Covered and Noncovered Services : Covered Services and Requirements

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, HealthCheck case management providers, or HealthCheck screener/case management 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 (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 follow-up lead clearance 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 that parents or guardians can take to decrease their child's lead exposure
• The importance of a well-balanced diet
• Recommendations for follow-up blood lead testing

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.

Note: 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.