Provider Manual
Provider Manual
Child and Teen Checkups (C&TC) is the name for Minnesota’s Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) program, a required service under Title XIX of the Social Security Act. C&TC is a comprehensive child health program provided to children and teens (newborn through the age of 20 years) enrolled in Medical Assistance (MA) or MinnesotaCare. The purpose of the program is to reduce the impact of childhood health problems by identifying, diagnosing, and treating health problems early, and to encourage the development of good health habits.
Child and Teen Checkups are based on the recommendations of the American Academy of Pediatrics (AAP) and the United States Preventive Services Task Force (USPSTF). MHCP regularly updates the C&TC Schedule of Age-Related Screening Standards (Periodicity Schedule) (DHS-3379) (PDF) according to federal requirements of the EPSDT program, state legislation, and the unique needs and epidemiology of Minnesota's C&TC-eligible population.
Minnesota is required to provide an annual report to CMS that includes our state’s participation rate based on eligible children receiving a C&TC screening service during the reporting year. Therefore, accurate billing and coding is critical in documenting the screenings that have been provided.
States are also required to follow up on referrals made as a result of an EPSDT screening to assure that children and families receive the necessary services to correct or improve health problems. It is important that providers report all referrals for complete C&TC health visit claims using one of the four HIPAA required referral codes. DHS provides these referral codes through a secure data system. C&TC program staff provide outreach communications and assistance to families of children younger than age 11 requiring further evaluation, diagnosis and treatment for a condition identified during the C&TC screening visit. Refer to the HIPAA Compliant C&TC Referral Codes Fact Sheet for more information.
The C&TC program emphasizes the need to avoid fragmentation of care and the importance of continuity of care in comprehensive health supervision. Providers can help reduce duplication of services by substituting a C&TC screening service (when appropriate) for other preventive health care visits, such as:
To be reimbursed for C&TC screening services, fee-for-service C&TC screening providers must be enrolled as either of the following:
Eligible treating providers include the following:
Nonenrolled public health nurses approved by the Minnesota Department of Health (MDH) may provide services after completing the two- to three-day C&TC screening component training.
Staff eligible to provide some components under supervision of a physician or dentist includes the following:
Eligible facility types include the following:
Some providers listed can complete only certain components that are within their scope of practice as a licensed professional. For more information about enrolling as an MHCP provider, refer to Requirements for Providers.
Children and teens, newborn through the age of 20 years, enrolled in Medical Assistance (MA) or MinnesotaCare are eligible for C&TC services. Children enrolled in MA or MinnesotaCare through a managed care organization (MCO) must receive screening services from their Prepaid Minnesota Healthcare Program provider.
Use MN–ITS Interactive Eligibility Request to verify a member’s eligibility for this service.
Refer to the C&TC Schedule of Age-Related Screening Standards (Periodicity Schedule) (DHS-3379) (PDF) for Minnesota’s age-related screening standards schedule details.
Foster care
Children or teens in foster care or out-of-home placement should receive C&TC visits more frequently, as recommended by the American Academy of Pediatrics (AAP). Refer to AAP Healthy Foster Care America Health Information Form (PDF) for health visit recommendations and to the Healthy Foster Care America (https://www.aap.org) website for a variety of resources.
Health education is a required component of screening services and includes anticipatory guidance. Health education and counseling to both parents (or guardians) and children is required.
Reimbursement for health education and anticipatory guidance is included in the payment of the Evaluation and Management (E&M) code for a C&TC screening.
For more information on health education and anticipatory guidance, refer to the Child and Teen Checkups Fact Sheets for anticipatory guidance, 0–5 years, 6–12 years, and 13–21 years.
Preventive counseling is included in the preventive medicine E&M service; do not bill for preventive counseling separately. Bill with CPT codes 99401–99404 if patient visit is for counseling only.
Health history needs to include social determinants of health effective March 1, 2018. For more information about social determinants of health, refer to the Health History Fact Sheet.
Developmental and social-emotional or mental health screenings are a C&TC screening component. Use a standardized screening instrument.
Refer to Developmental and Social-Emotional Screening of Young Children (0-5 years of age) in Minnesota for information about screening, recommendations and resources. Also see Screening for Autism Spectrum Disorder (ASD) later in this section. Currently, no recommended standardized instrument adequately covers both developmental and social-emotional domains. Two separate screening instruments are needed to adequately screen for potential developmental and social-emotional concerns.
Refer to the instruments the Minnesota Interagency Developmental Screening Task Force recommends in the Recommended Instruments section of the Minnesota Department of Health (MDH) website. The website also has information about some well-known instruments that the Task Force does not currently recommend.
Refer to the Mental Health Screening (6-21 years) FACT Sheet for more information about recommendations and requirements based on age and a list of instruments the DHS Children’s Mental Health Division and MDH recommend.
For more information on developmental and social-emotional or mental health screening and recommended instruments, refer to the DHS Children’s Mental Health Division Screening webpage and the Developmental Screening and Social-Emotional Screening (0-5 years) Fact Sheets developed by MDH and DHS.
Providers engaging in screening must meet the instrument-specific criteria, as outlined by the publisher. Providers using the standardized instruments may include physicians, nurse practitioners, physician assistants, nurses, medical assistants or other appropriately trained staff.
Maintain required documentation in the child’s health record. Documentation must include, at a minimum, the name of the screening instrument(s) used, the score(s), and the anticipatory guidance provided to the parent or caregiver related to the screening results. If the screening results are abnormal, documentation must include how this is being addressed, such as referral to the local school district (directly or via Help Me Grow), appropriate medical specialists, follow-up plan of care, and when appropriate, a referral to a local community service agency. For more information, see the Referral section of the Developmental and Social-Emotional Screening of Young Children (0-5 years of age) in MDH.
Bill developmental and social-emotional or mental health screenings on the same claim as other C&TC services. Use the following CPT codes:
You may bill for both a developmental and a social-emotional or mental health screening on the same date of service on the same claim. However, you may not bill for more than two developmental screenings and more than two social-emotional and mental health screenings on the same date of service.
When a developmental and social-emotional or mental health screening is provided at other pediatric visits, bill the developmental and social-emotional or mental health screening on the same claim as the other pediatric services.
Provide ASD-specific screening only after using an approved developmental and social-emotional screening during the last year.
When billing for an ASD-specific screening, use a standardized screening instrument according to the guidelines of the developer. Without the use of a standardized screening instrument, reimbursement for ASD-specific screening is included in the payment of the E&M code used for the C&TC visit.
Bill an ASD-specific screening on the same claim as other C&TC services using CPT code 96110 and modifier U1.
When an ASD-specific screening is completed in addition to another developmental screening using two separate standardized screening instruments, bill for the ASD-specific screening and the developmental screening on the C&TC claim using one of the following:
Maintain required documentation in the child’s health record. At a minimum, documentation must include the name of the screening instrument(s) used, the score(s) and the anticipatory guidance provided to the parent or caregiver related to the results. If the screening results are abnormal, documentation must include a follow-up plan of care including to whom you referred the child and family, as well as any other ways that abnormal screening results are being addressed.
Referrals
For more information on referrals, see the Referral section of the Developmental and Social-Emotional Screening of Young Children (0-5 years of age) on the MDH website.
The following are examples of providers or resources to refer children to when they need additional evaluation:
For more information about autism spectrum disorders, see the Minnesota Department of Health (MDH) Autism or the Minnesota Department of Human Services (DHS) Children with autism spectrum disorders webpages and the Early Intensive Developmental and Behavioral Intervention (EIDBI) section of the MHCP Provider Manual.
Maternal depression screening is covered as a C&TC service or at other pediatric visits. Suggested screening times are at the 0 to 1-month visit, the 2-month visit, and either the 4-month or 6-month visit; however, providers may do screening any time up to 13 months.
Use one of the following standardized screening instruments:
Providers that meet the instrument-specific criteria for administering the screening tool as outlined by the publisher, may perform maternal depression screenings. Depending on the tool, this may include physicians, nurse practitioners, physician assistants, nurses, medical assistants or other appropriately trained staff.
MHCP allows up to six maternal depression screenings for a mother for each child she has who is less than 13 months old. For documenting maternal depression screening service, record the name of the completed screening instrument and that you performed the screening as a “risk assessment” in the child’s medical record.
You are not required to include the screening score results or a copy of the screening instrument in the child’s record. You may give the mother a paper copy of the screening instrument to bring with her to a referral appointment or destroy it if she does not want it. For more information on maternal depression screening, referral and documentation, refer to Postpartum Depression - Information for Health Professionals and the Maternal Depression Screening FACT Sheet.
Refer to the DHS Children's mental health screening webpage for information on the relationship between maternal depression and children’s developmental, social-emotional and mental health.
Bill for the maternal depression screening only when using one of the standardized screening instruments. When billing for a maternal depression screening, refer to the following criteria:
On January 1, 2017, a new NCCI procedure-to-procedure (PTP) edit became effective that pairs immunization administration codes (90460, 90461, 90471-90474) with maternal depression screening. You may receive the NCCI edit when submitting claims for maternal depression screening with CPT code 96161.
These edits have a Correct Coding Modifier Indicator of “1” and, therefore, the PTP edit will be bypassed if you correctly add a PTP-associated modifier. See Minnesota National Correct Coding Initiative (NCCI) page for information about modifiers.
Risk assessment for tobacco, alcohol and drug use is required for ages 11 through 20 years, followed by appropriate action. For more information, including recommended risk assessment or screening tools, refer to the Tobacco, Alcohol or Drug Use Risk Assessment Fact Sheet.
Resources for adolescent health include the following:
Reimbursement for this assessment using a standardized tool is included in the payment of the Evaluation and Management (E&M) code used for a C&TC screening visit.
Review the immunization status of a child, teen or young adult compared to the current Recommended Childhood and Adolescent Immunization Schedule from the Advisory Committee on Immunization Practices (ACIP). ACIP is part of the Centers for Disease Control and Prevention (CDC) and provides current recommendations for vaccine administration, schedules of periodicity, and appropriate dosage and contraindications. You may also use the Minnesota Department of Health (MDH) Childhood and Adult Recommended Immunization Schedules, which are revised annually and incorporate the ACIP schedule.
State law requires all MHCP enrolled providers who administer pediatric vaccines to enroll in the Minnesota Vaccines for Children (MnVFC) program. MDH administers the MnVFC for MHCP members ages 1 through 18 to provide most pediatric vaccines to participating providers at no cost. Providers must obtain vaccines through MnVFC whenever available.
MHCP covers flu vaccines and other recommended vaccinations for adults aged 19 or older.
When billing for immunizations or vaccinations administered during a C&TC screening, enter the correct immunization or vaccination code(s) with the SL modifier when applicable, and add the correct administration code(s) to the C&TC claim. Refer to the MHCP Provider Manual – Immunizations and Vaccinations section for details on coding and billing criteria.
Immunization and vaccinations resources
Refer to the following documents and websites for more information:
For information about billing for lab services, refer to the Laboratory/Pathology Services section of this manual.
MHCP covers venipuncture and capillary specimen collection and handling.
A Clinical Laboratory Improvement Amendments (CLIA) certified lab must perform and bill for most lab services.
If a provider has a CLIA certified lab on site and lab services are provided on site, the CPT code for the lab service may be included in the C&TC visit claim. Payment for lab services is in addition to the C&TC bundled rate.
If a provider refers patients off site to a CLIA certified lab for lab tests or screenings that are required or part of a C&TC health visit, the off-site lab bills for the lab test(s), not the provider. That lab test will not be included on the C&TC health visit claim.
If a required lab service was not done at a C&TC visit, do not include it on the C&TC visit claim. Include documentation in the medical record with the date and results of any required lab screening or test that the C&TC provider or another provider performed within the required age range.
Document in the medical record if a required lab screening or test was not done during the required age range C&TC visit due to the child, adolescent or parent declining the test or being uncooperative. Attempt the screening or test again in the future.
Blood lead test
A blood lead test at ages 12 and 24 months is a federally required component of C&TC. (Research indicates that MA and MinnesotaCare children are at greater risk of lead poisoning.) Lead testing can occur at other times within the ranges that are indicated on the Schedule of Age-Related Screening Standards (Periodicity Schedule) (DHS-3379) (PDF) and when medically indicated. A blood lead test done between ages 9 and 15 months can fulfill the 12-month screening requirement. A blood lead test completed for a child between ages 16 months and 30 months can fulfill the 24-month screening requirement.
When billing a blood lead test use the correct CPT code for the lead test.
Refer to the following documents and websites for more blood lead resources:
Hemaocrit or hemoglobin
Hemoglobin (Hb) or hematocrit (Hct) screening is required as part of a C&TC visit at these ages for diagnosis and prevention of iron deficiency and iron-deficiency anemia:
For more information, including documentation of results and follow up, refer to the C&TC Hemoglobin or Hematocrit Fact Sheet
Tuberculosis (TB) testing
Evaluate all children and adolescents for their risk of exposure to TB. High-risk children include those in the following groups:
TB testing is not mandatory but is a covered service if clinical documentation supports the medical need for the test. When performing TB testing during a C&TC screening, bill with the appropriate CPT code on the C&TC screening claim. For more information and recommendations, review the C&TC TB Screening Fact Sheet.
Sexually transmitted infection (STI) risk assessment and human immunodeficiency virus (HIV) screening lab test
HIV testing is required beginning March 1, 2018.
Beginning no later than 11 years of age, assess all youth for risk of sexually transmitted infections at each C&TC well visit.
Universal HIV screening (offering HIV blood testing to all youth, regardless of risk factors) is required at least once between 15 and 18 years of age, as recommended by the American Academy of Pediatrics (AAP) and Centers for Disease Control and Prevention (CDC). Refer to the MDH Child and Teen Checkups Fact Sheets for Sexually Transmitted Infection (STI) Risk Assessment and Human Immunodeficiency Virus (HIV) Screening for more information, including appropriate documentation of confidential screening test results in medical records. Providers may screen for STIs without parental knowledge or consent. If the youth declines the HIV test or if his or her HIV status is already known, document the reason that the HIV blood test was not done. Youth who have risk factors for HIV exposure should be tested at least annually. (Minnesota Statutes 144.343)
Resources for adolescent health include the following:
Dyslipidemia risk assessment
Effective March 1, 2018, a risk assessment is required for children at the ages indicated on Schedule of Age-Related Screening Standards (Periodicity Schedule) (DHS-3379) (PDF). For risk assessment guidelines, refer to the Expert Panel on Integrated Guidelines for Cardiovascular Health and Risk Reduction in Children and Adolescents: Summary Report (www.nhlbi.nih.gov). For more information refer to the Dyslipidemia Risk Assessment Fact Sheet.
Vision screening
Provide distance visual acuity screening beginning at age 3. Effective March 1, 2018, add near visual acuity (plus lens) screening beginning at 5 years for children who pass their distance screening and do not already have corrective lenses. Use a wall chart at a 10 foot distance.
Starting at age 11, vision screening must be done once during each of the age ranges as indicated on the Periodicity Schedule (DHS-3379) (PDF).
Refer to the MDH Vision Screening website for detailed procedures and Equipment for visual acuity screening (PDF) for recommended wall charts and equipment. Instrument-based vision screening may be used as an alternative to wall charts for children 3-5 years old who are unable or unwilling to cooperate with routine vision screening. For more information refer to the Vision Screening Fact Sheet.
Bill instrument-based vision screening using CPT codes 99174 or 99177.
An NCCI procedure-to-procedure (PTP) edit pairs preventive visit CPT codes in the range of 99381–99397 with vision screening. You may receive the NCCI edit when submitting claims for vision screening with CPT code 99173. These edits have a Correct Coding Modifier Indicator of “1” and, therefore, the PTP edit will be bypassed if you correctly add a PTP-associated modifier. See Minnesota National Correct Coding Initiative (NCCI) page for information about modifiers.
Hearing screening
Effective March 1, 2018, beginning at 11 years, the addition of 6000 Hz at 20 dB to hearing screening is required to screen for noise-induced hearing loss once during each of the age ranges as indicated on the Periodicity Schedule (DHS-3379) (PDF). Refer to the MDH Hearing Screening for detailed procedures and instrument recommendations. For more information refer to the Hearing Screening Fact Sheet.
Oral health
Primary care provider requirements include the following:
Fluoride varnish application (FVA):
Obtain informed consent for this procedure, either verbally or in writing. Document that you obtained verbal consent, including discussion of benefits and risks of FVA, with each application. Alternatively, a written consent signed by the parent or guardian is valid for up to one year.
For more information on FVA by primary care and other non-dental providers, refer to Fluoride varnish in the Child and Teen Checkups (C&TC) setting and the Oral Health Fact Sheet in the MDH C&TC webpages, and the National Maternal and Child Oral Health Resource Center.
Refer to the Non-Dental Health Provider section under Dental Services for specific billing instructions or for more information.
The C&TC dental screening components include the following:
Refer to the Schedule of Age-Related Dental Standards (C&TC Dental Periodicity Schedule) (DHS-5544) (PDF) for Minnesota’s age-related dental standards schedule details. Refer to the American Academy of Pediatric Dentistry Guideline on Periodicity of Examination, Preventive Dental Services, Anticipatory Guidance/Counseling, and Oral Treatment for Infants, Children, and Adolescents (PDF) and the Dental Checkups Fact Sheet for more information.
For details on dental benefit coverage policy, refer to the Dental Services section of this manual.
Primary care provider requirements include the following:
The following services are also covered:
For some situations it is not possible or appropriate to require C&TC providers to complete certain components of the C&TC screening as outlined in the Schedule of Age-Related Screening Standards. According to the Administrative Uniformity Committee (AUC) recommendations, use the billing guidelines for the situations listed in the claim guideline exceptions table when you cannot perform screening component(s) or an initial screening is not appropriate.
Claims submitted using the following guidelines for an exception identified in the table will be recognized as completed C&TC claims. When submitting a claim, follow these requirements:
Claim guideline exceptions
Exception Reason |
Situation |
Claim Reporting and Medical Documentation |
Condition already identified (screening is not medically necessary) |
||
Screening recently provided |
||
Service is not applicable |
Child’s teeth have not yet erupted; therefore, fluoride varnish application (FVA) may not be provided. |
|
Service recently provided elsewhere |
FVA was provided in another setting, such as the dental home or public health setting within the last 30 days |
|
Parent or young adult declined |
||
Parent declined |
||
Unsuccessful attempt (Child uncooperative) |
||
Unsuccessful attempt (Child uncooperative) |
||
Screening instrument not reviewed |
A developmental screening instrument was sent to parents but not returned for review at the time of the C&TC screening. |
MHCP does not cover the following services under C&TC:
C&TC screening services and screening components do not require authorization. For diagnosis and treatment services that may require authorization, refer to the MHCP Provider Manual - Authorization Section. For clinic or physician services provided to a child not included in the C&TC screening benefit, refer to the MHCP Provider Manual – Physician Services section.
Use the 837P claim to bill for C&TC services. Refer to the MN–ITS User Guide for Child and Teen Checkups when submitting claims via MN–ITS Interactive. If billing X12 Batch, follow HIPAA electronic data interchange (EDI) as outlined in the X12 implementation guides and follow the standards as outlined in the Minnesota Uniform Companion Guides.
C&TC billing processes include complying with HIPAA, AUC and MHCP system and data requirements. Billing C&TC screening services accurately is necessary to do the following:
Follow the Schedule of Age-Related Screening Standards (Periodicity Schedule) (DHS-3379) (PDF) to identify required C&TC screening components for the periodic visit, including a referral to a dentist. Enter the appropriate CPT or HCPCS codes for each age-related component provided in MN–ITS-837P claim form. On claims for C&TC screening services, include the following:
Refer to the Schedule of Age-Related Dental Standards (Dental Periodicity Schedule) (DHS-5544) (PDF) for dental screening components.
For policy and billing dental screening components, refer to the Dental Services section of this manual.
If a significant, separately identifiable E&M service is provided at the time of the C&TC screening, bill that E&M code with the modifier 25. Documentation in the health record must support key components of billed E&M services. Follow CPT instructions for appropriate coding.
A referral for C&TC reporting purposes indicates that the child needs to be seen again for further assessment; diagnosis or treatment of a problem; or a concern that was identified during the C&TC screening. The referral can be made to the screening provider or to another provider.
C&TC HIPAA-compliant referral condition codes (also called referral codes) indicate if a referral was made as a result of the C&TC screening. C&TC claims must list the most appropriate HIPAA-compliant referral condition code: ST, S2, AV or NU. MHCP C&TC screening payment requires one of the four HIPAA-compliant referral condition codes to be entered at the claim (header) level.
DHS provides referral codes through a secure data system to C&TC programs throughout Minnesota (local public health and tribal health) under contract with DHS. C&TC program staff provide outreach communications and assistance to families of children younger than age 11 requiring further evaluation, diagnosis and treatment for a condition identified during the C&TC screening visit.
Refer to the HIPAA Compliant C&TC Referral Codes Fact Sheet for more information.
Use the most appropriate referral code from the table below:
HIPAA-compliant referral condition code |
Use this referral condition code for billing when a C&TC screening results in one of the following: |
ST |
|
S2 |
The patient is currently under treatment for a diagnostic or corrective health problem(s) |
AV – declined referral |
One or more referrals were made and the patient declined one or more of the referrals (AV) |
NU |
MHCP does not require the use of HCPCS code S0302 and considers this code as informational only. If a submitted charge is entered on the same line as the HCPCS Code S0302, MHCP will deduct that amount from the total charges on the claim.
If the HCPCS code S0302 is reported without a HIPAA-compliant referral condition code on that claim, the claim will deny.
DHS will recognize a claim as a C&TC screening only when a HIPAA-compliant referral condition code is entered on the claim.
Department of Human Services (DHS) C&TC resources
Use the MHCP Provider Manual in conjunction with the following DHS resources:
Minnesota Department of Health (MDH) C&TC resources
Other C&TC resources
Training and e-learning modules
Fluoride varnish online trainings
Minnesota Statutes 144.343 (minor consent)
Minnesota Statutes 256B.04 (Subd. 1b)
Minnesota Statutes 256B.0625 (Subd. 14) (preventative and screening services)
Minnesota Statutes 256B.0625, subd.39 (immunizations)
Minnesota Rules 9505.0275, 9505.1693 to 9505.1748 (C&TC)
42 CFR 440.40(b); 42 CFR 441.50-441.62 (C&TC)
The terminology used to describe people with developmental disabilities has changed over time. While DHS supports the use of “people first” language within its documents, certain outdated terms may still be found within historical and official documents, such as statutes and reports, and other documents created by third parties.
Title XIX, Sections 1902(a)(43), 1905(a)(4)(B), 1905(r) of the Social Security Act (C&TC)
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