EPSDT Example from Utah
97-14 Pediatricians and Audiologists: Hearing Screens for Infants.
Effective November 1, 1996, Medicaid covers hearing screens for newborn infants, using otoacoustic emissions, auditory brainstem response or, after six months of age, visual reinforcement audiometry. This service is limited to infants under the age of one year and is in accordance with the nationally recommended strategy to have all infants receive a hearing screen. The procedure code is V5008, hearing screening (infant).
Medicaid recipients, including newborns enrolled in a managed health care plan, such as an HMO, must receive all health care services through that plan. (The childs care provider is identified on the mothers Medicaid Identification Card.) All questions concerning services covered by or payments from a managed care plan must be directed to the appropriate plan. Refer to the Utah Medicaid Provider Manual, Section 1, Chapter 5, Verifying Eligibility, for information about how to verify a patients enrollment in a plan. For more information about managed health care plans, please refer to Section 1, Chapter 2, Capitated Managed Care Plans. A list of HMOs with which Medicaid has a contract to provide health care services is available.
Medicaid clients are considered fee-for-service clients for audiology services when they are not enrolled in a managed care plan. Fee-for-service clients may receive services covered by Medicaid from any Medicaid provider. As for all fee-for-service hearing services, the audiologist must receive a referral from a physician prior to performing the service. Standing orders from a hospital physician are acceptable.
Infants should be screened as soon as possible after birth; the recommendation is to have the screening done while the infant is still in the hospital. However, a screening performed when an infant is an inpatient is covered under the diagnosis-related group payment received by the hospital and is not separately billable. For rural hospitals where inpatient reimbursement is received on a fee-for-service basis, an audiologist may bill Medicaid separately for the service.
Instructions for completing newborn hearing screens are included in the updated CHEC (Child Health Evaluation and Care) Manual dated November 1996. The hearing screen requirements for infant CHEC exams are applicable as of November 1, 1996.
Please add procedure code V5008-hearing screening (infant), to page 6 of the Audiology Provider Manual, before code V5010, hearing aid assessment. The addition is as follows:
V5008 hearing screening (infant)
CRITERIA: Limited to infants under the age of one year and in accordance with the nationally recommended strategy to have all infant receive a hearing screen.
LIMITS: Documented medical need, medical clearance.
Contact Medicaid Information for questions concerning payment from Medicaid on fee-for-service claims.