Early and Periodic Screening, Diagnostic and Treatment Clinical Practice and Billing Guideline Form

EPSDT Early and Periodic Screening, Diagnostic and Treatment Clinical Practice & Billing Guideline Blue Cross and Blue Shield of New Mexico, a Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association 489951.0725

1 Contents Early and Periodic Screening, Diagnostic and Treatment Clinical Practice and Billing Guideline Well-Child Visit Scheduling..................................................................................................................................... 2 Clinical Practice Guidelines.................................................................................................................................... 2 Components of EPSDT Well-Child Visits and Services EPSDT Services........................................................................................................................................................ 3 Prior Authorization ................................................................................................................................................ 3 Early Intervention Services Criteria for Early Intervention Services in New Mexico..................................................................................... 4 Early Intervention Services.................................................................................................................................... 4 EPSDT Benefit: Treatment Services EPSDT Personal Care Services .............................................................................................................................. 5 Private Duty Nursing Services .............................................................................................................................. 5 Care Coordination .................................................................................................................................................. 5 Billing for Well-Child Visits EPSDT Well-Child Visits: New Patients.................................................................................................................. 6 EPSDT Well-Child Visits: Established Patients..................................................................................................... 6 Evaluation and Management Codes.................................................................................................................... 7 Immunizations......................................................................................................................................................... 7 Screening Requirements, Tools and Coding Screening Tools....................................................................................................................................................... 8 Maternal Depression Screening............................................................................................................................ 8 Autism Screening ................................................................................................................................................... 8 Developmental Screening...................................................................................................................................... 9 Anemia Screening................................................................................................................................................... 9 Lead Screening........................................................................................................................................................ 9 Vision Screening....................................................................................................................................................10 Hearing Screening.................................................................................................................................................10 Dyslipidemia Screening........................................................................................................................................11 Behavioral, Social and Emotional Screening.....................................................................................................11 Depression and Suicide Risk Screening.............................................................................................................11 Tobacco, Alcohol and Drug Use Assessment ..................................................................................................12 Dental Screening...................................................................................................................................................12 Human Immunodeficiency Virus Screening......................................................................................................12 Sexually Transmitted Infection Sceening ..........................................................................................................13 Disclaimer...............................................................................................................................................................13

2 Early and Periodic Screening, Diagnostic and Treatment Clinical Practice and Billing Guideline Early and Periodic Screening, Diagnostic and Treatment services are federally mandated to address the physical, mental and developmental health of children under the age of 21 who are enrolled in Medicaid. The goal of EPSDT is to discover and treat childhood health conditions before they become serious or disabling. The core of EPSDT is the well-child visit. All primary care providers who provide services to our Medicaid members under the age of 21 are required to provide comprehensive health care, EPSDT screenings and preventive services. We require partnering PCPs to provide all EPSDT services in compliance with federal and state regulations and per the Bright Futures/American Academy of Pediatrics periodicity schedule. Following is information on our clinical practice and billing guideline for well-child visits and screenings for our Medicaid members under 21. The evidence-based guideline is intended to help ensure that our members receive preventive and comprehensive services. We use this guideline to guide our quality improvement program. It is meant to support decision-making processes in patient care and not to substitute for clinical judgment in individual cases. Well-Child Visit Scheduling Well-child visits are called the Tot to Teen Healthcheck in New Mexico. According to the New Mexico Health Care Authority, these health checks should occur from infancy through age 20. They are regularly scheduled check-ups to help the child’s primary care provider identify any problems early and assist with a treatment plan for the child. The New Mexico Tot to Teen Healthcheck Schedule • Under age 1: Six visits (birth, 1, 2, 4, 6 and 9 months) • Ages 1-2: Four visits (12, 15, 18 and 24 months) • Ages 3-5: Three visits (3, 4 and 5 years) • Ages 6-9: Two visits (6 and 8 years) • Ages 10-14: Four visits (10, 12, 13 and 14 years) • Ages 15-18: Four visits (15, 16, 17 and 18 years) • Ages 19-20: Two visits (19 and 20 years) Clinical Practice Guidelines You can ensure that infants, children and adolescents receive the full benefit of their comprehensive health care coverage by following the Bright Futures/American Academy of Pediatrics Periodicity Schedule as the clinical practice guideline for well-child visits and screenings.

3 Components of EPSDT Well-Child Visits and Services EPSDT well-child visits should include: • Comprehensive health and developmental history • Comprehensive physical examination • Assessment of physical, emotional and developmental health • Immunizations appropriate to age • Laboratory tests including blood lead screening • Assessment of blood pressure beginning at age 3 • Assessment of mental and behavioral health • Assessment of mouth, oral cavity and teeth, including referral to a dentist starting at 1 year • Assessment of nutritional status • Assessment of vision, including referrals • Assessment of hearing, including referral for further evaluation, if needed • Assessment of overall health, including referral for further evaluation, if needed • Health education, which is also called anticipatory guidance • Management of identified health concerns, including referrals for specialty care and behavioral health • Assessment of safety, such as use of booster and car seats, and preventing access to firearms • Family planning services, including screening for sexually transmitted infections, contraceptives and referrals for additional services such as long-acting reversible contraception, if appropriate EPSDT Services • Preventive care screenings • Diagnosis and treatment • Personal care services • Home health aide services • Private duty nursing (RN, LPN) • Early intervention services • Physical, speech and occupational therapy • Behavioral and mental health services
• Case management • Specialty care • Vision services • Hearing services • Dental services • School-based services • Transportation, travel and scheduling assistance Prior Authorization For Medicaid members, prior authorization is required for the EPSDT services listed below. If approved, an authorization will be issued to the servicing agency. • Private duty nursing • Home health aide • Physical therapy • Occupational therapy
• Speech therapy • Behavioral therapy • Hearing services To request prior authorization, the provider or servicing agency may call the Utilization Management Intake department at 877-232-5518 (the servicing agency must have a PCP order to initiate the request). If approved, an authorization will be issued to the servicing agency. Always check eligibility and benefits before providing treatment or ordering services. This step helps confirm coverage details and prior authorization requirements and vendors, if applicable. Learn more about prior authorizations and our Medicaid prior authorization requirements.

4 Early Intervention Services Early Intervention Services are at no-cost to the infant or toddler, and the program is funded by the New Mexico Early Childhood Education and Care Department’s Family Infant Toddler Program, which provides services to infants and toddlers, from birth to 3 years old. Criteria for Early Intervention Services in New Mexico • Infants and toddlers who have or are at risk for a developmental delay or health concerns • Infants and toddlers with an established condition such as cerebral palsy, Down syndrome, hearing loss, vision loss, etc. • Infants and toddlers with a medical risk such as prematurity (less than a 32-week gestation), low birth weight, chronic ear infections, cleft lip and palate, etc. • Infants and toddlers with social risk factors or concerns such as being born to teen parents, having a Comprehensive Addiction and Recovery Act plan, etc. Early Intervention Services • Occupational therapy • Physical therapy • Family service coordination • Social work • Developmental instruction • Speech and language therapy • Behavioral therapy • Feeding and nutrition support and services • Activities to develop learning skills • Activities to help social and emotional development • Transition into school or other services as needed at age 3 or when graduating from the program Call 877-696-1472 to refer a baby or toddler to Early Intervention Services. You may also refer directly to an Early Intervention location. See the Family Infant Toddler Providers list by county on the FIT website.

5 EPSDT Benefit: Treatment Services Health problems should be identified and treated as early as possible, as medically necessary. If a well-child visit or EPSDT screening delivers an abnormal result, it’s important for the provider to educate the family and member on the various treatment options available within the EPSDT benefit and direct them toward the service(s) most appropriate for their needs. Some EPSDT services require a PCP order and/or letter of medical necessity for prior authorization.
EPSDT Personal Care Services PCS is an EPSDT benefit providing a range of services to the eligible recipient who is unable to perform some of the activities of daily living due to a disability, cognitive impairment or functional limitation. PCS requires a PCP order, and the member’s Care Coordinator will submit the request and required documentation to UM for review and approval. The member will also need to select a PCS agency prior to submission. Private Duty Nursing Services As part of the EPSDT program, PDN services are covered for members under the age of 21 who meet the established medically fragile criteria. A person who is medically fragile requires ongoing skilled nursing care, evaluation and decision making for the management of a complex chronic medical condition. Daily skilled nursing intervention is medically necessary for those members who have a medically fragile condition resulting in prolonged dependency on medical care. A person who is medically fragile most often requires life-sustaining medical equipment and devices such as monitors, ventilators, oxygen support, feeding pumps or dialysis. The Medically Fragile Case Management Program provides Registered Nurse case management and service coordination services statewide for children who are medically fragile and their families via six satellite offices. Care Coordination Our Care Coordinators are available to answer questions and provide further help in accessing EPSDT benefits. If you have additional questions or concerns, contact the member’s Care Coordinator. If the member isn’t enrolled in Care Coordination and would like to access this service, please direct them to call 877-232-5518 and select option 3.

6 Billing for Well-Child Visits When billing an EPSDT well-child visit, PCPs must use the appropriate well-child Current Procedural Terminology (CPT®) code. All associated screening and lab codes are reflective of provider participation in the EPSDT program. To reflect the outcome of an EPSDT visit, it is considered best practice to use one of the following ICD-10 diagnosis codes with the well-child visit (CPT) codes. EPSDT Well-Child Visits: New Patients CPT Codes ICD-10-CM Codes 99381 Infant (younger than 1 year) Z00.110 Health supervision for newborn under 8 days old or Z00.111 Health supervision for newborn 8 to 28 days old or Z00.121 Routine child health exam with abnormal findings or Z00.129 Routine child health exam without abnormal findings 99382 Early childhood (age 1–4 years) 99383 Late childhood (age 5–11 years) 99384 Adolescent (age 12–17 years) Z00.121 Routine child health exam with abnormal findings or Z00.129 Routine child health exam without abnormal findings 99385 18 years or older Z00.00 General adult medical exam without abnormal findings or Z00.01 General adult medical exam with abnormal findings EPSDT Well-Child Visits: Established Patients CPT Codes ICD-10-CM Codes 99391 Infant (younger than 1 year) Z00.110 Health supervision for newborn under 8 days old or Z00.111 Health supervision for newborn 8 to 28 days old or Z00.121 Routine child health exam with abnormal findings or Z00.129 Routine child health exam without abnormal findings 99392 Early childhood (age 1–4 years) 99393 Late childhood (age 5–11 years) 99394 Adolescent (age 12–17 years) Z00.121 Routine child health exam with abnormal findings or Z00.129 Routine child health exam without abnormal findings 99395 18 years or older Z00.00 General adult medical exam without abnormal findings or Z00.01 General adult medical exam with abnormal findings

7 Evaluation and Management Codes CPT Codes ICD-10-CM Codes 99202-99205 New patient 99212-99215 Established patient These E/M codes may also reflect a sick visit. You’re encouraged to catch up on the child’s well-child visit and EPSDT screenings during a sick visit. This includes immunizations, if no contraindications are present. An illness is separate from an EPSDT visit and can be billed in addition to the EPSDT well-child visit code if documentation supports the two separate visits billed on the same day. An EPSDT well-child visit must be completed with a sports physical. According to the American Academy of Pediatrics’ Coding for Pediatric Preventive Care: If an illness or abnormality is discovered, or a preexisting problem is addressed, in the process of performing the preventive medicine service, and if the illness, abnormality or problem is significant enough to require additional work to perform the components of a problem-oriented evaluation and management service (i.e., using medical decision making or time spent), the appropriate office or other outpatient service code (99202–99215) should be reported in addition to the preventive medicine service code. Append modifier 25 to the office or other outpatient service code (e.g., 99392 and 99213 25). Immunizations Well visits are an excellent time to ensure your patient’s immunizations are up to date in accordance with Immunize.org. Use the New Mexico Statewide Immunization Information System as a guide for what shots your patient needs. Offer immunizations at all visits, including sick visits, to ensure your patients are caught up on needed shots. A minor illness or cold is not a contraindication to a child receiving vaccines.

8 Screening Requirements, Tools and Coding We require contracted PCPs to provide all EPSDT services in compliance with federal and state regulations and according to the Bright Futures/American Academy of Pediatrics Periodicity Schedule. When billing an EPSDT well-child visit, use the appropriate well-child CPT code. In addition, all associated screening and lab codes reflect provider participation in the EPSDT program. Screening Tools At specified visits, universal screenings are required for developmental concerns, behavioral, social and emotional concerns, maternal depression, adolescent depression and suicide risk, substance use and oral health concerns. Refer to the Bright Futures table of commonly used screening instruments and tools. Maternal Depression Screening The infant’s PCP may be the first person to become aware of emerging depressive symptoms in a new mother. Newborn and infant visits offer the opportunity to assess how new parents are adjusting. Early detection of maternal depression allows you to quickly initiate support services, which could be crucial in preventing later problems. Refer to Bright Futures Postpartum Mood Disorders for more details. For EPSDT compliance, use an appropriate screening tool and submit the billing code as follows: Screening Type Codes Frequency Maternal depression screening and 6-month visits 96161 Required by age 1 month and at 2, 4 and 6-month visits Autism Screening Autism, also referred to as autism spectrum disorder, is a neurodevelopmental condition that presents with challenges of varying severity related to social skills, repetitive behavior, speech and nonverbal communication. In March 2023, the CDC released a report showing an increase in the prevalence of autism, now effecting an estimated one in 36 children age 8 years. ASD can be recognized in early childhood. EPSDT autism screenings are required at 18 and 24 months. If the screening is positive: The child must be referred for an autism evaluation and connected with a behavioral health care coordinator. These steps are crucial in ensuring that necessary support for the child and family begins as soon as possible. New Mexico has programs dedicated to providing ASD early intervention services. The New Mexico Autism Society helps families navigate next steps after receiving an ASD diagnosis. Additional behavioral health services such as Applied Behavior Analysis, if deemed medically necessary, is fully covered through the EPSDT benefit. For EPSDT compliance, use an appropriate screening tool and submit the billing code as follows: Screening Type Codes Frequency Autism screening 96110 with U1 modifier Z13.41 - Encounter for autism screening Required at age 18 months and 24 months old using a validated screening tool The U1 modifier distinguishes the autism screening from the developmental screening.

9 Developmental Screening Developmental delay is a condition in which a child is delayed in reaching the milestones expected at certain ages. The child will present with skill deficits in one or more of the following areas: cognition, social and emotional, speech and language or motor development. Early detection and treatment services are imperative for improving outcomes for children, families and communities. Providers are responsible for completing three developmental screenings before the child turns 3 years old. If a screening is positive, the child should be referred for evaluation of Early Intervention services. For EPSDT compliance, utilize an appropriate screening tool and submit the billing code as follows: Screening Type Codes Frequency Developmental screening 96110 Required at 9 months old, 18 months old and 30 months old using a validated screening tool Anemia Screening Anemia is a condition of low count, unhealthy red blood cells and hemoglobin resulting in decreased oxygen transport throughout the body. Selective screening is to be performed based on risk assessment. An abnormal menstrual cycle can be a risk factor for anemia in adolescent females. Children on Medicaid are in a higher risk category for developing iron-deficiency anemia; therefore routine universal anemia screening should be initiated at 9 to 12 months of age. The following diagnostic test is required for EPSDT compliance: Screening Type Codes Frequency Anemia screening 85018 - Blood count; hemoglobin Required at 9-12 months old, 2 years of age, 4 years of age (New Mexico Women, Infants, and Children and Head Start requirement) Annually for adolescent females if they have started their menstrual cycle Lead Screening Lead exposure can impact nearly every system in the body and often goes undetected because at low levels of exposure, it can occur without any obvious symptoms. Even low blood lead levels can diminish a child’s IQ, decrease their ability to pay attention and affect overall academic achievement. The developmental effects of lead toxicity are permanent. Blood lead level screenings are required by the Centers for Medicare & Medicaid Services and the American Academy of Pediatrics Providers should report screening results to the New Mexico Department of Health. Completion of a lead exposure risk assessment questionnaire does not meet the Medicaid EPSDT lead screening requirement. Following are the CPT code and screening frequency required for EPSDT compliance. Screening Type Codes Frequency Blood lead screening 83655 Required at age 9-12 months and 24 months; once between 2-6 years old, if the child has never been tested or if required by Head Start

10 Vision Screening Assessing vision through a physical examination is a routine part of every well-child visit. Formal acuity testing begins at 3 years old. Photoscreening codes are appropriate from 9 months through age 5 years or if medically necessary due to developmental or other medical conditions. The screening frequency below outlines the requirements for EPSDT compliance. Screening Type Codes Frequency Vision screening 99173 - Quantitative bilateral visual acuity exam 99174 - Instrument-based ocular screening (e.g., photoscreening, automated-refraction), bilateral, with remote-analysis and report 99177 - Instrument-based ocular screening (e.g., photoscreening, automated-refraction), bilateral; with on-site analysis Required at ages 3, 4, 5, 6, 8, 10, 12 and 15 years old Additional screening may occur at other intervals as medically necessary or if indicated for school related activities Hearing Screening The American Academy of Pediatrics recommends that all children have a hearing test at birth and again at ages 4, 5, 6, 8 and 10 years old with additional screenings between ages 11-14, 15-17 and 18-20 years old. These screenings can diagnose hearing changes at the earliest possible stage when interventions can have the greatest positive impact. See possible codes and EPSDT frequency below: Screening Type Codes Frequency Hearing screening 92551 - Screening test, pure tone, air only 92552 - Pure tone audiometry (threshold), air only 92587 - Distortion product evoked otoacoustic emissions; limited evaluation (to confirm the presence or absence of hearing disorder, 3-6 frequencies) or transient evoked Required at ages 4, 5, 6, 8, 10, between 11-14, between 15-17, and between 18-20 years old

11 Dyslipidemia Screening The American Academy of Pediatrics recommends universal screenings for lipid abnormalities. Diets consisting of foods that are processed and high in saturated and trans fats may increase cholesterol levels in children. In children who have obesity, the prevalence of dyslipidemia rises to 42%, according to the National Library of Medicine. These children are also at risk for developing hypertension; therefore blood pressure checks must be part of the physical examination beginning at 3 years old. EPSDT screening code and frequency requirements are: Screening Type Codes Frequency Dyslipidemia screening 80061 - Lipid panel [includes total cholesterol, high-density lipoprotein (HDL) cholesterol, and triglycerides] Required once between 9 and 11 years old and once between 17 and 20 years old Behavioral, Social and Emotional Screening Exposure to environmental, familial and psychosocial risks can affect a child at any age. It is important for providers to be aware of potential risk factors and perform screenings based on the child’s age and situation. Providers are to utilize a proper screening tool and submit the billing code as follows for EPSDT compliance. Screening Type Codes Frequency Behavioral, social or emotional screening 96127 Required for newborn up to 21 years old, every EPSDT visit Depression and Suicide Risk Screening Depression is a relatively common mental health problem among the adolescent and young adult population and is not always characterized by sadness. Depression may present as irritability, anger, boredom, an inability to experience pleasure or difficulty with family relationships, school and work. As a provider, it’s important to obtain family history regarding mental health, depression, substance abuse and suicide. For EPSDT compliance, providers are to utilize an appropriate screening tool and submit billing codes as follows: Screening Type Codes Frequency Depression and suicide risk screening 96127 with diagnosis code Z13.31 - Encounter for screening for depression Required annually for ages 12 to 21 years old

12 Tobacco, Alcohol and Drug Use Assessment
The use or abuse of tobacco, vape, alcohol and other drugs is a substantial health concern within the adolescent population. Even occasional drug and alcohol use can have serious consequences. Teens under the influence of alcohol or other drugs are at increased risk for unprotected sexual activity, violence and motor vehicle accidents. Drug abuse and dependency may lead to serious crimes and contribute to the rate of teen homicides and suicides. For EPSDT compliance, providers are encouraged to utilize an appropriate screening tool and submit the billing code as follows: Screening Type Codes Frequency Tobacco, vape, alcohol or drug use assessment 96160 Indicated for ages 11 through 20 years old Dental Screening Assess whether the child has a dental home. Referral to a dental home is indicated at 1 year. For EPSDT compliance, utilize a Dental Risk Assessment Tool for patients 6-8 months of age and again between 9-11 months of age. Apply fluoride varnish at first tooth eruption and every 3-6 months until a dental home is established. Submit billing code as follows: Screening Type Codes Frequency Application of topical fluoride varnish 99188 Recommended to be performed by PCP at first tooth eruption and every 3-6 months until dental home established Referral to dental home indicated at 1 year Human Immunodeficiency Virus Screening In 2021, the CDC reported that 20% of new HIV diagnoses in the U.S. were among young people ages 13-24. It’s estimated that almost half of young people with HIV don’t know they have it. In the U.S., most youth haven’t been tested for HIV and don’t believe they’re at risk for contracting the virus. EPSDT visits provide the opportunity for pediatricians to obtain an accurate assessment of the adolescent’s sexual and reproductive history. With any youth encounter, it’s key to create a safe and confidential environment, which allows for mutual respect and trust. According to the American Academy of Pediatrics, it’s the responsibility of the PCP to provide risk-reduction counseling and perform routine HIV testing and prophylaxis to adolescents and young adult patients beginning at age 15 years. See below for screening codes and testing frequency recommended for EPSDT compliance. Screening Type Codes Frequency HIV screening 86701 - Antibody; HIV-8 6703 - Antibody: HIV-1 and HIV-2; single assay Required once between the ages of 15 and 21 years old

13 Sexually Transmitted Infection Sceening Among pediatricians and PCPs, screening rates for sexually transmitted infections are remarkably low for adolescents despite STI screening recommendations by the American Academy of Pediatrics, CDC, the U.S. Preventive Services Task Force, the American Academy of Family Physicians and the American College of Obstetricians and Gynecologists. It’s estimated that adolescents ages 15-24 account for half of the approximated 20 million new STI cases each year in the U.S., according to a study in the National Library of Medicine. Studies indicate that 25% of female adolescents will contract an STI by age 19, according to the American Academy of Pediatrics. Some of the barriers preventing adequate STI screening for adolescents may include lack of visit time, provider prioritization of other health topics during preventive visits and adolescents declining STI screenings due to confidentiality concerns or not understanding their risk of infection. With any youth encounter, it’s key to create a safe and confidential environment, which allows for mutual respect and trust. It’s the PCP’s responsibility to identify sexual health risk behaviors (multiple partners; oral, anal or vaginal sex; or drug misuse behaviors) and provide risk-reduction counseling. Routine laboratory screening for common STIs is indicated for all sexually active adolescents. See below for screening codes and testing frequency recommended for EPSDT compliance from the CDC. Screening Type Codes Frequency STI Screening 87491 - Infectious agent detection by nucleic acid (DNA or RNA); C trachomatis, amplified probe technique 87591 - Infectious agent detection by nucleic acid (DNA or RNA); N gonorrhoeae, amplified probe technique 86780 - Syphilis: Treponemal Antibodies, Chemiluminescence Immunoassay 87521 - Infectious agent detection by nucleic acid (DNA or RNA); hepatitis C, amplified probe technique, includes reverse transcription when performed To be performed annually for sexually active adolescents Disclaimer The material presented here is for informational and educational purposes only and is not intended to be medical advice or a definitive source for coding claims and is not a substitute for the independent medical judgment of a physician or other health care provider. Health care providers are encouraged to exercise their own independent medical judgment based upon their evaluation of their patients’ conditions and all available information, and to submit claims using the most appropriate code(s) based upon the medical record documentation and coding guidelines and reference materials. References to other third party sources or organizations are not a representation, warranty or endorsement of such organizations. The fact that a service or treatment is described in this material, is not a guarantee that the service or treatment is a covered benefit and members should refer to their certificate of coverage for more details, including benefits, limitations and exclusions. Regardless of benefits, the final decision about any service or treatment is between the member and their health care provider. CPT copyright 2024 American Medical Association. All rights reserved. CPT is a registered trademark of the AMA.

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