Early and Periodic Screening, Diagnosis and Treatment
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1 Early and Periodic Screening, Diagnosis and Treatment 1
2 Healthchek Ohio Medicaid EPSDT Services Early Periodic Screening Diagnosis Treatment Identify problems early, starting at birth Check children s health at periodic, ageappropriate intervals Perform physical, mental, developmental, dental, hearing, vision, and other screening tests to detect potential problems Perform diagnostic tests to follow up when a risk is identified Treat the problems found 2
3 Federal Requirements Federal law* requires that Medicaid cover a very comprehensive set of benefits and services for individuals under 21 years of age, some of which are not available to adults. *Social Security Act Sec
4 Federal Requirements Early and Periodic Screening Screening services must be covered at established, periodic intervals and whenever a problem is suspected. Screening services include comprehensive health and developmental histories, unclothed physical exams, appropriate immunizations, laboratory tests, and health education. 4
5 Federal Requirements Diagnosis and Treatment Diagnostic services are provided for further evaluation when a screening exam indicates a need Treatment services are provided for medically necessary* treatment and other measures to correct or ameliorate defects, as well as physical and mental illnesses and conditions that may be discovered by the screening services *Ohio Administrative Code (previously 5101:3 1 01) defines medical necessity 5
6 Healthchek Requirements Healthchek is Ohio Medicaid s name for EPSDT Healthchek includes: Screening services Follow American Academy of Pediatrics Recommendations for Preventive Pediatric Health Care ( Any medically necessary screening, diagnostic, and treatment services May go beyond the benefit coverage and limitations 6
7 Healthchek Screening Frequency Nine (9) Healthchek exams are recommended during the first 15 months of life, including two (2) in the first week of life Exams at 18 months, 24 months, and 30 months Annual exams from ages 3 to 21 7
8 Healthchek Screening Exams Components of the periodic, well child visit: Comprehensive health and developmental history Comprehensive unclothed exam Health education, counseling, anticipatory guidance, and risk factor interventions Developmental screening Immunization screening Nutritional screening Vision and hearing screening Dental screening Appropriate laboratory tests 8
9 Comprehensive Health and Developmental History The history includes: Physical and mental health development Family and individual medical history Current complaints Current medications Allergies Social or physical environment impacting health For adolescents, sexual activity and contraception 9
10 Comprehensive Unclothed Exam Height and weight; percentiles Head circumference, as appropriate Blood pressure Examination of the following: Head, ears, eyes, nose and throat Respiratory, cardiovascular, gastrointestinal, reproductive, musculoskeletal and neurological systems A sick child visit is an opportunity to complete a full Healthchek exam. 10
11 Health Education, Counseling, Anticipatory Guidance, and Risk Factor Interventions Required component of each Healthchek visit Designed to provide information that assists the parent and individuals in understanding what to expect in terms of: the individual s development the benefits of healthy lifestyles and practices disease prevention 11
12 Developmental Screening Age appropriate developmental history Screening of motor, speech, social development, mental, and behavioral health 12
13 Immunization Screenings Immunization history and screening are required at each Healthchek visit. If an immunization is needed, the provider should administer or refer as needed. The Vaccines for Children (VFC) Program provides routine vaccines to participating health care providers who administer them to eligible children birth through 18 years of age. For immunization and/or VFC program information, contact State of Ohio, Department of Health, at , or visit the web site at For the Advisory Committee on Immunization Practices (ACIP) Immunization Schedule visit the website at 13
14 Nutritional Screening Screening of nutritional status Questions focused on dietary practices Measurement of height and weight (BMI percentile or BMI percentile plotted on an age growth chart) Laboratory testing, if medically indicated 14
15 Birth to 3 years Vision Screening Screen medical history for risk factors observations and ophthalmoscope exam 3 years and above External observation and ophthalmoscope exam Visual acuity test Ocular muscle balance test Stereopsis test Refer if potential visual problem 15
16 Hearing Screening 1 to 3 years: Review history for risk factors or symptoms indicative of hearing problems Observe child and question parent for physical behaviors or speech development that may indicate hearing impairment 3 years and older: Manually administer using specified equipment If equipment is not available, refer for pure tone test Refer if potential hearing problem 16
17 Dental Screening Emphasize importance of preventive dental health care Birth through 2 years: Screen for normal growth and development of the dentition and dento facial structure Inspect for caries Refer for dental visits at 2 years 3 years and older: Refer to dentist if not seen in the last 6 months 17
18 Appropriate Laboratory Tests Lead toxicity testing Test all children at 12 and 24 months Children 3 6 years test if not previously tested Whenever medically indicated Sickle cell At least once for at risk children Hemoglobin and hematocrit As medically indicated, such as for anemia and iron deficiency For all premature and low birth weight infants Pap smears, tests for STDs, tuberculin test, and other lab screens, as medically necessary 18
19 Treatment and Medicaid Coverable Services* Inpatient hospital services (other than services in an institution for mental disease) Outpatient hospital services Rural health clinic services and federally qualified health center services Other laboratory and X ray services Nursing facility services Early and periodic screening, diagnosis, and treatment services Family planning services and supplies Physicians' services Medical and surgical services furnished by a dentist Dental services Medical care or any other type of remedial care recognized under State law, furnished by licensed practitioners within the scope of their practice Home health care services Private duty nursing services Clinic services furnished by a physician or under the direction of a physician Physical therapy and related services (occupational therapy and services for individuals with speech, hearing, and language disorders) Prescribed drugs, dentures, and prosthetic devices and eyeglasses *Section 1905(a) of the Social Security Act [42 U.S.C. 1396d] lists the Medicaid coverable services. Each service may have limitations of coverage. By definition, some services are not applicable to the Healthchek population. 19
20 Treatment and Medicaid Coverable Services* Other diagnostic, screening, preventive, and rehabilitative services, including any medical or remedial services (provided in a facility, a home, or another setting) recommended by a physician or other licensed practitioner of the healing arts within the scope of their practice under State law, for the maximum reduction of physical or mental disability and restoration of an individual to the best possible functional level Inpatient hospital services and nursing facility services for individuals 65 years of age or over in an institution for mental diseases Services in an intermediate care facility for the mentally retarded Inpatient psychiatric hospital services for individuals under age 21 Services furnished by a nurse midwife, certified pediatric nurse practitioner, or certified family nurse practitioner Hospice care Case management services TB related services Respiratory care services Community supported living arrangement services Personal care services Services furnished under a PACE program Primary and secondary treatment and services for individuals who have sickle cell disease Any other medical care, and any other type of remedial care recognized under State law, as specified by the Secretary *Section 1905(a) of the Social Security Act [42 U.S.C. 1396d] lists the Medicaid coverable services. Each service may have limitations of coverage. By definition, some services are not applicable to the Healthchek population. 20
21 Treatment and Follow up Care When a screening service indicates the need for further evaluation and diagnosis, a referral or treatment is required without delay.* Evaluation, diagnosis, and/or treatment may be provided at the time of the Healthchek screening visit if the health care professional is qualified to provide the services. * Ohio Administrative Code and (previously 5101: and 5101:
22 Treatment and Follow up Care Follow up care can be provided by: Primary care providers (for example, family physicians or pediatricians) Specialists (for example, neurologists, ophthalmologists, and audiologists) Other health professionals (for example, dentists, advanced practice nurses, psychologists, and nutritionists) Community agencies (for example, WIC or schools) 22
23 Billing and Coding of Services Using proper billing codes when submitting claims and encounters is important to assure that: Your office receives the proper payment for services provided The State and the Medicaid Care Coordination Plans receive the correct information regarding the services provided to Medicaid members The State and the Medicaid Care Coordination Plans are able to report all provided EPSDT services to federal agencies *Note Contact your Provider Relations Representative for billing questions. 23
24 Referral Information Community Resources Social Support Services: Contact the local county Department of Medicaid Healthchek Coordinator Child development: Help Me Grow at GROW (4769) or Children with Special Needs: Bureau for Children with Medical Handicaps, Ohio Department of Health at (parents) or 24
25 Referral Information Community Resources Parenting skills: Ohio State University Extension Parenting Classes. To locate classes in your area, call Nutrition and Food Supplement Program: Women, Infants, and Children (WIC) Program at Domestic Violence hotline: National Domestic Violence Hotline at SAFE (7233) Child Abuse and Neglect: State of Ohio Child Protection at
26 Important Links M CHAT autism screening tool chat.pdf Ages and Stages Questionnaires (a fee may be associated) stages/pages/default.aspx For immunization and/or VFC program information, contact the State of Ohio, Department of Health, at , or visit the Web site at Immunization schedules are also available through the Centers for Disease Control at AAP Bright Futures is a national health promotion initiative dedicated to the principle that every child deserves to be healthy 26
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