Primary Care Coding Alert

Question: We are receiving denials from Medicaid stating 92551 (hearing exams) which we perform during an EPSDT exam is not covered and is included with the EPSDT. My staff has spoken to Medicaid several times and come back with different responses. We cannot bill with the modifier AF. What is it that we are doing wrong?

Washington Subscriber

Answer:

The Early Periodic Screening, Diagnosis and Treatment (EPSDT) exam is a federally required series of exams for Medicaid recipients through age 20.The EPSDT program was initiated as a comprehensive and preventive child health program for Medicaid recipients.

The screening component of the well child checkup includes a general health screening most commonly known as periodic well child exam. The required Well Child/EPSDT screening guidelines based on the American Academy of Pediatrics’ recommendations for preventive pediatric health care include:

• Comprehensive health and development history
• Developmental/behavioral assessment
• Age appropriate unclothed physical examination
• Height and weight measurements, and age appropriate head circumference
• Blood pressure for children 3 and older
• Immunization review and administration of appropriate immunizations
• Health education including anticipatory guidance
• Nutritional assessment
• Hearing, vision and dental assessment
• Blood lead level testing for children under 6 years of age
• Interpretive conference and appropriate counseling for parents or guardians
• Objective testing for developmental behavior, hearing and vision must be performed in accordance with theMedicaid periodicity schedule
• Laboratory services for tuberculin, hematocrit, hemoglobin, urinalysis, or other needed testing as determinedby the physician must be provided

When your physician performs an EPSDT exam, you’ll have to report an appropriate new (99381-99385, Initial comprehensive preventive medicine evaluation and management of an individual…) or established (99391-99395, Periodic comprehensive preventive medicine reevaluation and management of an individual…) preventive visit code depending on the age of the patient. The hearing screening should be reported with 92551 (Screening test, pure tone, air only) and vision screening should be reported with 99173 (Screening test of visual acuity, quantitative, bilateral).

However, you need to remember that all the codes that you report for an EPSDT examination should be appended with the modifier EP (Service provided as part of Medicaid early periodic screening diagnosis and treatment [EPSDT] program) in order to let the payer know that your clinician performed an EPSDT examination. So, the hearing screening should be reported as 92551-EP.

Also, you should note that the hearing screening and vision screening cannot be reported alone when performed as a component of an EPSDT examination. They have to be reported in conjunction with an EPSDT comprehensive age-appropriate screening.