The following contains information for Healthy Kids (EPSDT) providers regarding screening exams, referrals from a screening exam and treatment provided as a result of a screening exam. This information is outlined in greater detail in Chapter 1500 of the Medicaid Services Manual – Healthy Kids.

NEVADA MEDICAID POLICY: Screening exams (99381-99385 and 99391-99395, along with modifiers EP or TS) are preventative and diagnostic services designed to evaluate the general physical and mental health, growth, development and nutritional status of eligible recipients under the age of 21 years old. The Healthy Kids program encourages providers to follow the recommended periodicity schedule set forth by the American Academy of Pediatrics. Interperiodic exams may be performed when requested or based on medical necessity. See the Nevada Medicaid Service Manual, Chapter 1500 for more information and requirements.

A screening form is now available as an option for providers to use when performing the EPSDT screening exams. The forms act as a reminder by listing all the components of the screening, making it more streamlined for providers to do the exam. The forms do not need to be returned to Nevada Medicaid and can remain as part of the recipient’s medical record. Links for the forms, along with a guideline, can be found at the bottom of the page.

Screening services (including examinations and diagnostics) do not require prior authorization, however, ongoing treatment or services beyond the initial screening may require prior authorization based on specific program requirements. The following services are included in the screening exam and should not be billed separately: office visit, consultations, hematocrit, urinalysis dip stick, PPD or tine test, lead screening, objective vision and hearing.

Medically necessary health care, treatment or other measures to correct or ameliorate defects and physical and mental illnesses or conditions discovered by EPSDT screening services are a covered benefit, even if those services are not included as part of the covered services in the state plan. Requests for services that are beyond specific program policy or not covered under state plan must be made to the QIO-like vendor. For consideration, the services must have been recommended from an EPSDT screening exam or referral; have enough information to justify medical necessity; be safe, effective and not considered experimental or investigational.

EPSDT services are not available to recipients who are eligible solely because of pregnancy.

REFERRALS AND DIAGNOSTICS: A dated written referral should be given to the recipient, parent/guardian, or referral service provider that documents the need for referral or follow up.

CODING AND BILLING GUIDELINES:

Healthy Kids screenings should be billed using the most appropriate codes (99381-99385 or 99391-99385) with either modifier EP or TS. Use of modifier EP is for routine screening. Use of modifier TS indicates that referral or follow up is indicated. When using modifier TS, be sure to complete field 21 on the CMS-1500 claim form with the appropriate ICD-9 code to reflect the condition requiring follow up.

EPSDT Screening Forms:

Annual EPSDT Participation Report (CMS-416):

EPSDT TOOLKIT: For family-friendly education and outreach materials or screen/exam tools for providers please visit: Toolkit of Healthy Kids

The materials are produced by active community representatives and state personnel to increase the number of physicians conducting Healthy Kids preventive services (screening and exams) and to increase the number of children and teens who receive Healthy Kids screenings. This is a partnership among the state Title V agency (Bureau of Family Health Services in Nevada), Medicaid, and Nevada Check Up to do outreach and increase utilization rates. The website is linked to the Children with Special Health Care Needs information also.