EPSDT Clinical & Operational Guidelines

UPDATES:

• The EPSDT Periodicity Schedule has been updated to reflect the changes made by DHS Bulletin 99-22-07.
• The EPSDT Telemedicine Guide is now available.

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UPMC for You adopted Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) requirements based on changes implemented by the Pennsylvania Department of Human Services (DHS) in 2008.

UPMC for You and DHS recognize the importance of comprehensive childhood screenings and providing appropriate and timely follow‐up diagnostic treatment services. We encourage and support physicians in performing EPSDT services. UPMC for You developed EPSDT Clinical and Operational Guidelines to explain our requirements for payments and to provide sample billing instructions. We are also including a sample of the quarterly EPSDT reports, which were implemented in January 2009, and the 2009 immunization schedule.

Important points to know about the UPMC for You EPSDT requirements:

• Providers can perform and bill for a sick visit and an EPSDT visit on the same date of service in the following circumstances:
  • When it is determined that the illness or injury that led to the sick visit does not impede the ability to complete a well-child visit and
  • The child is due for an EPSDT visit
  
  Correct use of Modifier 25, which indicates when a significant and separately identifiable service is delivered, will result in reimbursement for both services.
• The EPSDT service will be paid in full if all of the appropriate services are rendered for the correct EPSDT periodicity visit, per the UPMC for You periodicity chart. Appropriate use of the 52 modifier will not result in a reduced payment. Properly billed claims with the 52 modifiers will receive payments in full.
• For services that can be provided, but a 52 modifier was used, the provider must complete the service at the next screening.
• Incorrect billing will result in a reduced rate.

Important information and forms:

• Periodicity Schedule
• EPSDT Billing Guide
• EPSDT Telemedicine Billing Guide
• Adolescent Well-care and Telehealth Tip Sheet
• Lead Screening Provider Tip Sheet
• Autism Screening Tip Sheet
• Developmental Screening: Provider Tip Sheet
• Weight Assessment and Counseling Tip Sheet
• Environmental Lead Investigative Request Form
• Recommendations for Preventive Pediatric Oral Health Care (Dental Periodicity Schedule)
• Dental Referral Form
• Early Intervention Referral Form
• Quarterly Report
• CMS 1500 Form
• Immunization Schedules (0-18 years and “catch-up”)
• Day Calculator – Please do not select the "Include end date in calculation (1 day is added)" option on the calculator page.
• Screening Tools*
  • Validated Screening Tools for Developmental Delays and Autism Spectrum Disorder
    • Developmental Screening Tools
      • For Purchase
        • Ages and Stages Questionnaire
        • Parents' Evaluation of Developmental Status (PEDS)
      • At No Cost
        • Survey of Well-being of Young Children
    • Autism Screening Tools
      • At No Cost
        • Modified Checklist for Autism in Toddlers, Revised, With Follow-up (M-CHAT-R/F)
        • Survey of Well-being of Young Children
  • Screening Tools for Maternal Depression
    • Depression Screening Tools
      • At No Cost
        • Patient Health Questionnaire-2 (PHQ-2)
        • Patient Health Questionnaire-9 (PHQ-9)
        • Edinburgh Postnatal Depression Scale
  • Tobacco, Alcohol, or Drug Use Assessment
    • Assessment Recommended by AAP
  
  *This is not an exhaustive list of validated screening tools. UPMC Health Plan and UPMC for You do not endorse or require the use of any specific screening tool.

  Childhood Nutrition and Weight Management Services:

  • Medical Assistance Bulletin: Childhood Nutrition and Weight Management Services for Recipients Under 21 Years of Age
  • Provider Quick Tip: Childhood Nutrition and Weight Management Services Reminder