5101:3-14-03 Covered Healthchek: early and periodic screening, diagnosis, and treatment (EPSDT) screening visits.

This rule describes the screening components that the healthchek (EPSDT) provider shall complete and document as part of initial and periodic healthchek (EPSDT) screening visits, unless the individual, or the individual's parent or guardian, refuses the components. The provider shall document such a refusal.

(A) Definitions.

(1) For the purposes of Chapter 5101:3-14 of the Administrative Code, "screening" is defined as the identification of individuals at risk of health problems. Results of a screening do not represent a diagnosis, but rather, indicate need for referral to an appropriate resource for additional evaluation, diagnosis, treatment, or other follow-up when concerns or questions remain as a result of the screening.

(2) For the purposes of Chapter 5101:3-14 of the Administrative Code, "CPT" (current procedural terminology) is defined in rule 5101:3-1-19.3 of the Administrative Code.

(B) Screening frequencies and indication of need for further evaluation.

(1) Screening components of the healthchek (EPSDT) visit shall be provided to individuals at ages and at frequencies in accordance with American academy of pediatrics recommendations for preventative pediatric health care (March, 2000), www.aap.org.

(2) Healthchek (EPSDT) screening providers shall coordinate with public and private resources to eliminate duplicative screening and ensure comprehensive screening, evaluation, diagnosis, and treatment.

(3) When a healthchek (EPSDT) screening visit indicates the need for further evaluation of an individual's health, the provider shall, without delay, make a referral for evaluation, diagnosis, and/or treatment. For individuals enrolled in the medicaid managed care program (MCP), the healthchek (EPSDT) provider shall utilize referral requirements specified in rule 5101:3-26-05.1 of the Administrative Code in satisfying the referral requirements for healthchek(EPSDT) services as defined in Chapter 5101:3-14 of the Administrative Code.

(C) Comprehensive health and developmental history.

(1) A "comprehensive health and developmental history" is a profile of the individual's medical history and includes a review of both physical and mental health development. The provider shall obtain the individual's medical history from the individual (if age appropriate), the individual's parent, or a responsible adult who is familiar with the individual's history.

(2) The provider shall obtain or update the comprehensive health and developmental history at each initial and periodic healthchek (EPSDT) screening visit. The comprehensive health and developmental history shall include at a minimum:

(a) Current complaints/concerns;

(b) The individual's and family's history of illnesses, diseases, and allergies;

(c) Current medications and adverse effects to medications;

(d) The individual's social or physical environment that may affect the individual's overall health; and

(e) For adolescents, the individual's sexual activity and contraceptive methods.

(D) The provider shall perform a comprehensive unclothed physical examination during each initial and periodic screening visit. The examination shall include at a minimum:

(1) Measurements of height and weight, including comparisons of age -appropriate percentiles;

(2) Blood pressure, as age-appropriate;

(3) Head circumference, including percentiles, as age-appropriate;

(4) Examination of head, ears, eyes, nose, and throat; respiratory, cardiovascular, gastrointestinal, reproductive, musculoskeletal and neurological systems;

(5) For age-appropriate females, a breast inspection and palpation, and instructions in breast self-examination;

(6) For age-appropriate males, testicular examination, and instructions in self-examination of the testes; and

(7) A pelvic examination may be provided for age-appropriate females as part of the healthchek (EPSDT) screening visit, when medically indicated. Pelvic examinations are considered part of the comprehensive unclothed physical examinations and are not reimbursed separately.

(E) Developmental screening (including physical and mental health development).

(1) The provider shall perform or update the developmental screening at each initial and periodic screening visit. The developmental screening shall include an age-appropriate developmental history and an a screening of the individual's motor, speech, mental, and social development.

(2) Formal developmental tests that are performed during the screening servicevisit will be reimbursed in addition to the healthchek (EPSDT) screening visit as described in rule 5101:3-14-04 of the Administrative Code.

(3) When the screening of the individual's mental health indicates the need for diagnostic and/or therapeutic mental health services, the services are covered and reimbursed separately in accordance with Chapters 5101:3-4 (physician services), 5101:3-8 (limited practitioner services), and 5101:3-27 (community mental health agency services) of the Administrative Code. Drug and alcohol rehabilitation shall be covered and reimbursed separately in accordance with Chapter 5101:3-30 (alcohol and drug addiction services) of the Administrative Code.

(F) Nutritional screening.

The provider shall perform a screening of the individual's nutritional status as part of the basic examination component of each initial and periodic healthchek (EPSDT) screening visit through questions about dietary practices, measurements of height and weight (in accordance with paragraph (D) of this rule), laboratory testing (if medically indicated, in accordance with paragraphs (J) and (K) of this rule), and a complete physical examination in accordance with paragraph (D) of this rule), and a dental screening (in accordance with paragraph (L) of this rule).

(G) Vision screening.

(1) The provider shall perform a vision screening shall be performed as a part of each initial and periodic healthchek (EPSDT) screening visit using the following criteria:

(a) Individuals ages birth to three years shall be screened by reviewing the individual's medical history for risk factors and by performing an external (gross) observation and (internal) ophthalmoscopy.

(b) Individuals ages three and older are required to be screened by:

(i) External (gross) observation and (internal) ophthalmoscopy;

(ii) Visual acuity test (e.g., Titmus, Snellen, Lea, or Tumbling E);

(iii) Ocular muscle balance test, administered at distance and near; and,

(iv) Stereopsis test (e.g., random dot E).

(2) A vision screening is considered part of the comprehensive healthchek (EPSDT) visit and is not reimbursed separately.

(3) When the vision screening indicates a potential visual problem or when a parent, teacher, professional, or responsible adult suspects that the individual has a vision problem, the provider shall, without delay, make a referral for the individual to an ophthalmologist or an optometrist for evaluation, diagnosis, and/or treatment.

(H) Hearing screening.

(1) The provider shall perform a hearing screening during each initial and periodic healthchek (EPSDT) screening visit using the following criteria:

(a) Individuals ages one to three years shall be screened by:

(i) Reviewing the individual's history for risk factors or symptoms indicative of hearing problems; and

(ii) Observing the child for, and questioning the parents about, physical behaviors or speech development that may suggest a hearing impairment.

(b) Individuals ages three and older shall be screened by:

(i) Using manually administered, individual pure-tone, air conduction equipment, if the provider has the equipment available; or

(ii) When pure-tone equipment is not available, providers are encouraged to refer children to another provider for a pure-tone test.

(2) If pure-tone equipment is used or other covered hearing services are provided, the service shall be separately reimbursed to the provider who performs the procedure as described in rule 5101:3-14-04 of the Administrative Code.

(3) When the hearing screening indicates a hearing impairment or a parent, teacher, professional, or other responsible adult reports that the child may have a hearing problem, the provider shall, without delay, make a referral for the child a health care provider who specializes in the evaluation, diagnosis, and treatment of hearing problems and is eligible to provide the service under the medicaid program.

(I) Immunization screening.

(1) The provider shall perform an immunization screening shall be as part of the basic examination component of each initial and periodic screening visit and shall include a history of past immunizations.

(2) If, at the time of screening, an immunization is needed, the provider shall provide the immunization, or refer the individual for the appropriate immunization unless the immunization is medically contraindicated. If medically contraindicated, the immunization shall be rescheduled as appropriate.

(3) The provider shall use the standard immunization schedule in accordance with rule 5101:3-4-12 of the Administrative Code.

(4) Immunizations shall be reimbursed separately as described in rule 5101:3-14-04 of the Administrative Code.

(J) Lead toxicity screening.

(1) The centers for medicare and medicaid services (CMS) and centers for disease control and prevention (CDC) require the following lead screening:

(a) All children must receive a blood lead screening test at twelve months and twenty-four months of age;

(b) Children between the ages of thirty-six months and seventy-two months of age shall receive a lead blood lead screening test if they have not been previously screened for lead poisoning.

(c) A blood lead screening test shall be used when screening.

(i) Blood lead screening tests are covered whenever medically indicated.

(ii) The test methodology used for the required blood lead screening test shall have the sensitivity to detect blood lead levels of ten micrograms per deciliter or lower.

(iii) The erythrocyte protoporphyrin test does not meet this standard, it and is not acceptable as a blood lead screening test. The erythrocyte protoporphyrin test may be used to diagnose other conditions such as iron deficiency.

(d) Children of any age may be screened.

(K) Laboratory tests.

(1) Based on the individual's medical and nutritional history, age, physical condition, ethnic background, and home environment, the primary health care provider shall determine and order the appropriate laboratory procedures.

(2) Reimbursement is available to a physician or clinic if the laboratory procedures are actually performed in the physician's office or clinic and the physician's office or clinic meets the requirements set forth in Chapter 5101:3-11 of the Administrative Code. Specimens that are sent to an outside laboratory for analysis must be billed by the laboratory that actually performs the procedure.

(3) These laboratory procedures shall include, but are not limited to, the following:

(a) Blood lead screening test, in accordance with paragraph (J) of this rule and rule 3701-82-02 of the Administrative Code.

(b) Hemoglobin and/or hematocrit.

Anemia is a common abnormalitycondition reported during the healthchek (EPSDT) screening visit. At a minimum, a hematocrit and/or hemoglobin is recommended on all premature and low birth weight infants during the first six months of life. If medical indications are noted in the physical examination, a test for anemia may be performed at any age. Such medical indications include a history of inadequate iron in the diet, a history of blood loss, family history of anemia, or pallor.

(c) Sickle cell test.

It is recommended that a test for sickle cell and/or other hemoglobinopathies be performed at least once on all children or of African-American, Greek, Italian, Arabian, Egyptian, Turkish, or Asiatic Indian descent. If it cannot be determined that a child has been tested previously, a test for the sickle cell or other hemoglobinopathies should be performed.

(d) Pap smears and tests for sexually transmitted infections.

Pap smears are recommended for all adolescent females age eighteen or older. Sexually active adolescents should be tested regardless of age. Tests for sexually transmitted infections are covered if medically indicated. Individuals shall be informed about all tests performed, given results of each test and provided health education regarding sexually transmitted infections, in accordance with paragraph (M) of this rule.

(e) Tuberculin test.

(i) A tuberculin test shall be performed on all individuals who:

(a) Are suspected of having a mycobacterial infection;

(b) Have a known history or exposure to active tuberculosis (TB);

(c) Are immigrants from high prevalence areas of TB;

(d) Are from areas of high endemic rates of TB; or

(e) Are members of families or social groups with an increased incidence of the disease.

(ii) If an individual does not meet at least one of the conditions listed in paragraph (K)(3)(e)(i) of this rule, TB testing is optional.

(iii) The tuberculin test shall be reimbursed as described in accordance with rule 5101:3-14-04 of the Administrative Code.

(f) Other laboratory screens as medically necessary.

(L) Dental screening.

(1) For children from birth through the age of two years, the provider shall perform a dental screening as part of the basic examination component of each initial and periodic screening visit, and shall include, at a minimum:

(a) A screening of the growth and development of the dentition and adjacent dento-facial structure, and an oral inspection for dental caries shall be performed. Individuals shall be provided health education regarding early childhood caries prevention in accordance with paragraph (M) of this rule.

(b) When a dental screening and oral inspection indicates the need for further evaluation, the provider shall, without delay, make a referral to a dentist or, in accordance with rule 5101:1-38-05 of the Administrative Code, to the county department of job and family services(CDJFS) for a referral to a dentist, for evaluation, diagnosis, and/or treatment.

(c) Diagnostic and preventive dental examinations shall be provided to individuals at ages and at frequencies in accordance with American academy of pediatrics recommendations for preventative pediatric health care. Providers are encouraged to refer children, beginning at age two years to a dentist or the CDJFS for a referral to a dentist.

(2) For children ages three years through twenty, the provider shall perform a dental screening during each initial and periodic screening visit, and shall include, at a minimum:

(a) Providers of the healthchek (ESPDT) screening visits shall provide individuals ages three years and older with referrals to a dentist or to the CDJFS, if the individual has not been seen by a dentist or dental hygienist under the direct supervision of a dentist during the last six months.

(b) Physicians are encouraged to emphasize the importance of preventive dental health care available under the medicaid program. Providers should explain that cleanings, examinations, and fluoride treatments are covered every six months. Dental sealants are covered for permanent first molars for children under age nine and for permanent second molars for individuals under age eighteen.

(M) Health education, counseling, anticipatory guidance, and risk factor reduction interventions.

(1) Health education, including counseling, anticipatory guidance, and risk factor reduction intervention, is a required component of each healthchek (EPSDT) screening visit. Health education should be designed to assist parents and individuals in understanding what to expect in terms of the individual's development and to provide information about the benefits of healthy lifestyles and practices, and disease prevention.

(2) Providers should encourage parents and individuals (if age appropriate) participating in the program to take advantage of screening services, dental services, vision services, and hearing services covered under medicaid.

(3) Health education and counseling is part of each initial and periodic healthchek (EPSDT) visit. Additional health education codes and counseling will not be reimbursed on the same date of service as a healthchek (EPSDT) visit.

(4) The preventive counseling code/anticipatory guidance shall be billed only when counseling/anticipatory guidance is provided at an encounter separate from the healthchek (EPSDT) screening visit.

(N) When a healthchek (EPSDT) screening visit indicates the need for further evaluation of an individual's health, the provider shall, without delay, make a referral for evaluation, diagnosis, and/or treatment. Evaluation, diagnosis, and/or treatment may be provided at the time of the healthchek (EPSDT) screening visit if the health care professional is qualified to provide the services.

Effective: 07/01/2006
R.C. 119.032 review dates: 11/10/2005 and 07/01/2011
Promulgated Under: 119.03
Statutory Authority: 5111.02
Rule Amplifies: 5111.01 , 5111.02
Prior Effective Dates: 4/7/77, 9/1/87, 1/15/90, 2/17/91, 4/1/92 (Emer), 7/1/92, 1/15/95, 1/4/00 (Emer), 3/20/00, 8/1/01