The Latest and Greatest from the 2016 Health

Check Program Guide

1

Objectives

•Review some of the key points in the Health Check Program Guide

•Describe coding changes impacting well child services

You Should Know That…

• Health departments were expected to implement the changes described in the Health Check Program Guide by October 31, 2016

• The 2016 Health Check Program Guide is used for clients served by Medicaid and is not meant to be a guide for clients served by Health Choice

3

You Should Also Know That…

• The most current version of the Health Check Billing Guide is called the Health Check Program Guide and can be found at: http://dma.ncdhhs.gov/medicaid/get-started/find-programs-and-services/health-check-and-epsdt

• Health departments should periodically check that site (i.e, monthly)

• There are CSRA Job Aids and Provider Training materials references which will be available in the future

• These materials will include additional billing instructions, additional modifiers, appropriate diagnosis codes, referral codes, and CPT codes related to immunization services

4

Key Reminders

• “North Carolina Medicaid’s periodicity schedule is only a guideline. Should a beneficiary need to have screening or assessment visits on a different schedule, the visits are still covered”

• See page 6 of the Health Check Program Guide

• “A complete Health Check Early Periodic (wellness) Screening requires all age related components/screening services to be completed, documented in the medical record and billed with appropriate coding and modifier combinations for each service required for that age”

• See pages 8 and 9 on the North Carolina’s Periodicity Schedule and Coding Guide for Early Periodic Screening tables in the Health Check Program Guide

5

Reminder: Required Claims Indicators

Providers must indicate referrals by listing Appropriate Indicators on Block 24H of the Claims Form (based on 2013 HCBG sample claims):

• Claims submitted via NC Tracks should list referral code indicator “E” when a referral is made for follow-up on a defect, physical or mental illness, or a condition identified through a Health Check screening assessment.

• Claim submissions should include referral code indicator “F” when a referral is made for Family Planning services

See page 29

6

Required Components of the Well Visit

• Comprehensive health history (no change)• Provider must update this in the record at each subsequent well

visit• Unclothed physical assessment and measurements (no

change)• Weight and height for all ages and HC through age 2 years • Document Weight for length or BMI (use of Z codes continues

to be encouraged)• BP and BP percentile starting at age 3 • Additional vital signs as appropriate • CHERRNs are no longer required to do routine scoliosis

screening • Be careful if you stop doing this screening that you do not

continue to document doing it• Nutritional assessment (no change)

• Document nutritional status using physical, lab, health risk assessment and diet with plan for risks identified

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Required Components of the Well Visit (cont.)

• Developmental surveillance (changes coming) • Developmental screening (changes in billing) • Autism screening (changes in billing)• Vision screenings (no change and use EP modifier)

• Objective screenings every visit from age 3 years to age 11 years and then every three years

• Selective screening at other ages based on risk

• Hearing screenings (no change and use EP modifier)• Objective screenings using audiometry or OAE annually for children

ages 4 through 10 years • Selective screening at all other ages based on provider’s assessment

of risk

8

Same Guidance With Uncooperative Children with Vision or Hearing Screening

• If child is uncooperative with a vision or hearing screening, providers may ask the parent to bring the child back to the office within 1-2 weeks for a second attempt

• If vision or hearing screening is not done during the well visit, document why it was not able to be done and submit the claim without the vision or hearing screening CPT code

• When the child comes back and another attempt at screening is made, the provider can bill for the screening then

• These are not changes from the previous guide

9

Required Components (cont.)

• Dental screenings (no change)• Perform a screening at every well child visit (must

document)• Recommend use of an oral health risk assessment • Dental home recommended by 1 year of age and

required beginning at age 3 years• Refer to recommended oral health periodicity

schedule (see pages 21-22)

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Dental Varnish

• This is an optional service but highly recommended• Providers should offer and bill for this recommended

dental varnish on the same day as the well visit for appropriate aged children

• Use the Dental Varnish Codes - Procedure code D1206 must be billed on the detail line before procedure code D0145

• Refer to guidance provided on the Into the Mouths of Babes website at the following link: https://www2.ncdhhs.gov/dph/oralhealth/partners/IMB-toolkit.htm

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Additional Required Components

• Immunizations ( check with your regional immunization consultant see page 23 and pages 56-69)

• Laboratory procedures (most do not need EP modifier)• Newborn metabolic/sickle cell screening • Hemoglobin (no change and cannot bill for routine required

screen at 9-12 months but report with EP modifier)• Lead testing (p. 30-38 with NEW specific discussion around

point of care lead testing and billing p. 34-38)• TB tests (no change)• Sexually transmitted infections (need to follow most current

CDC STD guidelines per state rule)

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Additional Required Components (cont.)

• Anticipatory guidance and health education • Age appropriate and targeted guidance must be included

as part of the well visit service• Follow-up and referral

• The assessment should list all problems, risks, concerns or conditions identified during the visit

• A plan must be provided for each problem, risk, concern or condition identified during the visit

• Plans can include but not be limited to one or more of the following

• Treatment with a medication • Returning to the clinic at a specified time to recheck or

monitor • Referral

• Follow up must also include plan for when the next well visit will occur with at least documentation of the month and year

13

Summary of Changes

• Preventive service visits AND problem focused E/M services can now be delivered on the same day (see pages 26-27)

• Maternal depression screening is encouraged at the 1, 2, 4 and 6 months of age well visits and will be reimbursed using CPT code 99420 (see pages 42-44)

• CPT coding changes will again occur in January 2017 for maternal depression screening and will need to use CPT code 96161

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Summary of Changes (cont.)

• CPT code 96110 is billable for general developmental screening

• CPT code 96110 is used for autism/ASD screening

• CPT code 96127 is used for social-emotional, and mental health screenings and for the CRAFFT when used as a brief screen

• Adolescent health risk screening uses CPT code 99420 up through December 31, 2016 and then must use CPT code 96160

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NEW: Requirements To Be Able to Provide Preventive and Focused Problem (E/M) Care on the

SAME DAY • Provider documentation must support billing of both services

• The documentation must clearly list in the assessment the acute/chronic condition(s) being managed at the time of the encounter

• All elements supporting the additional E/M service must be apparent to an outside reader/reviewer

• Modifier 25 must be appended to the appropriate E/M code

• Modifier 25 indicates that the patient’s condition required a significant, separately identifiable billable E/M service above and beyond the other service provided on the same date of the well visit

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See pages 26-27

NEW: Preventive Visit and Same Day Focused Problem Visit (cont.)

• Providers must create separate notes for each service rendered in order to document medical necessity

• The note documenting the focused (E/M) encounter should contain a separate history of present illness (HPI) paragraph and also ideally a review of systems (ROS) paragraph to help with level of decision making and required coding elements for appropriate evaluation and management (see PHNPD coding tool)

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A Note About Well Visit by CHERRN and Same Day Sick Visit with Advanced Practice Practitioner or

Physician• A CHERRN can complete the well child visit and document all

required components appropriately• In the plan of care, the CHERRN would document a referral to the

advanced practice practitioner/physician in the health department who would see the client on the same day as the well visit

• The advanced practice practitioner/physician would then need to evaluate the client for the needed referral and document a separate problem visit

• The CHERRN would bill for the well child visit and the advanced practice practitioner/physician would bill for the problem focused visit using the 25 modifier

• Please note that a Physician or Advanced Practice Practitioner does have the option to provide the well visit and a problem focused visit on the same day when a CHERRN is not involved

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Preventive and Focused Problem (E/M) Care on the SAME DAY (cont.)

• In deciding on appropriate E/M level of service rendered by the Advanced Practice Practitioner or Physician, only activity performed “above and beyond” that already performed during the well visit is to be used to calculate the additional level of E/M service

• If any portion of the history or exam was performed to satisfy the preventive service, that same portion of work should not be used to calculate the additional level of E/M service

• When providing evaluation and management of a focused complaint (CPT 9920x / 9921x) during a well child visit, the provider may claim only the additional time required above and beyond the completion of the well visit (CPT 9938x / 9939x) to address the complaint

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Components Related to Surveillance and Structured Screening for Risks for Developmental and

Emotional/Behavioral Health Problems

• Developmental surveillance is still required (p. 39-40)• Bright Futures tools help meet this requirement

• Screening of mother for risk of maternal postpartum depression is recommended (p. 42-44)

• Screening infant/child for risk for developmental delay should be done (p. 45-47)

• Screening for infant/child for autism and autism spectrum disorders is required (p. 45-47)

• Screening for infant, child or adolescent for emotional/behavioral health risks is recommended as appropriate (p. 47-49)

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Maternal Postpartum Depression Screening

• Recommend administer to mother during the infant’s 1, 2, 4, and 6 month well visits

• but does not have to be exactly at those ages• Examples of brief screening tools

• Edinburgh Postnatal Depression Scale• Patient Health Questionnaire (PHQ)-2 (and if positive

should be followed by the PHQ-9)• PHQ-9

• Bill using CPT code 99420 through December 31, 2016 for screening mother as caregiver of the infant (when infant is the client)

• Use EP modifier with well visits • If an immunization administration is done on the same

day, use 25 modifier with CPT code 99420 for maternal depression screening

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See pages 42-44

Maternal Postpartum Depression Screening (cont.)

• On and after January 1, 2017 use CPT code 96161 to bill administration of caregiver-focused health risk assessment (i.e. health hazard appraisal) for benefit of the patient with scoring and documentation per standardized instrument (stop using CPT code 99420 then)

• See the updated CCNC guidance document about maternal depression screening which will be available at: https://www.communitycarenc.org/pediatric-essentials/

• Training on use of these tools will be made available by Dr. Mattson by winter of 2017

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A Note About Using the PHQ-2 and PHQ-9 For Depression Screening

• If a provider uses a PHQ-2 and/or PHQ-9 for maternal depression screening of the client’s mother (who is not your patient), it is considered a health risk assessment of the caregiver of the infant (when the infant is your patient), then

• In this situation, the provider would bill the CPT code 99420 until December 31, 2016

• On and after January 1, 2017 the provider would bill the CPT code 96161

• If a provider uses a PHQ-2 and/or PHQ-9 for depression screening of the mother (who is could be an adolescent client and it is not being done as part of an infant well visit because the infant is not the patient for the visit) then the provider would bill CPT code 96127

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Structured Brief Screening for Risks for Developmental and Behavioral/Emotional Problems and Autism Spectrum

Disorders

• Providers must use “standardized and validated tools to identify risk for developmental delay or for behavioral/emotional problems”

• “Per CPT, definitions and AAP and CMS guidance, brief screens should be used only to “identify risk” for presence of a developmental or emotional/behavioral problem

• The use of a brief screen to assess or change an already diagnosed health condition or illness is not supported or recommended by CPT, AAP or CMS”

• When billing any brief screen, the child’s medical record must include: “documentation indicating the date on which the test was performed, standardized tool used, screening result/score, guidance given, and referrals made”

.

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See pages 41 and 48

Some Additional Clarification About the Use of Brief Screens

• A brief screen should only be used to identify a risk• Providers should not complete a brief screen for a client

that already has a diagnosed condition related to that particular screening (i.e., using an autism screening tool in a child who has already been diagnosed with autism)

• If a client has an already diagnosed mental health or developmental condition, the provider may consider making a referral for follow-up rather than providing additional brief screenings

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Screening for Risk of Developmental Delay

• Screenings should occur at 6, 12, 18 or 24 months, 3, 4, and 5 years of age

• Health Check recommends general developmental screenings at these well child visits

• NEW: These screens should be billed to N.C. Medicaid using CPT code 96110 with the EP modifier and these screens are reimbursed

• Examples of tools include the ASQ-3 and PEDS but additional examples of tools can be found at: https://brightfutures.aap.org/Bright%20Futures%20Documents/Developmental_Screening_Tools.pdf

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See pages 45-47

Screening for Risk of Developmental Delay (cont.)

• See updated CCNC guidance document about coding for developmental and behavioral screening which will be available at: https://www.communitycarenc.org/pediatric-essentials/

• The child’s medical record must include: “documentation indicating the date on which the test was performed, standardized tool used, screening result/score, guidance given, and referrals made”

• “The use of a brief screen to assess or change an already diagnosed health condition or illness is not supported or recommended by CPT, AAP or CMS”

27

See pages 41 and 48

Screening for Autism and Autism Spectrum Disorders

• Providers must perform routine screening for autism spectrum disorders at 18 and 24 months of age

• Examples of tools for screening for autism include M-CHAT R/F and additional tools can be found at: https://brightfutures.aap.org/Bright%20Futures%20Documents/Developmental_Screening_Tools.pdf

• A screen may be administered at a “catch-up” visit if the 18 or 24 month visit was missed

• Providers can use the M-CHAT R/F between 16-30 months of age • NEW: CPT code 96110 should be used to bill autism screening

with the EP modifier (no longer use CPT code 99420)

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See pages 45-47

Screening for Autism and Autism Spectrum Disorders (cont.)

• See updated CCNC guidance document about coding for developmental and behavioral screening which will be available at: https://www.communitycarenc.org/pediatric-essentials/

• The child’s medical record must include “documentation indicating the date on which the test was performed, standardized tool used, screening result/score, guidance given, and referrals made”

• Providers should not use a brief screen for a child with already diagnosed with autism

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Screening Infants, Children or Adolescents for Social Emotional or Mental Health Concerns

• In January 2015, CMS added CPT code 96127 which is a “brief emotional/behavioral assessment (screening) with scoring and documentation”

• NEW: CPT code 96127 with an EP modifier should be used to bill the administration of a structured screen for emotional and behavioral health risks, including attention-deficit/hyperactivity disorder (ADHD), depression, suicidal risk, anxiety, substance abuse (CRAFFT brief screen) and eating disorders, when their use is indicated by guidelines of clinical best practice and surveillance

• Medicaid will reimburse providers for CPT code 96127 to a maximum of two units per visit

• Providers should no longer use CPT code 99420 for these tools

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See pages 47-49

NEW: Coding Using Specific Social Emotional Screening Tools

• When providing adolescent depression screening for patients using the Patient Health Questionnaire (PHQ)-2 and/or PHQ-9 or PHQ-Modified for Adolescents bill using CPT code 96127 and the EP modifier and NOT CPT code 99420

• When providing other social emotional or mental health screening with the ASQ:SE or ASQ:SE2, Vanderbilt, SCARED, Pediatric Symptom Checklist, Youth PSC, Strengths and Difficulties Questionnaire, and other tools during a well visit bill using CPT code 96127 and the EP modifier and NOT CPT code 99420

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See pages 47-49

Screening Infant, Child or Adolescent for Emotional/Behavioral Health Risks (cont.)

• See updated CCNC guidance document about coding for developmental and behavioral screening for more information which will be available at: https://www.communitycarenc.org/pediatric-essentials/

• When billing any brief screen, the child’s medical record must include: “documentation indicating the date on which the test was performed, standardized tool used, screening result/score, guidance given, and referrals made”

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NEW: The CRAFFT As A Brief Screen • A brief screen alone (using the CRAFFT tool) can now be

billed using CPT code 96127 with EP modifier when none or minimal counseling (less than 15 minutes) is provided

• If the CRAFFT is used and the score is less than 2, then extensive counseling is not recommended by the developers of the tool

• According to the CRAFFT tool instructions, counseling for a negative score of 0 or 1 requires about 5 minutes

• CPT codes 99408 or 99409 is used when the CRAFFT screening tool is positive (which is a score of 2 or more) AND counseling is provided for at least 15 minutes (see later slide)

• CPT codes 96127 and 99408 or 99409 should not both be used for the use of a CRAFFT tool that includes counseling

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Additional Screenings Specific to Adolescents

• Screening for adolescent patient health risks (p. 50-52)

• Other screening-related services for adolescent patients

• Smoking and tobacco cessation counseling (p. 52-53)

• Alcohol and substance abuse screening (p. 53-54)

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Screening for Adolescent Health Risks

• For health risk screens in adolescent patients use CPT code 99420 (Health Risk Assessment) to bill when using a health risk screen for an adolescent patient (a Medicaid Beneficiary 11 years of age and older)

• The HEEADSSS is the tool used in local health departments as part of the Bright Futures tools (NOT the pre-visit questionnaire)

• However, the pre-visit questionnaire should be reviewed to identify risks and to help determine clarifying questions to be asked as part of the HEEADSSS

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Screening for Adolescent Health Risks (cont.)

• Providers must use CPT code 99420 with the EP modifier when billing for a health risk assessment through December 31, 2016

• Medicaid reimburses providers for CPT code 99420 to a maximum of two units per visit

• CPT code 99420 may not be used to claim a stand-alone administration of a CRAFFT (CPT code 96127) brief screen

• CPT code 99420 is end dating on December 31, 2016 (that CPT code will no longer be able to be used for any service)

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NEW: Coding for Screening for Adolescent Health Risks Starting in January

• NEW: After January 1, 2017, providers administering a health risk screen to adolescent patients must bill using CPT code 96160 (stop using CPT code 99420)

• CPT code 96160 is the administration of patient-focused health risk assessment instrument (e.g., ‘health hazard appraisal’), with scoring and documentation per standardized instrument

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Smoking Cessation Screens/Intervention With Adolescents Patients

• CPT code 99406 • Smoking and tobacco cessation counseling visit:

Intermediate, greater than 3 minutes, up to 10 minutes

• CPT code 99407• Smoking and tobacco cessation counseling visit:

Intensive, greater than 10 minutes

Use the both the 25 modifier and EP modifier with these codes for well visits

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See pages 52-53

Smoking Cessation/Intervention With Adolescents (cont.)

• Providers may bill the CPT codes 99406 or 99407 (with 25 and EP modifiers during well visits) only when counseling is provided directly to the beneficiary (adolescent patient)

• The CPT code is only appropriate for use when the patient is receiving the counseling for tobacco use and cannot be billed if counseling is provided to the parent or guardian

• Providers should always include documentation in the beneficiary’s medical record noting the intervention (i.e., 5A’s), patient response (i.e, contemplation) and current status, follow up plan and referrals (i.e., to NC Quit Line)

• There have been discussions with Patagonia about development of a tobacco cessation and intervention template to help with documentation for smoking cessation efforts

39

See pages 52-53

Alcohol and Substance Abuse Structured Screens/Intervention With Adolescents

• The CRAFFT is a validated screening tool that is part of the Bright Futures tools used in local health departments

• Providers should use this screening tool if any positive risk factors for alcohol or substance abuse are identified in the HEEADSSS screening tool or in any other way during the well visit with an adolescent patient

• As with any screen, the provider must document the screening tool used, the results of the screening tool, the discussion with parents, and any referrals made

40

See pages 53-54

Alcohol and Substance Abuse Structured Screens/Intervention With Adolescents

• CPT code 99408 • Alcohol and/or substance (other than tobacco)

abuse structured screening and brief intervention services; 15 to 30 minutes

• CPT code 99409 • Alcohol and/or substance (other than tobacco) abuse

structured screening and brief intervention services; greater than 30 minutes

• Use the both the 25 modifier and EP modifier with these codes for well visits

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Alcohol and Substance Abuse Structured Screens/Intervention (cont.)

• Providers may bill CPT codes 99408 or 99409 (with 25 and EP modifiers) only when alcohol and/or substance abuse screening is done AND counseling is provided directly to the adolescent beneficiary

• The provider should not bill for the CRAFFT using the CPT 99408 (or 99409) if the score is less than 2 (0 or 1 which is a negative score) because the tool developers estimate that 5 minutes or less of counseling is needed

• Reminder of NEW CPT code with CRAFFT brief screen: A brief screen alone (CRAFFT) without at least 15 minutes of counseling is to be billed using CPT code 96127 with EP modifier

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Summary of Changes

• Preventive service visits AND problem focused E/M services can now be delivered on the same day

• Maternal depression screening can be billed at the 1, 2, 4 and 6 months of age well visits using CPT code 99420

• CPT coding changes will again occur in January 2017 and will need to use CPT code 96161

• CPT code 96110 is billable for general developmental screening• CPT code 96110 is used for autism/ASD screening • CPT code 96127 is used for social-emotional, and mental health

screenings and for the CRAFFT when used as a brief screen• Adolescent health risk screening is billed using CPT code 99420

up through December 31, 2016 and then using CPT code 96160

43

Helpful CCNC One Pagers

• CCNC has developed one pagers for guidance about the following:

• Maternal depression screening• Coding for behavioral and developmental screening• Preventive and Same Day Visit Coding

• Check out the CCNC web site under Pediatric Essentials at:

• https://www.communitycarenc.org/pediatric-essentials/

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QUESTIONS?

Thank you for all that you do for the children and families of North Carolina!