperiodic Full Medical Screen for new patients, ages 0 through 20 years of age, who have already received an EPSDT Periodic Complete Medical Screen by another PCP within the current fiscal year.

Ventilator Equipment

Procedure codes must be billed either electronically or on paper with the modifiers indicated. Additionally, when billed on paper, procedure codes must be billed with a type of service (TOS) code "6" for individuals under age 21 or TOS code "9" for individuals of all ages.

Prior authorization requirements are shown under the heading PA.

CS Targeted Case Management

Providers of Children's Services targeted case management (TCM) must bill for services provided using the procedure code shown in the list below. Providers must use this code and the indicated modifiers when billing either electronically or on paper for Children's Services TCM services. Additionally, when billing on paper, the procedure code must be billed with a type of service code "9."

DDS Alternative Community Services (ACS) Waiver

The following procedure codes and any associated modifier(s) must be billed for DDS ACS Waiver Services. Prior authorization is required for all services.

Providers must bill for the repair of orthotic appliances and prosthetic devices utilizing the procedure codes listed in the table below. One unit of service equals 15 minutes. A maximum of 20 units of service is allowed per date of service. Any applicable pages from the manufacturer's catalog and the manufacturer's invoice for parts must be attached to all repair claims.

Reimbursement for orthotic appliances and prosthetic devices requiring manual pricing will be calculated using the manufacturer's invoice price plus 10%. The manufacturer invoice must be attached to all repair claims.

When billed either electronically or on paper, procedure codes found in this section must be billed with modifier EP for beneficiaries under 21 years of age or modifier NU for beneficiaries age 21 and over. When a second modifier is listed, that modifier must be used in conjunction with either EP or NU.

Additionally, when billed on paper, procedure codes must be billed with a type of service (TOS) code "6" for individuals under age 21 or TOS "H" for individuals age 21 and over.

Modifiers in this section are indicated by the headings M1 and M2. Type of service is indicated by the heading TOS. Prior authorization requirements are shown under the heading PA. If prior authorization is needed, the information is indicated with a "Y" in the column; if not, an "N" is shown.

* Prior authorization is not required when another insurance pays at least 50% of the

Medicaid maximum allowable reimbursement amount.

***(...) This symbol, along with text in parentheses, indicates the Arkansas Medicaid description of the product.

Respiratory and Diabetic Equipment, All Ages (section 242.110)

Providers will be reimbursed for a minimum of 30 days of rental when the equipment is used less than 30 days. Initial rental codes should only be billed when equipment is used less than 30 days during the first month of rental.

Arkansas Medicaid will only reimburse for one initial minimum 30 days of rental per state fiscal year period per beneficiary per procedure code. The provider will not be reimbursed for the same procedure code utilizing another modifier and type of service for the same time period.

Procedure codes found in this section must be billed either electronically or on paper with modifier NU for individuals of all ages. When a second modifier is listed, that modifier must be used in conjunction with the NU modifier.

Additionally, when billed on paper, procedure codes must be billed with a type of service (TOS) code "H" for individuals of all ages. Modifiers in the section are indicated by the headings M1 and M2. Type of service is indicated by the heading TOS. Prior authorization is indicated by the heading PA.

Procedure codes found in this section must be billed either electronically or on paper with modifier NU for individuals of all ages. When a second modifier is listed, that modifier must be used in conjunction with the modifier NU.

Additionally, when billed on paper, procedure codes must be billed with a type of service (TOS) code "H" for individuals of all ages.

Modifiers in this section are indicated by the headings M1 and M2. Type of service is indicated by the heading TOS.

Procedure codes found in this section must be billed either electronically or on paper with modifier EP for beneficiaries under 21 years of age or modifier NU for beneficiaries age 21 and older. When a second modifier is listed, that modifier must be used in conjunction with either EP or NU.

Additionally, when billed on paper, procedure codes must be billed with a type of service (TOS) code "6" for individuals under age 21 or TOS code "H" for individuals age 21 and older.

Modifiers in this section are indicated by the headings M1 and M2. Type of service is indicated by the heading TOS.

Prior authorization requirements are shown under the heading PA. If prior authorization is needed for individuals age 21 and older, that information is indicated with a "Y" in the column; if not, an "N" is shown. When prior authorization is not applicable (for U21) that information is shown with an "N/A" in the column.

When codes are payable for all ages, "All" is indicated in the column, "U21" is shown when the code is payable only for individuals under age 21 and "21+" is shown when the code is payable only for those individuals age 21 and older.

** This item is not a covered service for the diagnosis of Carpal Tunnel Syndrome prior to surgery.

***(...) This symbol, along with text in parentheses, indicates the Arkansas Medicaid description of the product.

Orthotic Appliances, All Ages (section 242.180)

Orthotic Appliances, All Ages (section 242.180)

Procedure codes found in this section must be billed either electronically or on paper with modifier EP for beneficiaries under 21 years of age or modifier NU for individuals age 21 and older. When a second modifier is listed, that modifier must be used in conjunction with either EP or NU.

Additionally, when billed on paper, procedure codes must be billed with type of service (TOS) code "6" for individuals under age 21 or TOS code "H" for beneficiaries age 21 and older.

Modifiers in this section are indicated by the headings M1 and M2. Type of service is indicated by the heading TOS.

Prior authorization requirements are shown under the heading PA. If prior authorization is needed for individuals age 21 and older, that information is indicated with a "Y" in the column; if not, an "N" is shown. When codes are payable for all ages, "All" is indicated in the column, "U21" is shown when the code is payable only for individuals under age 21 and "21+" is shown when the code is payable only for those individuals age 21 and older.

* Replacement only

***(...) This symbol, along with text in parentheses, indicates the Arkansas Medicaid description of the product.

Prosthetic Devices, All Ages (section 242.190)

for Individuals Age Two Through Adult

Procedure codes found in this section must be billed either electronically or on paper with modifier EP for beneficiaries under 21 years of age or modifier NU for beneficiaries age 21 and older. When a second modifier is listed, that modifier must be used in conjunction with either EP or NU.

Additionally, when billed on paper, procedure codes found in this section must be billed with a type of service (TOS) code "6" for individuals under age 21 or TOS code "H" for individuals age 21 and older.

Modifiers in this section are indicated by the headings M1 and M2. The type of service code is indicated by the heading TOS. Prior authorization requirements are shown under the heading PA. If prior authorization is needed, that information is indicated with a "Y" in the column; if not, an "N" is shown.

Other coding information found in the chart:

Procedure codes found in this section must be billed either electronically or on paper with modifier EP for beneficiaries under 21 years of age or modifier NU for beneficiaries age 21 and over. When a second modifier is listed, that modifier must be used in conjunction with either EP or NU.

Additionally, when billed on paper, procedure codes must be billed with a type of service (TOS) code "6" for individuals under 21 years of age or TOS code "H" for individuals age 21 or over.

Modifiers in this section are indicated by the headings M1 and M2. Type of service is indicated by the heading TOS. Prior authorization requirements are shown under the heading PA. If prior authorization is needed, that information is indicated with a "Y" in the column; if not, an "N" is shown.

** Indicates that providers may bill only for individuals under age 21.

* Prior authorization is not required when another insurance pays at least 50% of the

Medicaid maximum allowable reimbursement amount.

***(...) This symbol, along with text in parentheses, indicates the Arkansas Medicaid description of the product.

Specialized Rehabilitative Equipment, All Ages (section 242.192)