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Welcome  » August 4, 2020 12:50 PM
Program Name: BadgerCare Plus and Medicaid Handbook Area: HealthCheck (EPSDT)
08/04/2020  

Covered and Noncovered Services : Covered Services and Requirements

Topic #2405

An Overview of HealthCheck Services

The purpose of EPSDT is to ensure that children receive early detection and care, so that health problems are prevented or diagnosed and treated as early as possible. HealthCheck is the term used for EPSDT in Wisconsin.

The HealthCheck benefit provides periodic, comprehensive health screening exams (also known as "well child checks"), as well as interperiodic screens, outreach and case management, and additional medically necessary services (referred to as HealthCheck "Other Services") for members under 21 years of age.

The HealthCheck benefit consists of the following service types:

A HealthCheck screen may be distinguished from other preventive health care under Wisconsin Medicaid because HealthCheck includes a strong anticipatory guidance and health education component, a schedule for periodic examinations (based on recommendations by the AAP).

Topic #11239

Blood Lead Screening Test

A capillary finger stick test can be done for a blood lead screening test. A confirmatory venous blood test is required only if the capillary blood lead level is 5 mcg/dL or greater.

Providers may be reimbursed for collection of a capillary blood specimen (e.g., finger, heel, ear stick) using CPT procedure code 36416 (collection of capillary blood specimen [e.g., finger, heel, ear stick]). This procedure is frequently used when doing a finger stick blood draw for blood lead testing.

Providers may be reimbursed for CPT procedure code 36416 and lab handling fee CPT procedure code 99000 when drawing a finger stick blood specimen to be mailed to the laboratory for analysis.

Providers may be reimbursed for CPT procedure code 36416 and CPT procedure code 83655 (Lead) when doing on-site blood lead testing. Providers will not be reimbursed for the lab handling fee CPT procedure code 99000 in this situation.

Blood Lead Testing at WIC Clinics

Many of the children seen in WIC clinics in Wisconsin are ForwardHealth members. The majority of WIC clinics do some blood lead testing of BadgerCare Plus-enrolled children when performing routine blood tests for hemoglobin or hematocrit. Confusion often exists when a finger stick is performed at the WIC clinic for hemoglobin or hematocrit as parents may assume that their child was also tested for lead. To validate that a blood lead test was previously performed on a particular child and to obtain the result of the test, providers may use the Wisconsin Blood Lead Registry or contact the WCLPPP.

Wisconsin Blood Lead Registry

The Lead Registry is a web-based tool that allows providers to check a child's blood lead testing history online during an office visit. The Lead Registry is linked to the WIR and updated by WCLPPP each week with new test results done at all locations, including WIC, Head Start, and physicians' offices. The Lead Registry can help providers easily identify children who have not yet been tested or are due for another test. For information on how to access the Lead Registry, providers may contact the WCLPPP.

Office-Based Blood Lead Testing

Providers are encouraged to draw capillary (finger stick) blood lead samples within their office or clinic. Performing the finger stick in the clinic ensures the test is completed. If the child is referred to an outside area, the test may not be done.

Providers wanting to provide blood lead testing in their office should refer to provider handbooks for information on the CLIA requirements. CLIA requires laboratories and providers performing tests for health assessment or for the diagnosis, prevention, or treatment of disease or health impairment to comply with specific federal quality standards.

Topic #771

Certificate of Need for Transportation

ForwardHealth covers SMV services if the transportation is to and from a facility where the member receives Medicaid-covered services and the member meets the criteria for SMV services. The following are criteria for SMV services:

  • A member must be indefinitely disabled, legally blind, or temporarily disabled.
  • A member must have a medical condition that contraindicates safe travel by common carrier such as bus, taxi, or private vehicle.

If a member meets the criteria, a physician, physician assistant, nurse practitioner, or nurse midwife should complete a Certification of Need for Specialized Medical Vehicle Transportation form.

Inconvenience or lack of timely transportation are not valid justifications for the use of SMV transportation. The presence of a disability does not by itself justify SMV transportation.

The medical provider gives a copy of the completed form to the member who then gives the form to the SMV provider. The medical provider does not need to keep a copy of the completed form on file, but they are required to document the medical condition necessitating SMV transportation in the member's medical record.

Physicians are required to complete a new Certification of Need for Specialized Medical Vehicle Transportation form upon expiration. For members who are indefinitely disabled, the form is valid for three years (36 months) from the date the medical provider signed the form. For members who are temporarily disabled, the form is valid for the period indicated on the form, which must not exceed 90 days from the date the medical provider signed the form.

Medical providers must not complete the forms retroactively for SMV providers or members.

Providers may not charge members for completing the Certification of Need for Specialized Medical Vehicle Transportation form. Wisconsin Medicaid will reimburse providers at the lowest level E&M CPT procedure code if the member is in the office when the form is completed and no other medical service is provided.

Topic #2404

Choosing Appropriate Components for a Member

Each of the required components of a comprehensive HealthCheck screen must be assessed and documented. On occasion, not every exam component needs to be performed to be a comprehensive screen, but each component must be documented. For example, a hearing test is unnecessary for a member previously referred to an audiologist via a school screening exam referral.

The periodicity schedule indicates recommended exam components for specific member ages.

Topic #2402

Comprehensive HealthCheck Screening Components and Periodicity

Required Components for Comprehensive Screens

Comprehensive HealthCheck screens are age-appropriate medical wellness check-ups that occur on a regular basis for Medicaid members under 21 years of age, and include the following components:

  • A comprehensive health and developmental history, including:
    • A health history
    • A nutritional assessment
    • A developmental-behavioral assessment
    • Health education and anticipatory guidance for the member and caregiver
  • A comprehensive unclothed physical exam
  • A hearing screen
  • A vision screen
  • An oral assessment, plus referral to a dentist beginning when the first tooth erupts or by age 1
  • Appropriate immunizations (according to age and health history, per the CDC's ACIP guidelines)
  • Appropriate laboratory tests (including blood lead level testing when appropriate for age)

HealthCheck provides access to comprehensive medical, vision, hearing, and dental screens according to the periodicity schedule recommended by the AAP.

As required by 42 C.F.R. § 441.58, Wisconsin Medicaid follows AAP's periodicity schedule for screening services.

Conditions identified during a HealthCheck screen may be referred for additional evaluation, which is covered by Wisconsin Medicaid. These conditions may result in recommendations for services that may be covered as HealthCheck "Other Services."

Accessing Comprehensive Screens

Comprehensive HealthCheck screens are available without PA. Primary care providers, including pediatricians, nurse practitioners, local health departments, and physician clinics, should provide the appropriate components of a HealthCheck screen, based on AAP or other best practice guidelines, as part of a comprehensive well child exam. No special forms are required.

Providers are required to maintain documentation of the HealthCheck screen and all areas that were assessed in the member's medical record. Clinics or agencies may use their own documentation system, or they may use forms available from Wisconsin Medicaid that meet the documentation requirements. These forms are available free of charge.

Note: Medicaid reimbursement is limited to Medicaid-enrolled providers.

Topic #44

Definition of Covered Services

A covered service is a service, item, or supply for which reimbursement is available when all program requirements are met. Wis. Admin. Code § DHS 101.03(35) and ch. DHS 107 contain more information about covered services.
Topic #2401

Dental Sealants

ForwardHealth reimburses HealthCheck nursing agencies enrolled in Wisconsin Medicaid for providing dental sealants to BadgerCare Plus and Medicaid members under age 21 when they are provided by a dentist or a dental hygienist as a HealthCheck service. Medicaid coverage for sealants in HealthCheck nursing agencies is limited to tooth numbers 02, 03, 14, 15, 18, 19, 30, and 31. Sealants for other teeth require PA.

The dentist or dental hygienist providing sealants is not required to be Medicaid-enrolled since the HealthCheck nursing agency is Medicaid-enrolled. Dental hygienists may provide sealants at a HealthCheck nursing agency under one of the following:

  • A dentist's order
  • A physician's order
  • An agency protocol

Submitting Claims

HealthCheck nursing agencies are required to submit claims for dental sealants using either the ADA 2006 Claim Form or the ADA 2012 Claim Form with CDT procedure code D1351 and the appropriate tooth number(s). Providers should submit claims fee-for-service, even if the member is enrolled in an HMO, including HMOs that cover dental services. Providers should use the appropriate claim form instructions for the ADA 2006 or 2012 claim forms when submitting these claims for dental sealants provided by HealthCheck nursing agencies.

There is a once-per-three-year limitation on sealants for permanent first and second molars. To exceed the once-per-three-year limitation, a narrative must be attached to the claim explaining why the limitation was exceeded. The narrative must be signed by a licensed dentist.

Prior Authorization

PA is required for tooth numbers/letters 01, 04-13, 16, 17, 20-29, 32, A-T, and supernumerary teeth (AS-TS, 51-82). For these teeth, HealthCheck providers are required to refer the member to a Medicaid-enrolled dentist to request PA and provide these services. If the PA request is approved, Wisconsin Medicaid will reimburse the dentist for the service.

Topic #4580

Dental and Dental Hygienist Services

The following procedure codes are reimbursable for HealthCheck agencies submitting claims for services performed by dentists and dental hygienists. Dentists and dental hygienists are not required to be Medicaid-enrolled.

Dental Hygienists

Diagnostic Procedures

Procedure Code

Description of Service

D0191

Assessment of a patient


Preventative Procedures

Procedure Code

Description of Service

Dental Prophylaxis

D1110

Prophylaxis — adult

D1120

child

Topical Fluoride Treatment (Office Procedure)

D1206

Topical application of fluoride varnish

D1208

Topical application of fluoride

Other Preventative Services

D1351

Sealant — per tooth

D1354

Interim caries arresting medicament application — per tooth


Periodontics Procedures

Procedure Code

Description of Service

D4341

Periodontal scaling and root planing — four or more teeth per quadrant

D4342

Periodontal scaling and root planing — one to three teeth, per quadrant

Dentists

Dental Examinations

Procedure Code

Description of Service

D0120

Periodic oral evaluation

D0150

Comprehensive oral evaluation — new or established patient

Topic #3544

Description of Required Components of a HealthCheck Screen

Guidelines for Completing Components

Providers may use the following guidelines when documenting components of a HealthCheck screen:

  1. A comprehensive health and developmental history, including:
    1. A health history — A review of the member's and family's health and treatment history to identify special risk factors or prior conditions/treatments pertinent to future care.
    2. A nutritional assessment — A review of the individual's eating patterns/habits should be included in order to identify persons who may require a more in-depth dietary assessment and counseling, particularly if other nutrition-related risk factors exist (for example, iron deficiency anemia, abnormal height/weight).
    3. Health education and anticipatory guidance for the member and caregiver — All screening exams must include preventive health education and an explanation of screening findings. This may include discussion of:
      • Proper nutrition, parenting skills, family planning concerns, alcohol and other drug abuse/mental health concerns
      • Preventive health and healthy lifestyle actions (for example, use of infant car seats, poison prevention, injury prevention, hot water temperature settings, avoidance of tobacco products)
      • Normal stages of growth and development
      • Screening findings and explanation of any problems found and the importance of necessary follow-up care
    4. Developmental-behavioral assessment — Observed behavior and attainment of developmental milestones (including emotional status) should be compared to age-specific norms to identify developmental delays or subtle indications of hidden problems. Parental concerns and observations regarding the child's development and health should be reviewed to identify possible special conditions warranting more careful examination. Adolescent health visits should involve seeing the adolescent alone, as well as with the parents whenever possible. The adolescent should be assured of the confidentiality of the interview.
    5. Forms — Although optional, a number of forms are available to document details of the screen for the member's medical record, assisting with this requirement. Available forms include the following:
  2. A comprehensive unclothed physical exam
    1. Unclothed physical exam and physical growth assessment — This should be a systematic examination of each body system according to accepted medical procedure. Blood pressure readings must be taken for all children beginning at 3 years of age.

      Note: The screener should be alert for any indication of physical or sexual abuse. State law requires that signs of abuse be reported immediately to Child Protection Services of the certifying agency.

    2. Growth assessment — Comparison of member's height, weight, and head circumference to age-specific norms to identify growth abnormalities. This includes the calculation of the child's length to age percentile, weight to length percentile, and head circumference to age percentile.
    3. Sexual development to members who have reached puberty — At the request of the member or parent, the screener is required to provide counseling on sexual development, birth control, and sexually transmitted diseases, as well as appropriate prescriptions and testing, or the screener is required to refer the member to an appropriate resource. A pelvic examination or referral for the appropriate testing should be offered to all females who have reached puberty.
  3. A vision screen — All children should be observed for:
    • Appropriate visual acuity
    • Strabismus
    • Abnormal disc reflex (under age 1)
    • Response to cover test
    • Amblyopia
    • Color blindness
    Use of vision charts must be attempted to measure visual acuity beginning at age 4.
  4. A hearing screen
    1. All hearing screens in infancy and early childhood should include an otoscopic exam and/or tympanometric measurements for the detection of chronic or recurrent otitis media.
    2. Screen at birth through age 2 using both methods outlined in High Risk Factors for Hearing Loss in Neonates and Infants and the HealthCheck/Your Child's Speech and Hearing form. Children failing either screening method should be referred for audiological assessment.
    3. Administer puretone audiometric screen as follows: annually to all children ages 3 to 8 and at four-year intervals thereafter up to age 16; and to any children older than age 8 with excessive exposure to noise, delayed speech and language development, or who are receiving a HealthCheck screen for the first time.
  5. An oral assessment, plus referral to a dentist beginning when the first tooth erupts or by age 1 (This exam must be sufficient to identify children in need of early examination by a dentist. Parents with children under 3 years of age should be questioned regarding their child's problematic thumb sucking, lip biting, caries, tongue thrusting, non-erupted teeth, extra teeth, extended use of pacifier, or bottle feeding practices conducive to early dental caries or malfunction of oral cavity. All children age 1 or older (and younger where medically indicated) must be referred to a dentist if they are not already receiving such care.)
  6. Medically necessary services, which are not otherwise covered, may be covered under HealthCheck "Other Services." The following dental services are covered only to members under age 21 to address concerns identified during a HealthCheck screen:

    • Orthodontics (Once started, orthodontic services will be reimbursed to completion regardless of the member's eligibility. PA is required.)
    • One additional cleaning per year with PA for children ages 13 through 20 (One cleaning is allowed per year for members between the ages of 13 and 20.)
    ForwardHealth has identified criteria for effective oral assessments.
  7. Appropriate immunizations (according to age and health history per the CDC's ACIP guidelines) (Federal regulations require that immunizations recommended by the ACIP are automatically covered after approval by the CDC. The majority of required childhood immunizations are available through the Wisconsin Immunization Program's VFC Program.)
  8. Wisconsin Medicaid reimburses only the administration fee for children 18 years of age or younger when a VFC vaccine is available. For members 19 years of age or older, Wisconsin Medicaid reimburses for the vaccine component and the administration component.

    Additional resources include the following:

  9. Appropriate laboratory tests (including blood lead level testing when appropriate for age)
  10. Blood lead level test — CMS, through EPSDT guidelines, requires that all children who are enrolled in ForwardHealth receive a blood lead level test at about 12 months and again at about 24 months. In addition, children between the ages of 3 and 5 must receive a blood lead level test if they have never been tested before. Providers are responsible for assuring that children receive blood lead level tests at the required ages. Testing of all children enrolled in ForwardHealth applies regardless of the presence or absence of recognized blood lead level exposure risks. According to the AAP, a low blood lead level concentration in a 1 year old does not preclude elevation later. Therefore, providers are required to repeat blood lead level testing at about 2 years of age, regardless of the results of the 1-year test.

    Additional resources include the following:

    • WCLPPP
    • Wisconsin Blood Lead Registry (contact the WCLPPP to request access to this registry)
    HealthCheck nursing agencies should perform any additional laboratory tests indicated by their protocol. Physicians should order any additional laboratory tests they feel appropriate.
Topic #2400

Diagnosis and Treatment

All appointments for any further diagnosis or treatment as a result of the screening should be scheduled within 60 days of the date of the HealthCheck screening. All BadgerCare Plus and Medicaid services on a HealthCheck referral should be provided within six months of the screening date.

Topic #2392

Discussing Results

Following performance of a HealthCheck screening, test results must be explained to educate the member or parent about preventive measures that can be taken. Discuss the need for referred follow-up care (e.g., dentist) and schedule the next periodic examination when possible.

Adolescent health visits should involve seeing the adolescent alone as well as with the parents. The adolescent should be assured of the confidentiality of the interview.

Topic #85

Emergencies

Certain program requirements and reimbursement procedures are modified in emergency situations. Emergency services are defined in Wis. Admin. Code § DHS 101.03(52), as "those services that are necessary to prevent the death or serious impairment of the health of the individual." Emergency services are not reimbursed unless they are covered services.

Additional definitions and procedures for emergencies exist in other situations, such as dental and mental health.

Program requirements and reimbursement procedures may be modified in the following ways:

  • PA or other program requirements may be waived in emergency situations.
  • Non-U.S. citizens may be eligible for covered services in emergency situations.
Topic #2398

Environmental Lead Investigation Services

ForwardHealth covers ELI services provided by the following:

  • Local health departments, as defined in Wis. Stat. § 250.01(4), enrolled as HealthCheck screening providers.
  • Wisconsin DHS-certified lead hazard investigators (or risk assessors) contracted with local health departments. Note: Providers are reminded that they are legally, programmatically, and fiscally responsible for the services provided by their contractors and their subcontractors' services.

ELI services include all of the following:

  • An initial comprehensive environmental lead investigation, billed under HCPCS procedure code T1029 (comprehensive environmental lead investigation, not including laboratory analysis, per dwelling)
  • Follow-up lead clearance investigations, billed under procedure code T1029 with modifier TS (Follow-Up Service)
  • Nursing education visits related to lead poisoning, billed under procedure code T1002 (RN services, up to 15 minutes)

ELI services may be Medicaid reimbursable if the following criteria are met:

  • A child 0–20 years old is shown to have lead poisoning or lead exposure as defined in Wis. Stat. § 254.11(9).
  • The ELI services are provided in the child's home.
  • The person (including contractors and subcontractors) doing the investigation is Wisconsin DHS-certified as a lead hazard investigator (or risk assessor).
  • The person doing the lead poisoning education is a registered nurse.

Additional Coverage Criteria

The following requirements also apply to the coverage of ELI services:

  • If more than one child in the home has lead poisoning or lead exposure, all ELI services must be billed under one child's Medicaid ID only.
  • An initial comprehensive environmental lead investigation (T1029) is limited to one per rolling year, per provider, per residence. Add modifier TS to indicate follow-up environmental lead clearance investigations.
  • Nurse education visits (T1002) are limited to four units (i.e., one hour) per date of service, per provider, per member. If a child is diagnosed with lead exposure or lead poisoning, a nurse education visit for lead poisoning is covered regardless of whether an environmental lead investigation will be conducted.

Components of a Comprehensive Lead Investigation

Environmental lead investigation of the child's home involves not only the identification of all sources of lead exposure, but also advising parents or guardians about identified and potential sources of lead and ways to reduce exposure. Once home owners or rental property owners are notified of the problem and have an opportunity to remedy the situation, a follow-up lead clearance investigation should be conducted to assure that the lead hazards are resolved. Additional information about aspects of the environmental lead investigation can be obtained from the Lead-Safe Wisconsin website.

Technical aspects of a comprehensive lead investigation must include all of the following:

  • Interview with parents or guardians and property owner to determine physical characteristics and usage of dwelling
  • A complete lead risk assessment of the property, including:
    • A visual assessment of the dwelling and property to determine the locations of deteriorated paint and lead paint hazards
    • Collection of samples and/or use of X-ray fluorescence analyzer to measure lead in the environment (dust, paint, soil, or water)
    • Identification and evaluation of any non-paint lead hazards
    • Provision of a complete lead risk assessment report to the property owner and parents or guardians, including findings and any work orders or recommendations for lead hazard reduction

Technical aspects of a comprehensive lead investigation must include all of the following:

  • A visual assessment to determine that all identified lead hazards have been remediated, no visible dust or debris remains, and non-paint hazards have been removed
  • For interior lead paint hazards, collection of clearance dust-wipe samples to verify safe completion and clean-up of the work
  • Provision of a written clearance report to the contractor, property owner, and parents or guardians

Education Home Visits by a Registered Nurse

An education home visit involves advising parents or guardians of the child's blood lead level and what it means, the impact of lead poisoning on children, risk factors and possible sources of lead exposure, steps parents or guardians can take to decrease their child's lead exposure, the importance of a well-balanced diet, and follow-up blood lead testing recommendations. Additional information about lead poisoning prevention education can be obtained from Lead-Safe Wisconsin.

Claim Submission

Local health departments that are enrolled as HealthCheck providers may submit claims for ELI services even if a comprehensive HealthCheck screen has not previously been done.

The following applies to claims submitted for ELI services:

  • POS code must be 12 (home).
  • Member must have a diagnosis of lead poisoning or lead exposure.
  • For procedure code T1002 (RN services, up to 15 minutes), the claim must include diagnosis code Z77.011 (Contact with and [suspected] exposure to lead).
  • The service must have the HealthCheck service modifier EP submitted in the primary modifier position.
  • If procedure code T1029 is billed and the service represents a follow-up lead clearance investigation, modifier TS must also be submitted in the second modifier position.

If a member is enrolled in a managed care program, providers are required to submit claims to Wisconsin Medicaid fee-for-service for ELI services. Providers should not submit claims to the member's MCO because ELI services are covered on a fee-for-service basis for all members and, thus, will not be reimbursed by the member's managed care organization.

Topic #2237

Fluoride — Topical Applications

Topical application of fluoride to a child's teeth is a safe and effective way to prevent tooth decay as part of a comprehensive oral health program.

It is recommended that children under age 5 who have erupted teeth receive topical fluoride treatment. Children at low or moderate risk of early childhood caries should receive one or two applications per year; children at higher risk should receive three or four applications per year.

The most accepted mode of fluoride delivery in children under age 5 is a fluoride varnish. OTC mouth rinses are not covered.

Allowable Providers

Topical applications of fluoride may be provided by nurses and dental hygienists employed at Medicaid-enrolled HealthCheck nursing agencies. Nurses may provide topical fluoride applications at a HealthCheck nursing agency under one of the following:

  • A physician's order
  • An agency protocol

Dental hygienists may provide topical fluoride applications at a HealthCheck nursing agency under one of the following:

  • A dentist's order
  • A physician's order
  • An agency protocol

Submitting Claims

When submitting claims for topical fluoride treatment, indicate procedure code D1208 (Topical application of fluoride). Providers may also submit claims with HealthCheck and office visit procedure codes for these services.

In cases where more than two fluoride treatments per year are medically necessary, providers are required to retain supporting clinical documentation in the member's file indicating the need for additional treatments.

Ancillary staff (e.g., physician assistants, nurse practitioners) are required to follow certain billing procedures.

Wisconsin Medicaid will separately reimburse providers for the appropriate level office visit or preventive visit at which the fluoride application was performed.

Training Materials

An Oral Health Provider Training guide describing how providers may perform lift-the-lip oral screenings, apply fluoride varnish to a small child's teeth, and provide basic oral health guidance to parents is available.

Topic #503

Immunizations

Providers are required to indicate the procedure code of the actual vaccine administered, not the administration code, on claims for all immunizations. Reimbursement for both the vaccine, when appropriate, and the administration are included in the reimbursement for the vaccine procedure code, so providers should not separately bill the administration code. Providers are required to indicate their usual and customary charge for the service with the procedure code.

The immunizations identified by CPT subsections "Immune Globulins" (procedure codes 90281-90399) and "Vaccines, Toxoids" (procedure codes 90476-90749) are covered.

Immune globulin procedure codes and the unlisted vaccine/toxoid procedure code are manually priced by ForwardHealth's pharmacy consultant. To be reimbursed for these codes, physicians are required to attach the following information to a paper claim:

  • Name of drug
  • NDC
  • Dosage.
  • Quantity (e.g., vials, milliliters, milligrams)

Medicaid reimbursement for immune globulins, vaccines, toxoid immunizations, and the unlisted vaccine/toxoid procedure codes includes reimbursement for the administration component of the immunization, contrary to CPT's description of the procedure codes. Procedure codes for administration are not separately reimbursable.

Vaccines for Children 18 Years of Age or Younger

Most vaccines provided to members 18 years of age or younger are available through the federal VFC Program at no cost to the provider. If a vaccine is available through the VFC Program, providers are required to use vaccines from VFC supply for members 18 years of age or younger. ForwardHealth reimburses only the administration fee for vaccines supplied by the VFC Program.

For vaccines that are not supplied by the VFC Program, providers may use a vaccine from a private stock. In these cases, ForwardHealth reimburses for the vaccine and the administration fee.

The Wisconsin Immunization Program has more information about the VFC program. Providers may also call the VFC program at 608-267-5148 if internet access is not available.

Vaccines that are commonly combined, such as MMR or DTaP, are not separately reimbursable unless the medical necessity for separate administration of the vaccine is documented in the member's medical record.

If a patient encounter occurs in addition to the administration of the injection, physicians may receive reimbursement for the appropriate E&M procedure code that reflects the level of service provided at the time of the vaccination. If an immunization is the only service provided, the lowest level E&M office or other outpatient service procedure code may be reimbursed, in addition to the appropriate vaccine procedure code(s).

Vaccines for Members 19 Years of Age or Older

For vaccines from a provider's private stock that are administered to members 19 years of age or older, ForwardHealth reimburses for the vaccine and the administration fee.

Topic #2396

Interperiodic Visits

Wisconsin Medicaid covers medically necessary interperiodic screens to follow up on detected problems or conditions.

Interperiodic screens are visits with qualified providers that occur outside the AAP periodicity schedule. They may be recommended by any professional who comes into contact with the child, such as physicians, dentists, health officials, or educators.

An interperiodic screen can be problem-focused or may include any or all components of the comprehensive screen. These visits may be required to diagnose a new illness or condition or to determine whether a previously diagnosed illness or condition requires additional services. Interperiodic screens ensure that access to a necessary service is not delayed by waiting until the next scheduled wellness check-up. Examples of interperiodic screens include the following:

  • Immunizations
  • Retesting for an elevated blood lead level
  • Retesting for a low hematocrit
  • Addressing nutrition concerns

Like comprehensive HealthCheck screens, conditions identified during an interperiodic screen may result in recommendations for further evaluation or services which may be covered.

Accessing Interperiodic Screens

Interperiodic HealthCheck screens are available without PA, and any Medicaid-enrolled provider, within the scope of their license, may provide these screens. No special forms are required.

Topic #3416

Documentation of Guidelines for Evaluation and Management Services

BadgerCare Plus has adopted the federal CMS 1995 and 1997 Documentation Guidelines for Evaluation and Management Services in combination with BadgerCare Plus policy for E&M services. Providers are required to present documentation upon request indicating which of the guidelines or BadgerCare Plus policies were utilized for the E&M procedure code that was billed.

The documentation in the member's medical record for each service must justify the level of the E&M code billed. Providers may access the CMS documentation guidelines on the CMS website. BadgerCare Plus policy information can be found in service-specific areas of the Online Handbook or on the ForwardHealth Portal.

Topic #912

Laboratory Test Preparation and Handling Fees

The laboratory provider who performed the clinical diagnostic laboratory test is reimbursed, and the provider who collected the specimen is reimbursed a handling fee.

The independent laboratory or a physician's office is reimbursed a handling fee when the independent laboratory or physician's office sends specimens to an outside laboratory for analysis or interpretation. The handling fee covers the collection, preparation, forwarding, and handling of obtained specimen(s).

When forwarding a specimen from a physician's office to an outside laboratory, providers should submit claims for preparation and handling fees using procedure code 99000. When forwarding a specimen from a location other than a physician's office (e.g., an independent laboratory) to an outside laboratory, submit claims using procedure code 99001. It is not necessary to indicate the specific laboratory test performed on the claim.

A handling fee is not reimbursable if the physician or independent laboratory is reimbursed for the professional and/or technical component of the laboratory test.

Additional Limitations

Additional limitations on reimbursement for handling fees include the following:

  • One lab handling fee is reimbursed to a physician or independent laboratory per member, per outside laboratory, or per DOS, regardless of the number of specimens sent to the laboratory.
  • More than one handling fee is reimbursed when specimens are sent to two or more laboratories for one member on the same DOS. Indicate the number of laboratories and the total charges on the claim. The name of the laboratory does not need to be indicated on the claim; however, this information must be documented in the provider's records.
  • The DOS must be the date the specimen is obtained from the member.
Topic #84

Medical Necessity

Wisconsin Medicaid reimburses only for services that are medically necessary as defined under Wis. Admin. Code § DHS 101.03(96m). Wisconsin Medicaid may deny or recoup payment if a service fails to meet Medicaid medical necessity requirements.

Topic #86

Member Payment for Covered Services

Under state and federal laws, a Medicaid-enrolled provider may not collect payment from a member, or authorized person acting on behalf of the member, for covered services even if the services are covered but do not meet program requirements. Denial of a claim by ForwardHealth does not necessarily render a member liable. However, a covered service for which PA was denied is treated as a noncovered service. (If a member chooses to receive an originally requested service instead of the service approved on a modified PA request, it is also treated as a noncovered service.) If a member requests a covered service for which PA was denied (or modified), the provider may collect payment from the member if certain conditions are met.

If a provider collects payment from a member, or an authorized person acting on behalf of the member, for a covered service, the provider may be subject to program sanctions including termination of Medicaid enrollment.

Topic #4272

On-Site Blood Lead Testing

Providers who currently hold a CLIA certificate of waiver or higher complexity CLIA certification level may be reimbursed for on-site blood lead testing using LeadCare II or similar CLIA-waived instruments if the following guidelines are met:

  • Providers are successfully participating in a proficiency testing program as administered by the WSLH or another CMS-approved proficiency testing program.
  • Providers are reporting all blood lead test results, regardless of the lead level, to the WCLPPP as required.

To be reimbursed for the on-site blood lead test, providers should indicate on the claim procedure code 83655 (Lead). Procedure code 99000 (Handling and/or conveyance of specimen for transfer from the office to a laboratory) is not separately reimbursable when procedure code 83655 is billed. Providers are eligible to be reimbursed for an appropriate office visit.

On-site blood lead testing is covered under these guidelines for Medicaid and BadgerCare Plus. There is no copayment for on-site blood lead testing in either plan.

Proficiency Testing

Reimbursement for on-site blood lead testing of Medicaid and BadgerCare Plus members is conditional on successful participation in a proficiency testing program. Programs are available through the WSLH and other proficiency testing providers, e.g., the CAP.

The WSLH has more than one proficiency testing option available. Testing sites using instruments viewed as using moderate or high complexity test methods must participate in a program meeting a specific CLIA configuration of three 5 sample events per year. Sites employing instruments viewed as waived technology under CLIA, e.g. LeadCare II, have the option of enrolling in a less expensive program that is more limited in scope, with two 3 sample events per year. For additional information about proficiency testing, and what option is best for your instrumentation, you can contact WSLH at 800-462-5261.

Reporting of Results

Providers are required to report all on-site blood lead test results to the WCLPPP, regardless of the lead level. For reporting requirements, refer to Wis. Admin. Code § DHS 181. Providers may use the Blood Lead Lab Reporting form. To establish a mechanism for reporting results, providers may call the WCLPPP at 608-266-5817 and ask for the data manager.

Topic #3667

Online Resources for Information on the Treatment and Prevention of Lead Poisoning

Lead-Safe Wisconsin includes information on the prevention and treatment of childhood lead poisoning, including blood lead testing guidelines, medical management, public health interventions, surveillance data, and educational materials and resources for families.

Providers may also contact the WCLPPP.

Topic #2394

Periodicity Schedule

As required by 42 C.F.R. § 441.58, Wisconsin Medicaid follows the AAP's periodicity schedule for screening services.

HealthCheck provides access to comprehensive medical, vision, hearing, and dental screens according to the periodicity schedule recommended by the AAP.

This schedule specifies the time period when services appropriate at each stage of the member's life should be done, beginning with a neonatal examination at birth up to the member's 21st birthday.

Claims submitted for comprehensive screening packages performed more frequently than allowed under the periodicity schedule are not reimbursable. A comprehensive screening may only be billed if all age-specific components of a screen are assessed and documented.

Topic #66

Program Requirements

For a covered service to meet program requirements, the service must be provided by a qualified Medicaid-enrolled provider to an enrolled member. In addition, the service must meet all applicable program requirements, including, but not limited to, medical necessity, PA, claims submission, prescription, and documentation requirements.

Topic #2393

Referrals

The member must be referred for any needed follow-up care that cannot be provided at the time of the HealthCheck screen, including mandatory referral for an annual dental examination beginning when the first tooth erupts or by age 1 if the member is not regularly receiving dental care.

Referral Requirements

Following a HealthCheck screen, the case management provider is responsible for ensuring that all necessary referral appointments are kept. A critical responsibility of the case manager is the removal of all barriers a member may encounter for accessing various services on referral. Prompt scheduling of all appointments and referrals will enable the case manager to complete timely member follow-up.

Types of Referrals

Treatment Referral

Treatment referrals result from a HealthCheck interperiodic or comprehensive screen, when findings indicate the need for further evaluation, diagnosis, or treatment.

Mandatory Dental Referral

Beginning when the first tooth erupts or by age 1, all children must be referred to a dentist for an oral assessment.

Self-Referral

Self-referrals may occur when the member expresses a particular need to the case manager (e.g., day care, Head Start) or chooses to receive services from a provider other than the screening provider or the screener's referral. Case managers are required to be sensitive to these requests and assist the member with identification of other sources of treatment and services.

Referral From Another Provider

Referrals from other providers may result from a previous screening referral or the referral provider may make additional referrals for member care. Case managers are required to be prepared to assist and follow-up these referrals.

Support Referral

Support referrals (for non-Medicaid-reimbursable services) may include other maternal and child health services in the community, employment development programs, food assistance, WIC, nutrition counseling, food stamps, special educational services, housing, and other needs. Case managers must develop a thorough knowledge of local community resources and the member's needs to facilitate these referrals.

Discussion and Resolution of Potential Barriers

The referral process must also include a discussion and resolution of potential barriers to member follow through, such as the following:

  • Transportation difficulties
  • Cost concerns
  • Lack of knowledge of providers
  • Language and cultural barriers
  • Failure to understand the need for care
  • Confidentiality concerns (adolescents)

The member should also know the periodicity schedule and date of the next periodic exam. It is recommended that case managers send a reminder notice one week prior to the next periodic screening date.

Topic #824

Services That Do Not Meet Program Requirements

As stated in Wis. Admin. Code § DHS 107.02(2), BadgerCare Plus and Wisconsin Medicaid may deny or recoup payment for covered services that fail to meet program requirements.

Examples of covered services that do not meet program requirements include the following:

  • Services for which records or other documentation were not prepared or maintained
  • Services for which the provider fails to meet any or all of the requirements of Wis. Admin. Code § DHS 106.03, including, but not limited to, the requirements regarding timely submission of claims
  • Services that fail to comply with requirements or state and federal statutes, rules, and regulations
  • Services that the Wisconsin DHS, the PRO review process, or BadgerCare Plus determines to be inappropriate, in excess of accepted standards of reasonableness or less costly alternative services, or of excessive frequency or duration
  • Services provided by a provider who fails or refuses to meet and maintain any of the enrollment requirements under Wis. Admin. Code ch. DHS 105
  • Services provided by a provider who fails or refuses to provide access to records
  • Services provided inconsistent with an intermediate sanction or sanctions imposed by DHS
Topic #21257

Silver Diamine Fluoride

ForwardHealth covers silver diamine fluoride services for children and adults without PA. Silver diamine fluoride is a conservative treatment of an active, non-symptomatic carious lesion by topical application of a caries-arresting or inhibiting medicament without mechanical removal of sound tooth structure.

Clinical Criteria

The following are clinical criteria for coverage of silver diamine fluoride services:

  • Treat and/or stabilize asymptomatic teeth with active carious lesion
  • Treat difficult dental carious lesions such as exposed roots and root furcation
  • Treat members with extreme caries risk (Xerostomia or Severe Early Childhood Caries)
  • Treat carious lesions for members challenged by behavioral or medical management
  • Treat carious lesions that may not all be treated in one visit
  • Treat members who have limited and/or no access to restorative dental care

Providers are encouraged to review American Academy of Pediatric Dentistry policy guidelines and chairside guide regarding appropriate use of silver diamine fluoride.

Allowable Procedure Code

ForwardHealth covers the application of silver diamine fluoride identified by CDT procedure code D1354 (Interim caries arresting medicament application- per tooth) without PA.

Limitations and Requirements

The following limitations and requirements apply to coverage of silver diamine fluoride services:

  • Allowed for treatment of asymptomatic and active dental caries only
  • Allowed once per tooth, per six-month period
  • Allowed for all ages
  • Not allowed on the same DOS as the restoration of that tooth
  • Reimbursable when rendered by dentists, dental hygienists, and HealthCheck providers only

Note: Frequency limitation may be exceeded for up to four times per tooth per 12-month period for members with high caries risk. Providers are required to retain documentation demonstrating medical necessity.

Claim Submission

When submitting claims for silver diamine fluoride services, providers are required to include the tooth number(s) or
letter(s).

Reimbursement

Reimbursement for procedure code D1354 is allowed once per day, per member, per tooth. For reimbursement amounts, refer to the maximum allowable fee schedule.

Additional Provider Responsibilities

Providers are required to disseminate the risks and benefits of silver diamine fluoride use and to discuss treatment alternatives as applicable. Providers are required to obtain written consent from the member or parent/legal guardian, particularly highlighting expected staining to treated lesion, potential staining of skin and clothes, and the need for reapplication for disease control, prior to providing the service. To ensure compliance with program requirements, the written consent document should be retained with the member's dental record and be available upon request.

Topic #510

Telehealth

Information is available for DOS before January 1, 2020.

Information is available for DOS between January 1, 2020 and March 1, 2020.

ForwardHealth allows certain covered services to be provided via telehealth (also known as "telemedicine"). Telehealth enables a provider who is located at a distant site to render the service remotely to a member located at an originating site using a combination of interactive video, audio, and externally acquired images through a networking environment.

Allowable Providers

There is no restriction on the location of a distant site provider. The following types of providers may be reimbursed for providing telehealth services at a distant site:

  • Audiologists
  • Individual mental health and substance abuse practitioners not in a facility certified by the DQA
  • Nurse midwives
  • Nurse practitioners
  • Ph.D. psychologists
  • Physician assistants
  • Physicians
  • Psychiatrists
  • Professionals providing services in mental health or substance abuse programs certified by the DQA

Allowable Originating Sites

For DOS on or after March 1, 2020, ForwardHealth will allow coverage of telehealth for any originating site. However, only the following originating sites will be eligible for a facility fee reimbursement:

  • Hospitals, including emergency departments
  • Office/clinic
  • Skilled nursing facility

Requirements and Restrictions

Services provided via telehealth must be of sufficient audio and visual fidelity and clarity as to be functionally equivalent to a face-to-face visit where both the rendering provider and member are in the same physical location. Both the distant and originating sites must have the requisite equipment and staffing necessary to provide the telehealth service.

Coverage of a service provided via telehealth is subject to the same restrictions as when the service is provided face-to-face (e.g., allowable providers, multiple service limitations, PA).

Providers are reminded that HIPAA confidentiality requirements apply to telehealth services. When a covered entity or provider utilizes a telehealth service that involves PHI, the entity or provider will need to conduct an accurate and thorough assessment of the potential risks and vulnerabilities to PHI confidentiality, integrity, and availability. Each entity or provider must assess what are reasonable and appropriate security measures for their situation.

Note: Providers may not require the use of telehealth as a condition of treating a member. Providers must develop and implement their own methods of informed consent to verify that a member agrees to receive services via telehealth. These methods must comply with all federal and state regulations and guidelines.

Noncovered Services

The following are not covered as telehealth services:

  • Store and forward services (defined as the asynchronous transmission of medical information to be reviewed at a later time by a provider at a distant site)
  • Services that are not covered when delivered face-to-face

Claims Submission and Reimbursement for Distant Site Providers

Claims for services provided via telehealth by distant site providers must be billed with the same procedure code as would be used for a face-to-face encounter along with HCPCS modifier GT (via interactive audio and video telecommunication systems).

Claims must also include POS code 02 (Telehealth: the location where health services and health-related services are provided or received through telehealth telecommunication technology). ForwardHealth reimburses the service rendered by distant site providers at the same rate as when the service is provided face-to-face.

Ancillary Providers

Claims for services provided via telehealth by distant site ancillary providers should continue to be submitted under the supervising physician's NPI using the lowest appropriate level office or outpatient visit procedure code or other appropriate CPT code for the service performed. These services must be provided under the direct on-site supervision of a physician who is located at the same physical site as the ancillary provider and must be documented in the same manner as services that are provided face to face.

Pediatric and Health Professional Shortage Area-Eligible Services

Claims for services provided via telehealth by distant site providers may additionally qualify for pediatric (services for members 18 years of age and under) or HPSA-enhanced reimbursement. Pediatric and HPSA-eligible providers are required to indicate POS code 02, along with modifier GT and the applicable pediatric or HPSA modifier, when submitting claims that qualify for enhanced reimbursement.

Claims Submission and Reimbursement for Originating Site Facility Fee

In addition to reimbursement to the distant site provider, ForwardHealth reimburses an originating site facility fee for the staff and equipment at the originating site requisite to provide a service via telehealth. Eligible providers who serve as the originating site should bill the facility fee with HCPCS procedure code Q3014 (Telehealth originating site facility fee). HCPCS modifier GT should not be included with procedure code Q3014.

Eligible providers who bill on a professional claim form should bill Q3014 with a POS code that represents where the member is located during the service. The POS must be a ForwardHealth-allowable originating site for procedure code Q3014 in order to be reimbursed for the originating site fee. The originating site fee is reimbursed based on a maximum allowable fee.

Eligible providers who bill on an institutional claim form should bill Q3014 as a separate line item with the appropriate revenue code. ForwardHealth will reimburse these providers for the facility fee based on the provider's standard reimbursement methodology.

Documentation Requirements

All services provided via telehealth must be thoroughly documented in the member's medical record in the same manner as services provided face-to-face. As a reminder, documentation for originating sites must support the member's presence in order to submit a claim for the originating site facility fee. In addition, if the originating site provides and bills for services in addition to the originating site facility fee, documentation in the member's medical record should distinguish between the unique services provided.

Telestroke Services

Telestroke, also known as stroke telemedicine, is a delivery mechanism of telehealth services that aims to improve access to recommended stroke treatment.

ForwardHealth allows providers to be reimbursed for telestroke services. Telestroke services typically consist of the member and emergency providers at an originating site consulting with a specialist located at a distant site.

Claims Submission for Telestroke Services

Providers are required to use CPT consultation and E&M procedure codes when billing telestroke services. Telestroke services are subject to the same enrollment policy, coverage policy, and billing policy as telehealth services. All other services rendered by the provider at the originating site, and by any providers to which the member is transferred, should be billed in the same manner as visits or admissions that do not involve telehealth services.

Originating sites that have established contractual relationships for telestroke services may bill as they would for any other contracted professional services for both the professional service claim on behalf of the distant site provider and the originating site fee.

Additional Policy for Certain Types of Providers

Out-of-State Providers

ForwardHealth policy for services provided via telehealth by out-of-state providers is the same as ForwardHealth policy for services provided face-to-face by out-of-state providers. Out-of-state providers who do not have border status enrollment with Wisconsin Medicaid are required to obtain PA before providing services via telehealth to BadgerCare Plus or Medicaid members.

Note: Wisconsin Medicaid is prohibited from paying providers located outside of the United States and its territories, including the District of Columbia, Puerto Rico, the Virgin Islands, Guam, the Northern Mariana Islands, and American Samoa.

Community Health Centers, Tribal Federally Qualified Health Centers, and Rural Health Clinics

CHCs, tribal FQHCs, and RHCs may serve as originating site and distant site providers for telehealth services.

Distant Site

Tribal FQHCs and RHCs may report services provided via telehealth on the cost settlement report when the FQHC or RHC served as the distant site and the member is an established patient of the tribal FQHC or RHC at the time of the telehealth service.

Services billed with modifier GT (modifier indicating telehealth) will be considered under the PPSreimbursement method for non-tribal FQHCs. Billing HCPCS procedure code T1015 (Clinic visit/encounter, all-inclusive) with a telehealth procedure code will result in a PPS rate for fee-for-service encounters.

Originating Site

The originating site facility fee is not a tribal FQHC or RHC reportable encounter on the cost report. Any reimbursement for the originating site facility fee must be reported as a deductive value on the cost report.

For CHCs, originating site services should be billed, but no reimbursement will be issued as all costs for providing originating site services have already been incorporated into the PPS rates for CHCs. Claims billed by CHCs for originating site services may be used for future rate setting purposes.

Allowable Services

ForwardHealth only covers telehealth delivery of individual services. For those procedure codes that can be used for either individual or group services, providers may not submit claims for telehealth delivery of group services. Allowable providers may be reimbursed, as appropriate, for the following services (and applicable procedure codes) provided through telehealth.

Note: The use of E&M codes is subject to E&M documentation guidelines.

Type of Service Procedure Codes
Adult Mental Health Day Treatment Services H2012 (for individual services only)
Audiology Services 92550, 92585, 92586, 92587, 92588
Child/Adolescent Day Treatment Services (HealthCheck "Other Services") H2012 (for individual services only)
Community Support Program Services H0039 (for individual services only)
Comprehensive Community Services H2017 (for individual services only)
Crisis Intervention Services S9484
End-Stage Renal Disease-Related Services 90951-90952, 90954-90958, 90960-90961, 90967-90970
E-Visits 98970-98972, 99421-99423
Health and Behavior Assessment/Intervention 96156, 96158-96159, 96167, 96170-96171
Initial Inpatient Consultations 99251-99255
Inpatient Consultations 99231-99233, 99356-99357
Nursing Facility Service Assessments 99307-99310
Office or Other Outpatient Services 99201-99205, 99211-99215*
Office or Other Outpatient Consultations 99241-99245*
Outpatient Mental Health Services (Evaluation, Psychotherapy) 90785, 90791-90792, 90832-90834, 90836-90840, 90845-90847, 90849, 90875, 90876, 90887
Outpatient Substance Abuse Services H0022, H0047, T1006
Phone Services, Qualified Health Professional 99441-99443
Substance Abuse Day Treatment H2012 (for individual services only)

* Telehealth services that are medical in nature and would otherwise be coded as an office visit or consultation evaluation and management visit are covered for members residing in a skilled nursing facility. Some Nursing Facility Service Assessments are not covered as telehealth services (e.g. 99304-99318). Domiciliary, Rest Home, or Custodial Care Services and Oversight Services (codes 99324-99340) are not allowable as telehealth services.

Topic #3545

Vaccines for Children Program

The federal VFC Program was created to provide vaccines to eligible children through enrolled public and private providers. The VFC Program is part of a national approach to improving immunization services and immunization levels.

Any child 18 years of age or younger who meets at least one of the following criteria is eligible for the VFC Program:

  • Eligible for BadgerCare Plus or Medicaid.
  • American Indian or Alaska Native, as defined by the Indian Health Services Act.
  • Uninsured.
  • Underinsured. (These children have health insurance but the benefit plan does not cover immunizations. Children in this category may only receive immunizations from a FQHC or an RHC; they cannot receive immunizations from a private health care provider using a VFC-supplied vaccine.)

When a vaccine becomes available through the VFC Program, the VFC Program notifies providers with clinical information about new vaccines, including the date they may begin ordering the vaccine. On the first of the month following that date, Wisconsin Medicaid will begin reimbursing only the administration fee for that vaccine.

Benefits of the VFC Program

The VFC Program provides the following benefits:

  • Vaccines are provided at no charge to public and private providers to immunize all eligible children.
  • Eliminates or reduces vaccine costs as a barrier to the vaccination of eligible children.
  • Vaccines recommended by the ACIP are automatically covered after approval by the CDC.

Reimbursement for Vaccines Provided to Children

If a vaccine is available through the VFC Program, providers are required to use vaccines from VFC supply for members 18 years of age or younger. Wisconsin Medicaid reimburses only the administration fee for vaccines supplied by the VFC Program.

For vaccines that are not supplied by the VFC Program, providers may use a vaccine from a private stock. In these cases, Wisconsin Medicaid reimburses for the vaccine and the administration fee.

 
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