Child Health Check-Up (formerly EPSDT) - Herman & Associates ...

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Child Health Check-Up Coverage and Limitations HandbookReferral Code InformationRequired ChildHealth Check-UpReferral CodesFor Child Health Check-Up screening services, enter the referral code thatidentifies the health screening of the child:U Complete NormalIndicator is used when there are no referrals made.2 Abnormal, Treatment InitiatedIndicator is used when a child is currently undertreatment for referred diagnostic or corrective healthproblem.T Abnormal, Recipient ReferredIndicator is used for referrals to another provider fordiagnostic or corrective treatments or scheduled foranother appointment with check-up provider fordiagnostic or corrective treatment for at least one healthproblem identified during an initial or periodic check-up(not including dental referrals).V Patient Refused ReferralIndicator is used when the patient refused a referral.Note: See specific instructions for using these codes in the Florida MedicaidProvider Reimbursement Handbook, CMS-1500 for paper claim submission andfor electronic claim submission, contact the Medicaid fiscal agent EDI help deskat 800-829-218.Reimbursement InformationChild HealthCheck-Up ClaimForm withHIPAAImplementationFor paper claim submission, beginning with HIPAA implementation, a ChildHealth Check-Up service must be billed on the CMS-1500 claim form.Note: See the Medicaid Provider Reimbursement Handbook, CMS-1500 forinstructions on completing the claim form.Note: For electronic claim submission, beginning with HIPAA implementation,contact the Medicaid fiscal agent EDI help desk at 800-829-0218.Child HealthCheck-UpReimbursementTo be reimbursed, Child Health Check-Up providers must assess and documentin the child’s medical record all the required components of a Child HealthCheck-Up (see Chapter 2 for the required components of a Child Health Check-Up). Medicaid reimburses on an all-inclusive fee basis for a Child Health Check-Up, except for immunizations and laboratory services.All providers may be reimbursed for immunization services, in addition to a ChildHealth Check-Up. Certain providers may also be reimbursed for blood leadtesting and other laboratory services. Reimbursement for immunizations andlaboratory services is described as follows.3-4 October 2003
Child Health Check-Up Coverage and Limitations HandbookReimbursement Information, continuedImmunizationServicesReimbursementIn addition to a Child Health Check-Up, providers may be reimbursed forimmunization services through their provider-specific Medicaid programs, suchas physician services. The provider may bill for immunization services on theCMS-1500 claim form in addition to a Child Health Check-Up service.Note: See the service-specific coverage and limitations handbook for informationon reimbursement for immunization services.Tuberculin SkinTestReimbursementIn addition to the Child Health Check-Up, providers may be reimbursed fortuberculin skin tests through their provider-specific Medicaid programs, such asphysician services. The provider may bill for the tests on the CMS-1500 claimform in addition to a Child Health Check-Up service.Note: See the service-specific coverage and limitations handbook for informationon reimbursement for tuberculin skin tests.Laboratory TestsReimbursementIn addition to a Child Health Check-Up, certain providers may be reimbursed forlaboratory testing, including dipstick urine and finger stick hemoglobin andhematocrit, through their provider-specific Medicaid programs, such as physicianservices. The provider-specific Medicaid program must allow reimbursement forlaboratory tests. Medicaid does not reimburse for the collection and handling ofspecimens during a physician’s office visit.To perform laboratory tests and analyze the results, the provider’s officelaboratory must be certified by the Clinical Laboratories ImprovementAmendment of 1988 (CLIA).The provider may bill for laboratory tests on the CMS-1500 claim form in additionto a Child Health Check-Up service.County health departments and federally qualified health centers may not bereimbursed for laboratory tests in addition to their encounter rate for a ChildHealth Check-Up.October 2003 3-5
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Jeb BushGovernorRhonda M. Medows, M
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