EPSDT Provider Reference Kit

What is KBH and EPSDT?

The KAN Be Healthy (KBH) program in Kansas requires all Medicaid coverable, appropriate, and medically necessary services needed to correct and ameliorate health conditions as described in the federal Early and Periodic Screening, Diagnostic, Treatment (EPSDT) program be provided to Medicaid beneficiaries under 21 years of age.

• (E) Early – Assessing and identifying problems early.
• (P) Periodic – Checking children’s health at periodic, age-appropriate intervals.
• (S) Screening – Providing physical, mental, developmental, dental, hearing, vision, and other screening tests to detect potential problems.
• (D) Diagnosis – Performing diagnostic tests to follow up when a risk is identified.
• (T) Treatment – Control, correct, or reduce health problems.

Medically necessary services identified through a screening examination will be covered regardless of whether the service is covered in a state’s Medicaid plan. Coverage of medically necessary services not generally covered will be subject to a prior authorization process, e.g. sleep study, applied behavior analysis, elective surgery.

Listed below are the components of KBH/EPSDT screening services which includes hearing, vision, and dental services.

A KBH screen must consist of at a minimum the following:

• Medical history
• Physical growth
• Body systems
• Developmental/emotional
• Nutrition
• Health education & anticipatory guidance
• Blood lead
• Laboratory
• Immunizations
• Hearing screening
• Vision screening
• Dental screening

There are four categories of screens that comprise a KBH examination: medical, dental, vision and hearing.

• Medical screenings (M) must follow the KBH minimum documentation requirements when billing an E&M preventive medicine or office visit CPT code found in the CPT codebook.
• Vision screenings (V) are a required component of each KBH visit. School vision screenings are a separate process and are not billed by physicians.
• Hearing screenings (H) are a required component of each KBH visit. As with vision screenings school hearing screenings are a separate process and are not billed by physicians.
• Dental screenings (D) are a required component of each KBH visit. Only screenings performed by dentists will update the KBH screen. Medical providers can meet this requirement by completing the dental portion of the KBH form: Sees dentist, fluoride varnish, last dental exam date, or whether a dental referral was made.

The State of Kansas Medicaid Agency uses the Bright Futures/AAP Periodicity Schedule developed by the American Academy of Pediatrics (AAP) and the American Academy of Pediatric Dentistry (AAPD) to define recommended timeframes for KBH/EPSDT components. The KBH/EPSDT periodic screenings schedule is displayed below. This timetable is suggested for the vast majority of children, adolescents and young adults; however, more than one visit a year is covered as needed. Additional information regarding the Bright Futures recommendations can be found on the AAP website.

Every KBH visit must have all components completed and documented.

Dental screening/attention should be initiated once teeth erupt, as early as 6 months of age.

Appropriate immunizations in accordance with the schedule of pediatric vaccines established by the Advisory Committee on Immunization Practices (ACIP) is an important component of the KBH/EPSDT well child visit. Below is the immunization schedule available on CDC's website:

• *Three to four doses dependent on vaccine used.
• **Two to three doses dependent on vaccine used.
• ***Two to three doses dependent upon age at initial vaccination, ages 9-14 at initial vaccination receives a two-dose series, ages 15 or older at initial vaccination receives a three-dose series.
• ****Two doses, separated by at least four weeks, for children ages 6 months–8 years who have received fewer than two influenza vaccine doses before July 1, 2022, or whose influenza vaccination history is unknown (administer dose two even if the child turns 9 between receipt of dose one and dose two). One dose for children ages 6 months–8 years who have received at least two influenza vaccine doses before July 1, 2022. One dose for all persons ages 9 years or older.
• #Catch-up opportunity.

Sunflower Health Plan is committed to providing preventive health screenings and improving the overall health of children enrolled in its health plan. With the proportion of children in the population, the ability to impact the incidence of EPSDT screening is of vital importance to the overall health and well-being of our membership.

How Sunflower Engages Members to Seek Preventive Services

Sunflower uses incentives and outreach communication to our members to encourage preventive services for the health of our child/adolescent members. Listed below are some of our incentives and outreach communications.

• My Health Pays^® Healthy Rewards program provides financial rewards for members who seek various healthy activities. Many of the healthy activities are objectives of the EPSDT program.
• Transportation assistance via gas mileage reimbursement or non-emergency medical transportation services.
• Conduct phone outreach to encourage members to access preventive care and assist with making appointments as necessary.
• Post card mailing to members – happy birthday for all members to age 21. Welcome letters are sent to the parents of babies born in the previous month.
• Automated phone call reminders are sent to the parents/guardians of children who are due for a well-child visit, encouraging them to schedule and attend the child's upcoming visit.

Provider Support

In addition to the member motivation activities listed above, Sunflower sends HEDIS Physician Quality Reports throughout the year to providers who have at least one patient who may not be current on their well-child visits or immunizations.

Because the HEDIS Physician Quality Reports do not address all of the EPSDT components, Sunflower can give support to providers by monitoring and creating reports for EPSDT participation if requested.

The EPSDT participation reports may be helpful to providers to identify moderate to large panels of EPSDT eligible members with low participation scores. This report will be made available to requestors in order to increase communication and participation in the EPSDT program.

Sunflower welcomes your suggestions for improving our EPSDT rates or feedback regarding EPSDT services. Please contact Sunflower's EPSDT coordinator toll free 1-877-644-4623 (TTY: 711).

Well-Child Visits in the First 15 Months of Life

Children should have at least 6 well-child (Kan-Be-Healthy) visits with PCP within the first 15 months of life.

Lead Screening in Children at 12 and 24 months

HEDIS requires children to have blood lead level tests at 12 and 24 months, regardless of score on the KBH-EPSDT Blood Lead Screening Questionnaire.

Well-Child Visits, Ages 3 to 20 Years Old

Children/Adolescents/Young Adults should have at least one comprehensive well care (Kan-Be-Healthy) visit every year with a PCP.

Childhood and Adolescent Immunizations

Vaccines for Children (VFC) administered vaccinations:

In order to be reimbursed for administration of VFC vaccines, the provider must bill the appropriate CPT^® codes for administration and for the vaccine(s) covered under the VFC program for all children 18 years of age and younger.

If using PACS software which requires a charge on each line item being submitted, providers need to indicate a charge of $.01 on the line for the vaccine/toxoid code. Please refer to the KMAP Professional Manual for additional information (must use Internet Explorer browser). If you need further assistance, please contact your local PR representative through Sunflower.

Additional KBH/EPSDT Screens and Billing Codes

Dental Screenings and Cleanings

Infants should see a dentist after the first tooth erupts but no later than 12 months of age. After 12 months of age, a child should be seen every 6 months for regular screenings and cleanings. The following CPT^® codes are used for dental screenings only.

• D0120
• D0140
• D0150
• D0170
• D9420

Vision Screenings and Exams

Newborns up to 30 months should have a vision screening at every visit and then annually from three to 20 years. The following CPT^® codes are used for vision screens only.

• 92002
• 92004
• 92012
• 92014
• 99173

Hearing Screenings

Newborns up to 30 months should have a hearing screening at every visit and then annually from three to 20 years. The following CPT^® codes are used for hearing screens only.

• 92555
• 92556
• 92557
• 92582
• 92587

Please refer to the KMAP-KBH Provider Information internet site.

All KBH screening forms are on the Kansas Medical Assistance Program (KMAP) website: KMAP-KBH Provider Information.

Effective with dates of service on and after November 1, 2018, modifier EP will be informational only. It can be used with any Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) screening code but will no longer result in the bundled payment for an EPSDT screen. Providers will need to bill each service provided with the appropriate HCPCS code. For children receiving EPSDT services, any limits on services may be exceeded when medically necessary.

When a child is seen for a sick visit, they also can be seen for a KBH (well-child) check. This requires all the components of the EPSDT screening to be completed and to be billed utilizing an ICD-10 code as the first diagnosis. The second diagnosis is then determined by the detected problem.

Sports physicals may qualify as an EPSDT screening as long as all criteria are included in the exam.

Providers must use the appropriate CPT^® codes in order for Sunflower to pay claims correctly and in a timely manner.

Claims will not recognize an EPSDT visit, unless the preventive visit codes are used correctly. This includes the CPT^® codes for well-child visit, lead screening (when age appropriate), immunizations, dental screenings, vision screenings and hearing screenings. All of this information can be found at KMAP-KBH Provider Information. If this is not done correctly, claims will not reflect that a KBH visit was completed and the KBH data will not be updated.

For any additional billing questions or concerns, please refer to the Sunflower Provider Manual, billing manual, or your local provider relations representative.