Annual Wellness ExamAnnual Wellness ExamEPSDTEPSDT

Paula LeSueur MSN, CFNPPaula LeSueur MSN, CFNPSBHC Medicaid ConsultantSBHC Medicaid Consultant

Envision NMEnvision NM

20072007

EPSDT EPSDT Early Periodic Screening, Diagnosis and Early Periodic Screening, Diagnosis and

TreatmentTreatment

Objectives for our SBHCs:Objectives for our SBHCs: Provide comprehensive preventive health Provide comprehensive preventive health

care.care. Identify student’s assets, risk behaviors and Identify student’s assets, risk behaviors and

health risks.health risks.

Components of Complete Components of Complete EPSDT ScreenEPSDT Screen

A comprehensive health and developmental history, A comprehensive health and developmental history, including an assessment of both physical and including an assessment of both physical and mental health development.mental health development.

A comprehensive, unclothed physical exam.A comprehensive, unclothed physical exam. Appropriate immunizations, according to age and Appropriate immunizations, according to age and

health history, unless medically contraindicated at health history, unless medically contraindicated at the time.the time.

Laboratory tests, including an appropriate lead Laboratory tests, including an appropriate lead blood level assessment (at 1 and 2 yrs of age).blood level assessment (at 1 and 2 yrs of age).

Health education, including anticipatory guidance.Health education, including anticipatory guidance.

Preventive Health Guidelines for Preventive Health Guidelines for Children and AdolescentsChildren and Adolescents

EPSDT recommended every year from EPSDT recommended every year from birth to age 20. birth to age 20.

Physical exam and developmental / Physical exam and developmental / behavioral health assessment.behavioral health assessment.

Nutrition screening.Nutrition screening. Measurements include; ht, wt, BMI Measurements include; ht, wt, BMI

percentile, and blood pressure (from age 2 percentile, and blood pressure (from age 2 to 20).to 20).

Developmental/Behavioral Developmental/Behavioral Health AssessmentHealth Assessment

Utilize the Recommended Developmental Utilize the Recommended Developmental and Behavioral Health Assessment for and Behavioral Health Assessment for ages birth to 21 (HEADSS).ages birth to 21 (HEADSS).

The OSAH Student Health Questionnaire The OSAH Student Health Questionnaire provides the required information. Use provides the required information. Use appropriate SHQ for Elementary School, appropriate SHQ for Elementary School, Middle School or High School. Middle School or High School.

Sensory ScreeningSensory Screening

Vision—Snellen eye chartVision—Snellen eye chart at age 3 through age 12,15 & 18.at age 3 through age 12,15 & 18.

Hearing/speechHearing/speech at age 4 through age 12, 15 & 18.at age 4 through age 12, 15 & 18. use audiometer, under earphones, at 1000, use audiometer, under earphones, at 1000,

2000 and 4000 Hertz at 20 decibels.2000 and 4000 Hertz at 20 decibels.

Physical Exam includes:Physical Exam includes:

Complete unclothed physical exam.Complete unclothed physical exam. External genital exam and Tanner staging External genital exam and Tanner staging

is required. Document in chart if student is required. Document in chart if student declines the exam (e.g. deferred at patient declines the exam (e.g. deferred at patient request). Tanner staging may be done by request). Tanner staging may be done by self report.self report.

Provide education re: testicular and breast Provide education re: testicular and breast self-exam as appropriate. self-exam as appropriate.

Lab ScreeningsLab Screenings

Urinalysis - to be performed at age 5 and Urinalysis - to be performed at age 5 and 15. May use Chemstrip 9.15. May use Chemstrip 9.

Hematocrit/hemoglobin - to be done at 9 Hematocrit/hemoglobin - to be done at 9 months and age 13. If indicated, may months and age 13. If indicated, may repeat after menarche in females. repeat after menarche in females.

High Risk Factor ScreeningsHigh Risk Factor Screenings

Tuberculin Test - Tuberculin Test - Screen all teens for high-risk factors.Screen all teens for high-risk factors. Test if high individual risk. Test if high individual risk. Risk factors include immigration or travel to Risk factors include immigration or travel to

areas of high prevalence, IV drug use, areas of high prevalence, IV drug use, incarceration, homelessness, HIV infection or incarceration, homelessness, HIV infection or living with person with HIV, working or living with person with HIV, working or volunteering in health care setting.volunteering in health care setting.

High Risk Factor ScreeningsHigh Risk Factor Screenings

Pelvic exam - Pelvic exam - To be done with all sexually active females, with To be done with all sexually active females, with

their consent, or initial exam at age 18 to 21.their consent, or initial exam at age 18 to 21. DOH Family Planning Division protocol states DOH Family Planning Division protocol states

pelvic exam should be performed within 6 months pelvic exam should be performed within 6 months of contraceptive use and PAP test should be of contraceptive use and PAP test should be performed after 3 years of sexual activity or age performed after 3 years of sexual activity or age 21, whichever comes first.21, whichever comes first.

May complete the GYN or FP exam and schedule May complete the GYN or FP exam and schedule a return visit for the remainder of the EPSDT. a return visit for the remainder of the EPSDT.

High Risk Factor ScreeningsHigh Risk Factor Screenings

STD Screen – all sexually active youth STD Screen – all sexually active youth Urine chlamydia/gonorrhea .Urine chlamydia/gonorrhea . HIV test if high risk- positive contact with HIV test if high risk- positive contact with

known partner at risk, past STDs, multiple known partner at risk, past STDs, multiple partners, IV drug use or sex in exchange for partners, IV drug use or sex in exchange for money or drugs.money or drugs.

For males: sex with other males.For males: sex with other males. For syphilis only: test if reside in areas of For syphilis only: test if reside in areas of

prevalence. NM is not in an area of prevalence. NM is not in an area of prevalence.prevalence.

High Risk Factor ScreeningsHigh Risk Factor Screenings

Cholesterol - Cholesterol - Perform or refer for the test if high risk.Perform or refer for the test if high risk. Testing is based on individual risk,Testing is based on individual risk,

i.e. familial hyperlipidemia, family history of i.e. familial hyperlipidemia, family history of early onset of cardiovascular disease in early onset of cardiovascular disease in parents or grandparents at age 55 or less, parents or grandparents at age 55 or less, obesity, diabetes, high blood pressure or obesity, diabetes, high blood pressure or cigarette smoker.cigarette smoker.

ImmunizationsImmunizations

Tetanus Booster - Tdap done between ages 12-15. Tetanus Booster - Tdap done between ages 12-15. Required for 7th grade entry for 2007-08.Required for 7th grade entry for 2007-08.

MMR, varicella and HepA - assess, give if indicated MMR, varicella and HepA - assess, give if indicated and not previously given.and not previously given.

HepB - series should be completed in early HepB - series should be completed in early childhood or by 7th grade.childhood or by 7th grade.

Influenza for high risk groups.Influenza for high risk groups. HPV (3 doses). HPV (3 doses). Immunizations should be given according to the Immunizations should be given according to the

most current Advisory Committee of Immunization most current Advisory Committee of Immunization Practice (ACIP) schedule. (www.cdc.gov/nip).Practice (ACIP) schedule. (www.cdc.gov/nip).

Procedure for SBHCs Procedure for SBHCs (how to make appointments)(how to make appointments)

Who are the students served?Who are the students served? Means test – Means test –

what is the screening question?what is the screening question? Do you have a PCP?Do you have a PCP? Have you had a physical exam within the past Have you had a physical exam within the past

year?year? Will you need a sports physical exam (SPE) Will you need a sports physical exam (SPE)

some time this year?some time this year?

Procedures, con’t. Procedures, con’t.

Who and when will EPSDTs be scheduled? Who Who and when will EPSDTs be scheduled? Who will do vital signs, ht., wt., BMI % and lab tests? will do vital signs, ht., wt., BMI % and lab tests? Who does the exam, the counseling and the Who does the exam, the counseling and the education?education?

Instruct student to be prepared for unclothed Instruct student to be prepared for unclothed exam, come wearing t-shirt and gym shorts or exam, come wearing t-shirt and gym shorts or boxers. Have gowns or drapes.boxers. Have gowns or drapes.

Student to complete Student Health Question-Student to complete Student Health Question-naire for the Annual EPSDT and present the naire for the Annual EPSDT and present the health history form for the SPE, if needed.health history form for the SPE, if needed.

Procedures, con’t.Procedures, con’t.

Schedule annual exam (EPSDT) in SBHC for Schedule annual exam (EPSDT) in SBHC for all students registered who have a signed all students registered who have a signed parent consent form.parent consent form.

Include components of Sports Physical and Include components of Sports Physical and complete form, if needed.complete form, if needed.

Complete EPSDT, submit claim to Salud if an Complete EPSDT, submit claim to Salud if an approved Medicaid-SBHC provider.approved Medicaid-SBHC provider.

Provide referrals for lab tests or procedures Provide referrals for lab tests or procedures as necessary. Document referral.as necessary. Document referral.

Encounter Form/ Billing formEncounter Form/ Billing form

99215 Comprehensive, high complexity, 40 min.

99213 Expanded problem focused, 15 min.

99214 Comprehensive, mod. complexity, 25 min.

99211 Minimal, 5 min.

99212 Problem focused, 10 min.

OFFICE VISIT - ESTABLISHED PATIENT

Consider use of Modifier 25 (write in -25 after code)

99355x1 Prolonged Physician Service; face-to-face patient contact; 75-104 min. (also check 99354)

Comprehensive, mod. complexity, 45 min.

99205 Comprehensive, high complexity, 60 min.

Prolonged Physician Service; face-to-face patient contact; beyond usual service 30 - 74 min.99354

99201

Consider use of Modifier 25 (write in -25 after code)

Problem focused, 10 min.

Expanded problem focused, 20 min.99202

OFFICE VISIT - NEW PATIENT

99203 Detailed, 30 min.

99204

X X

Infant

1-4 years

5-11 years

12-17 years

18+ years

EPSDT Well Child Exam/Prev. Med. - New Patient

EPSDT Well Child Exam/Prev. Med. - Established Patient

5-11 years

12-17 years

18+ years

99392

99393

99394

99395

99382

99383

99384

99385

99381 99391 Infant

1-4 years

CodingCoding

Schedule return visit for STD/Family Planning Schedule return visit for STD/Family Planning services. Use E&M code, as indicated.services. Use E&M code, as indicated.

Reminder - If student refuses genital or any Reminder - If student refuses genital or any other part of the exam, including screening other part of the exam, including screening tests, document and state reason. tests, document and state reason.

Chaperone may be required for genital exam Chaperone may be required for genital exam of the opposite sex, which should be allowed of the opposite sex, which should be allowed upon student request. upon student request.

NotificationNotification

Inform parents of results of the exam, including Inform parents of results of the exam, including any screening tests or lab results, except any screening tests or lab results, except confidential information. Present results per phone confidential information. Present results per phone or written report.or written report.

Notify Primary Care Provider that Annual Notify Primary Care Provider that Annual Exam/EPSDT was performed by use of the New Exam/EPSDT was performed by use of the New Mexico SBHC Services Notification Form. Include Mexico SBHC Services Notification Form. Include any pertinent findings.any pertinent findings.

Schedule follow-up appointments for confidential, Schedule follow-up appointments for confidential, behavioral health or other health care services.behavioral health or other health care services.

Documentation to support billingDocumentation to support billing

ICD-9 code is V20.2 for youth to age 17.ICD-9 code is V20.2 for youth to age 17. ICD-9 code is V70.0 for youth 18 or older.ICD-9 code is V70.0 for youth 18 or older. Use of Modifier 25 – Use of Modifier 25 –

When the principal reason for the visit is an When the principal reason for the visit is an EPSDT and during the visit another separate EPSDT and during the visit another separate identifiable health condition requires identifiable health condition requires additional evaluation and management above additional evaluation and management above and beyond the other service, then a 25 and beyond the other service, then a 25 modifier can be attached to the secondary modifier can be attached to the secondary CPT.CPT.

Medical Chart DocumentationMedical Chart Documentation

No required state forms, but No required state forms, but documentation must be an auditable form documentation must be an auditable form (a single sheet) in the medical chart.(a single sheet) in the medical chart.

Recommend use of OSAH Progress notes Recommend use of OSAH Progress notes for elementary, middle or high school for elementary, middle or high school students.students.