Annual HP Workshop EPSDT MCE Combined Presentation

1. Annual HP Workshop EPSDT MCE Combined Presentation P0608

2. EPSDT – Screening Components • The following components of a screening must be provided and documented to provide quality care to the members and receive enhanced reimbursement: • Health and developmental history, including assessment of physical and mental health development • Unclothed physical exam • Nutritional assessment • Developmental assessment • Vision observation at each screen and direct referral to an optometrist • Hearing observation at each screen and objective testing with audiometer at 4 years old • Dental observation at each screen and direct referral to a dentist starting at 6 – 12 months old • Laboratory tests, including blood level assessment appropriate for age and risk factors • Immunizations administered or referred, if needed at time of the screen • Health education, including anticipatory guidance • This is often provided, but frequently not documented. P0608

3. EPSDT – MCE Billing • The following billing procedures must be followed to permit correct reimbursement. Every claim for a HealthWatch/EPSDT visit must be coded with the following: • The appropriate patient examination code (99381 – 99385, and 99391 – 99395) must be included on the first detail line of the medical claim form. • The preventive health diagnosis code, V20.2, as the Primary diagnosis. • Physicians are strongly encouraged to include all applicable diagnosis codes and procedure codes on the claim form. • The usual and customary appropriate EPSDT reimbursement rate for the initial or established patient exam should be billed. The enhanced reimbursement rate is $75 for codes 99381 – 99385 and $62 for codes 99391 – 99395. • Providers must provide all components of the EPSDT program to submit for the enhanced reimbursement. • Providers must report on the claim form all screens and immunizations administered during the HealthWatch/EPSDT visits. P0608

4. EPSDT – MCE Billing Vaccines • The MCE’s follow HP guidelines and reimburse Vaccines for Children (VFC) services for the administration fee. • The VFC fee is a maximum of $8.00 or lower of the submitted charge from the provider. • For appropriate claims submission for $8.00 reimbursement, V20.2 is submitted as the primary diagnosis code. • A list of covered VFC available vaccines, visit the EPSDT HealthWatch Provider Manual at the IHCP Web site under Section 3, General VFC Billing Information. • HEDIS guidelines and the Periodicity and Screening Schedule provide guidelines, and recommended timelines for immunizations for members. • Providers should utilize CHIRP to record, manage, and tally immunizations for their office. P0608

5. EPSDT – MCE Billing • If a patient is evaluated and treated for a problem during the same visit as an EPSDT annual exam or well – child service, the problem oriented exam can be billed separately accompanied by the 25 modifier (separate significantly identifiable E&M service). The problem must require additional moderate level evaluation to qualify as a separate service on the same date. • FQHC’s and RHC’s – Providers should NOT use the T1015 encounter code in addition to the CPT or HCPCS codes when billing MCEs. These providers should bill the appropriate EPSDT services provided to the member. P0608

6. EPSDT – Missed Appointments • If a member misses a well – child appointment, the office should reach out to the member and reschedule the visit. • The provider office can also reach out to the MCE for additional member education. • Provider offices should take every opportunity to educate a member, provide preventive care, and immunizations per the screening schedule as early detection and treatment help prevent diseases in members. P0608

7. HEDIS Measures • Each MCE will help providers focus on the EPSDT program in conjunction with the HEDIS well – child measures for the following performance measures: • Well – Child Visits 0 – 15 Months • Frequency of Visits • Health and Developmental history, physical and mental • Health Education and Anticipatory Guidance • Well – Child Visits 3 – 6 Years • Annual well – child visit • Health and Developmental history, physical and mental • Health Education and Anticipatory Guidance • Well – Child Visits 12 – 21 Years • Annual well – child visit • Health and Developmental history, physical and mental • Health Education and Anticipatory Guidance *Please see 2010 HEDIS Performance Measure poster for additional details on MDwise well – child and additional performance measures. P0608

8. EPSDT – Lead Screening • Lead poisoning is preventable. Children from 9months to 6 years are at greatest risk for elevated blood levels. • Ensure lead screenings are a part of a well – child exam. • If children are identified with elevated lead levels, ensure they have recommended follow – up treatment. • Codes for billing lead screenings are the following: • 83655 – U1 • 83655 – U2 • 83655 P0608

9. EPSDT – Documentation • It is imperative when member receives all components of the EPSDT program, that the services are documented and incorporated into the members medical chart. • A provider should document the family and medical history: • Reason for visit • Initial observation • Perinatal history • Nutritional status • Developmental history • Medical history • Body system review • Family health history • Referrals must be documented and recorded in the member’s medical chart. • Anticipatory guidance provided during the EPSDT visit and/or the well – child visit must be documented in the member’s medical chart. P0608

10. EPSDT – Documentation • A provider should perform the following during an EPSDT exam: • Measurements • Height • Weight • Weight for height/BMI • Head circumference • Blood pressure • General physical examination of the systems • Screenings for referrals *Please refer to the EPSDT Health Watch Manual for testing and referral charts. P0608

11. Well – Child Services • If all components of the EPSDT program are not provided to the member, but the following components are documented and provided, the provider can submit for well – child services and not EPSDT services and not receive enhanced reimbursement: • Annual well – child visit • Health and Developmental history, physical and mental • Health Education and Anticipatory Guidance • The provider should submit the claim with the appropriate E&M procedure code and the V20.2 diagnosis code. • The services will count towards the provider’s quality measures to receive credit for the services provided and increase the measure. P0608

12. Billing Scenarios • If a member presents for an EPSDT exam and all components were provided and documented, submit a claim following these guidelines: P0608

13. Billing Scenarios • If a member presents for an EPSDT exam and all components were provided and documented, and VFC immunizations were also provided, submit a claim following these guidelines: P0608

14. Billing Scenarios • If a member presents for an EPSDT exam and all components were provided and documented, and a member complains of ear pain so they are being seen for a sick visit, submit a claim following these guidelines: P0608

15. Additional EPSDT Tips • By ensuring appropriate coding of the services that are provided, it will demonstrate that the care being provided also meets quality measures. • Reimbursement can be maximized by correct coding. • Remember to submit charges if the member has third party liability (TPL). • Well child services can be billed for reimbursement when they do not include all components of an EPSDT visit. • A comprehensive prenatal visit meets all of the requirements for a preventive care visit and can be billed in conjunction with the V20.2 to count towards the HEDIS measure. • By increasing EPSDT services, performance measures in the well – child targeted measures will rise. • Complete the Notification of Pregnancy (NOP) to ensure the MCE’s are aware of new member’s becoming pregnant and to ensure they receive the required prenatal services. P0608

16. Periodicity and Screening Schedule P0608

17. Hoosier Healthwise Managed Health Services (MHS) Interventions • MHS HEDIS Reporting and Material – MHS Team (Provider Relations and Quality Improvement) mail quarterly scorecard information to PMP network, providing snapshot of current metrics and listing of members identified as not receiving service to date to aid in patient outreach. • MHS Education Sessions – MHS is holding workshops & individual sessions throughout the State to assist our provider network in education regarding what is needed to achieve goals. • Billing/Claims assistance – MHS team providing one on one education sessions with office to provide instruction on appropriate EPSDT and HEDIS billing procedures. • Educational Material – MHS has developed and issued education material such as HEDIS Quick Reference Guide and Healthwatch (EPSDT) chart tool. • Connections Representatives – A team dedicated to providing one-on-one education for members with compliance issues (i.e. missed appointments, ER utilization, etc.) • In addition, the Quality Outreach Team provides telephone follow-up on EPSDT/Well Child mailings assisting members with obtaining appointments and arranging transportation if needed. P0608

18. Hoosier Healthwise Managed Health Services (MHS) Interventions P0608

19. Hoosier Healthwise Managed Health Services (MHS) Interventions P0608

20. Members Needing Service P0608

21. Service Needing Members P0608

22. P0608

23. Hoosier Healthwise Anthem Interventions Anthem Education – Anthem’s NERs, Outreach, Health Promotions staff assist in educating providers on a one on one basis related to HEDIS, EPSDT guidelines, and documentation standards. Educational Materials –Anthem’s educational materials consist of the HEDIS Measure Physician Documentation Guidelines and Administrative Codes brochure to assist physicians in identifying the criteria/requirements for services and the elements of documentation needed for each visit. Anthem provides age appropriate forms to providers promoting anticipatory guidelines, growth and development, and physical and mental health exams. Anthem provides P4P brochures to providers as a baseline regarding measures scored per HEDIS, as well as individual provider scores implementing continuous plans for improvement. P0608

24. Hoosier Healthwise Anthem Interventions • Anthem Reports – Anthem provides Gap in Care reports to physicians as an outreach effort to assist with getting members in for preventive care. • Outreach – Anthem’s Outreach Specialists provide one on one education, telephone and home visits to members per provider request or those needing assistance with getting in to see their PMPs, transportation services, missed appointments, ER usage, etc. • Anthem Outreach Specialists have clinic days arranged to target and educate members in need of preventative care. • Anthem Webinars – Anthem provides educational webinars to assist providers in gaining knowledge of the required measures, billing guidelines, and documentation needed to increase their HEDIS scores. P0608

25. Anthem - Age Appropriate Documentation Formfor Well Visits 3-6 Years P0608 • Areas covered with the form: • Nursing Intake • Interval History • Growth – Development • Parental/Patient Concerns • Physical Examination • Assessment • Plan • Orders • Anticipatory Guidance

26. Anthem - Age Appropriate Documentation Formfor Adolescent 12-21 Years • Areas covered with the form: • Nursing Intake • Interval History • Growth – Development • Parental/Patient Concerns • Physical Examination • Assessment • Plan • Orders • Anticipatory Guidance P0608

27. Clinical Quality Compliance Administrators for Anthem Acquanetta McKinney, CQA RN BSN acquanetta.mckinney@anthem.com (219) 796-9543 Tamela Queen, CQA RN PLNC tamela.queen@anthem.com (812) 469-7540 P0608

28. Hoosier Healthwise MDwise Interventions • MDwise Member Advocates - MDwise Member Advocates provide one – on – one education and telephone outreach with members with special needs or compliance issues (e.g. missed appointments, PMP conflicts, ER utilization, etc.) or those who are not accessing their PMP. • Billing guidelines – To help prevent coding problems, providers are encouraged to refer to the MDwise educational materials and the Indiana Medicaid supplemental manual on EPSDT @Indiana Medicaid Website: http://www.indianamedicaid.com/ihcp/Manuals/Other/EPSDT_Healthwatch.pdf P0608

29. Hoosier Healthwise MDwise Interventions • MDwise Education – MDwise along with its Network Improvement team, and Delivery Systems (Reps and Quality Management staff) will work one on one with providers to educate on EPSDT and HEDIS to ensure specific goals are met. • Created to take improvement efforts to a higher level • Educating providers on HEDIS and ROQ standards. • Providing providers information about their quality performance • Diagnose office practices that may result in missed opportunities to provide care or cause services to not be billed correctly • Creating and distributing reference/educational materials and tools • Educational Materials – MDwise has developed education materials such as the HEDIS poster, the well – child campaign and flyers for providers and office staff to help promote early detection and treatment. • Reports – MDwise Delivery Systems will provide it’s PMP’s reports that will identify members who are delayed in their check ups. P0608

30. Converting Acute Visits to Well Visits P0608

31. Hoosier Healthwise MDwise Reports P0608

32. Hoosier Healthwise MDwise Reports P0608

33. Hoosier Healthwise MDwise Reports P0608

34. Questions? • Thank You for attending! P0608