Arkansas Administrative Code
Agency 016 - DEPARTMENT OF HUMAN SERVICES
Division 06 - Medical Services
Rule 016.06.05-099 - Child Health Services / Early and Periodic Screening, Diagnosis and Treatment (EPSDT) Provider Manual Update Transmittal #71

A comprehensive medical screening program for all eligible Medicaid children requires the medical provider to assume overall responsibility for detection and treatment of conditions found among these young patients. This means the provider should have knowledge of specialized referral services available within the community and should maintain continuing relationships with physician specialists. It also requires the provider to work closely with the Arkansas Department of Health and Human Services office staff to ensure that eligible children in need of medical attention take full advantage of the medical services available to them.

The screening procedures outlined in Sections 213.000 and 215.000 of this manual are considered the minimal elements of a comprehensive screening. Other procedures may be included depending upon the child's age and health history. Each of the screening procedures is based on recommendations from the federal Department of Health and Human Services and the American Academy of Pediatrics. Each screening should be billed separately, providing the appropriate information for each of the applicable screening components. Other specific procedures may be used at the screener's discretion as long as the following federally mandated components are included in the complete medical screening procedure: observe and measure growth and development, give nutritional advice, immunize, counsel and give health education and perform laboratory procedures applicable for the age of the child.

Requirements for Periodic Medical, Visual, Hearing and Dental Screenings

Distinct periodicity schedules have been established for medical screening services, vision services, hearing services and dental services (i.e., each of these services has its own periodicity schedule). Periodic visual, hearing and dental screens should not duplicate prior services.

The Child Health Services (CHS) Early and Periodic Screening, Diagnosis and Treatment (EPSDT) Program is a federally mandated child health component of Medicaid. It is designed to bring comprehensive health care to individuals eligible for medical assistance from birth to age 21. Even if the person eligible for medical assistance is a parent, he or she is eligible for Child Health Services (EPSDT) if under age 21. Physicians and other health professionals who provide Child Health Services (EPSDT) screening may diagnose and treat health problems discovered during the EPSDT screening or may refer the child to other appropriate sources for such care.

The following is a broad definition of the components of the Child Health Services EPSDT program.

Early means as soon as possible in the child's life, or as soon as his or her family's eligibility for assistance has been established.

Periodic means at intervals established for screening by medical, dental, visual and other health care experts. The types of screening procedures performed and their frequency will depend on the child's age and health history. In Arkansas, the medical periodic screening schedule has been established following the recommendations of the American Academy of Pediatrics.

Screening is the use of quick, simple procedures to sort out apparently well persons from those who may have a disease or abnormality and to identify those in need of a more definitive examination.

Diagnosis is the determination of the nature or cause of a disease or abnormality through the combined use of health history, physical, developmental and psychological examination, laboratory tests and X-rays.

Treatment means physician, hearing, visual or dental services or any other type of medical care and services recognized under state law to prevent, correct or ameliorate disease or abnormalities detected by screening or by diagnostic procedures. Treatment for conditions discovered through a screen may exceed limits of the Medicaid Program. Services not otherwise covered under the Medicaid Program will be considered for coverage if the services are prescribed by a physician as a result of an EPSDT screen. The services must be medically necessary and permitted under federal Medicaid regulations.

The following steps are necessary in order to complete a Child Health Services (EPSDT) screen:

See section 212.000 for EPSDT screening terminology.

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.

Services must be filed with the appropriate national procedure codes and applicable modifiers.

The following procedure codes with the applicable modifier represent an EPSDT Periodic Complete Medical Screen that includes both hearing and vision screens.

EPSDT Periodic Complete Medical Screen claims must be filed with the appropriate CPT-4 procedure codes and modifier. Procedure codes 99381 through 99385 (New Patient), with modifiers EP and U1, and procedure codes 99391 through 99395 (Established Patient), with modifiers EP and U2, will represent an EPSDT periodic complete medical screen, which includes both hearing and vision screens.

Immunizations and laboratory tests may be billed separately.

Example for EPSDT Periodic Complete Screen for an established patient:

99391, Modifiers EP and U2 = EPSDT Periodic Complete Medical Screen

Child Health Services (EPSDT) screens do not include laboratory procedures unless the screen is performed by the beneficiary'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: