Transcript Annual Wellness Exam EPSDT/SPE

Annual Wellness Exam
EPSDT
Paula LeSueur MSN, CFNP
SBHC Medicaid Consultant
Envision NM
2007
EPSDT
Early Periodic Screening, Diagnosis and
Treatment
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Objectives for our SBHCs:
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Provide comprehensive preventive health
care.
Identify student’s assets, risk behaviors and
health risks.
Components of Complete
EPSDT Screen
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A comprehensive health and developmental history,
including an assessment of both physical and
mental health development.
A comprehensive, unclothed physical exam.
Appropriate immunizations, according to age and
health history, unless medically contraindicated at
the time.
Laboratory tests, including an appropriate lead
blood level assessment (at 1 and 2 yrs of age).
Health education, including anticipatory guidance.
Preventive Health Guidelines for
Children and Adolescents
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EPSDT recommended every year from
birth to age 20.
Physical exam and developmental /
behavioral health assessment.
Nutrition screening.
Measurements include; ht, wt, BMI
percentile, and blood pressure (from age 2
to 20).
Developmental/Behavioral
Health Assessment
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Utilize the Recommended Developmental
and Behavioral Health Assessment for
ages birth to 21 (HEADSS).
The OSAH Student Health Questionnaire
provides the required information. Use
appropriate SHQ for Elementary School,
Middle School or High School.
Sensory Screening
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Vision—Snellen eye chart
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at age 3 through age 12,15 & 18.
Hearing/speech
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at age 4 through age 12, 15 & 18.
use audiometer, under earphones, at 1000,
2000 and 4000 Hertz at 20 decibels.
Physical Exam includes:
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Complete unclothed physical exam.
External genital exam and Tanner staging
is required. Document in chart if student
declines the exam (e.g. deferred at patient
request). Tanner staging may be done by
self report.
Provide education re: testicular and breast
self-exam as appropriate.
Lab Screenings
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Urinalysis - to be performed at age 5 and
15. May use Chemstrip 9.
Hematocrit/hemoglobin - to be done at 9
months and age 13. If indicated, may
repeat after menarche in females.
High Risk Factor Screenings
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Tuberculin Test 
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Screen all teens for high-risk factors.
Test if high individual risk.
Risk factors include immigration or travel to
areas of high prevalence, IV drug use,
incarceration, homelessness, HIV infection or
living with person with HIV, working or
volunteering in health care setting.
High Risk Factor Screenings
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Pelvic exam  To be done with all sexually active females, with
their consent, or initial exam at age 18 to 21.
 DOH Family Planning Division protocol states
pelvic exam should be performed within 6 months
of contraceptive use and PAP test should be
performed after 3 years of sexual activity or age
21, whichever comes first.
 May complete the GYN or FP exam and schedule
a return visit for the remainder of the EPSDT.
High Risk Factor Screenings
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STD Screen – all sexually active youth
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Urine chlamydia/gonorrhea .
HIV test if high risk- positive contact with
known partner at risk, past STDs, multiple
partners, IV drug use or sex in exchange for
money or drugs.
For males: sex with other males.
For syphilis only: test if reside in areas of
prevalence. NM is not in an area of
prevalence.
High Risk Factor Screenings
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Cholesterol 
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Perform or refer for the test if high risk.
Testing is based on individual risk,
i.e. familial hyperlipidemia, family history of
early onset of cardiovascular disease in
parents or grandparents at age 55 or less,
obesity, diabetes, high blood pressure or
cigarette smoker.
Immunizations
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Tetanus Booster - Tdap done between ages 12-15.
Required for 7th grade entry for 2007-08.
MMR, varicella and HepA - assess, give if indicated
and not previously given.
HepB - series should be completed in early
childhood or by 7th grade.
Influenza for high risk groups.
HPV (3 doses).
Immunizations should be given according to the
most current Advisory Committee of Immunization
Practice (ACIP) schedule. (www.cdc.gov/nip).
Procedure for SBHCs
(how to make appointments)
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Who are the students served?
Means test –
what is the screening question?
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Do you have a PCP?
Have you had a physical exam within the past
year?
Will you need a sports physical exam (SPE)
some time this year?
Procedures, con’t.
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Who and when will EPSDTs be scheduled? Who
will do vital signs, ht., wt., BMI % and lab tests?
Who does the exam, the counseling and the
education?
Instruct student to be prepared for unclothed
exam, come wearing t-shirt and gym shorts or
boxers. Have gowns or drapes.
Student to complete Student Health Questionnaire for the Annual EPSDT and present the
health history form for the SPE, if needed.
Procedures, con’t.
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Schedule annual exam (EPSDT) in SBHC for
all students registered who have a signed
parent consent form.
Include components of Sports Physical and
complete form, if needed.
Complete EPSDT, submit claim to Salud if an
approved Medicaid-SBHC provider.
Provide referrals for lab tests or procedures
as necessary. Document referral.
Encounter Form/ Billing form
OFFICE VISIT - NEW PATIENT
99201
Consider use of Modifier 25 (write in -25 after code)
Problem focused, 10 min.
99202
Expanded problem focused, 20 min.
99203
Detailed, 30 min.
99204
Comprehensive, mod. complexity, 45 min.
99205
Comprehensive, high complexity, 60 min.
99354
Prolonged Physician Service; face-to-face patient contact; beyond usual service 30 - 74 min.
99355x1
Prolonged Physician Service; face-to-face patient contact; 75-104 min. (also check 99354)
OFFICE VISIT - ESTABLISHED PATIENT
Consider use of Modifier 25 (write in -25 after code)
99211
Minimal, 5 min.
99212
99213
Problem focused, 10 min.
Expanded problem focused, 15 min.
99214
Comprehensive, mod. complexity, 25 min.
99215
Comprehensive, high complexity, 40 min.
EPSDT Well Child Exam/Prev. Med. New Patient
X
EPSDT Well Child Exam/Prev. Med. Established Patient
X
99381
Infant
99391
Infant
99382
1-4 years
99392
1-4 years
99383
5-11 years
99393
5-11 years
99384
12-17 years
99394
12-17 years
99385
18+ years
99395
18+ years
Coding
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Schedule return visit for STD/Family Planning
services. Use E&M code, as indicated.
Reminder - If student refuses genital or any
other part of the exam, including screening
tests, document and state reason.
Chaperone may be required for genital exam
of the opposite sex, which should be allowed
upon student request.
Notification
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Inform parents of results of the exam, including
any screening tests or lab results, except
confidential information. Present results per
phone or written report.
Notify Primary Care Provider that Annual
Exam/EPSDT was performed by use of the New
Mexico SBHC Services Notification Form.
Include any pertinent findings.
Schedule follow-up appointments for
confidential, behavioral health or other health
care services.
Documentation to support billing
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ICD-9 code is V20.2 for youth to age 17.
ICD-9 code is V70.0 for youth 18 or older.
Use of Modifier 25 –
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When the principal reason for the visit is an
EPSDT and during the visit another separate
identifiable health condition requires
additional evaluation and management above
and beyond the other service, then a 25
modifier can be attached to the secondary
CPT.
Medical Chart Documentation
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No required state forms, but
documentation must be an auditable form
(a single sheet) in the medical chart.
Recommend use of OSAH Progress notes
for elementary, middle or high school
students.