CHDP Transition to National Standards (chdp trans)



This section contains information about the requirement for Child Health and Disability Prevention

(CHDP) billers to submit CPT codes on a CMS-1500 or UB-04 claim form, rather than continuing to

submit CHDP codes on a Confidential Screening/Billing Report (PM 160). Providers who render Early and Periodic Screening, Diagnostic and Treatment/CHDP (EPSDT/CHDP) services in a school-based

setting must follow billing instructions in the CHDP Transition to National Standards: School-Based Services section of this manual.

Transition Overview The Health Insurance Portability and Accountability Act (HIPAA) of

And Phases 1996 requires medical billers to use standard sets of billing codes and claim forms.

CHDP program laboratory-only billers transitioned to national standards for dates of service on or after February 1, 2017, during Phase 1 of the CHDP transition project.

CHDP providers who bill other CHDP services (health assessments, vaccinations and laboratory services in combination with other services) transitioned to national standards for dates of service on or after July 1, 2017, during Phase 2 of the CHDP transition project.

Providers who render CHDP services in a school-based setting transitioned to national standards for dates of service on or after November 1, 2018, during Phase 3 of the CHDP transition project. For billing instructions, refer to the CHDP Transition to National Standards: School-Based Service section in this provider manual.

In addition to meeting HIPAA standards, this transition adapts CHDP billing to the American Academy of Pediatrics (AAP) Bright Futures periodicity schedule and enhanced Bright Futures services.

FQHC, RHC and Federally Qualified Health Centers (FQHCs), Rural Health Clinics

IHS-MOA Clinic (RHCs) and Indian Health Services – Memorandum of Agreement

Required Reporting Data (IHS-MOA) 638, Clinics bill EPSDT/CHDP services using the UB-04 claim. Effective September 1, 2019, FQHCs, RHCs and IHS-MOAs no longer submit the Confidential Screening/Billing Report Information Only (PM 160 Information Only) with claims to fulfill reporting purposes. Instead, these providers fulfill reporting requirements by including informational lines on their claims. Required reporting data will be extrapolated from the informational lines.

Providers submitting paper claims can refer to a sample UB-04 claim populated with informational lines in the Rural Health Clinics (RHCs) and Federally Qualified Health Centers (FQHCs) Billing Examples provider manual section. Instructions for submitting informational lines on electronic claims is available in the Medi-Cal Computer Media Claims (CMC) Billing and Technical Manual, “Special Billing Instructions: Federally Qualified Health Centers, Rural Health Clinics, and Indian Health Services-Memorandum of Agreement” section.

Change Chart The following chart illustrates how claims processed as

Medi-Cal/EPSDT claims differ from claims previously processed in the proprietary CHDP claim processing system.

|Medi-Cal/EPSDT providers use: |CHDP providers use: * |

|California Medicaid Management Information System (CA-MMIS) claims |CHDP claim processing subsystem, which does not allow claim status |

|processing, which allows providers to check claim status during |checks during processing |

|processing | |

|HIPAA compliant CMS-1500 and UB-04 claim forms |Non-HIPAA-compliant Confidential Screening/Billing Report (PM 160) |

| |proprietary form |

|HIPAA compliant ASC X 12N 837P or 837I v.5010A1 electronic health |Non-HIPAA-compliant CHDP computer media claims (CMC) electronic |

|care transactions |transactions |

|HIPAA compliant CPT and HCPCS procedure code(s) |Non-HIPAA-compliant two-character CHDP local codes |

|Modifiers |No modifiers (local codes are billed as full components) |

|Single claim line processing |Whole claim processing |

|Remittance Advice Details (RAD) form with payment information for |Non-HIPAA-compliant CHDP Remittance Advice (RA) with fee adjustment |

|paper claims |codes |

|or | |

|ASC X 12N 835 v.5010A1 Health Care Claim Payment/Remittance Advice | |

|(RA) with payment information for electronic claims | |

|Medi-Cal warrant for payment of services rendered |CHDP Remittance Advice (RA) for payment of services rendered |

|Claims Inquiry Form (CIF) to request claim adjustments |A new PM 160 to request balance due or adjustment |

|CIF to track submitted claim |A new PM 160 to trace claim |

|Appeal Form (90-1) to challenge denials. Appeal reference number |A new PM 160 to initiate the CHDP appeal process. (No ability to |

|(ARN) to track appeal status. |track appeal.) |

* Items in this column apply for claims with dates of service prior to the transitions of Phase 1 and 2.

Medi-Cal Policy, After a provider transitions (in either Phase 1 or Phase 2) to billing

Procedures and Rates per national standards, they bill qualified CHDP/Early and Periodic

Screening, Diagnostic and Treatment (EPSDT) services in

accordance with Medi-Cal policy, procedures, limitations and rates. Providers who have transitioned to national standards no longer:

• Bill CHDP local codes on national claim forms

• Submit the PM 160

• Receive payment at CHDP rates

• Follow CHDP billing guidelines

Modifiers and ICD-10-CM Providers follow Medi-Cal policy and billing procedures for use of

Diagnosis Codes modifiers and ICD-10-CM diagnosis codes on national claims.

Reimbursement Medi-Cal maximum reimbursement rates for the preceding codes are contained in the Medi-Cal rate table, which may be accessed from the Medi-Cal website at medi-cal. by clicking the “Medi-Cal Rates” link.

Six-Month Billing Limit Claims are subject to Medi-Cal’s six-month billing limit. Information about the billing limit is included in the Claim Submission and Timeliness Overview section of the Part 1, Medi-Cal Provider Manual.

Frequently Asked To see answers to questions related to the CHDP conversion to

Questions (FAQs) billing with national procedure codes on national CMS-1500 and

UB-04 claim forms, providers may refer to the Frequently Asked Questions on the “CHDP Provider Manual and Bulletins” web page of the Medi-Cal website.

School-Based Providers Billing and policy information for school-based providers is available in the CHDP Transition to National Standards: School-Based Services section of this manual. FAQs titled Frequently Asked Questions: School-Based Services are available on the “CHDP Provider Manual and Bulletins” web page of the Medi-Cal website.

Health Assessment CHDP/EPSDT health assessment codes are listed in the following

Codes chart.

Health Assessment These codes reflect the transition of CHDP health assessment

Periodicity periodicity to the American Academy of Pediatrics Bright Futures periodicity schedule and enhanced Bright Futures services.

Billing Providers submitting claims for health assessment services may refer to the following Medi-Cal provider manual sections for helpful billing information:

• Evaluation and Management: Refer to the “Preventive Medicine Services for Children” entry.

• For information about HCPCS code S3620 (newborn metabolic screening):

– Genetic Counseling and Screening

– Genetic Screening Billing Examples: CMS-1500

• Correct Coding Initiative: National. This section provides information about how the National Correct Coding Initiative (NCCI) may impact claims. NCCI edits are designed to control incorrect coding combinations or unlikely excessive services reported on claims with CPT and HCPCS Level II codes.

|CPT Code |Description |

|92551 |Screening text, pure tone, air only |

|92552 |Pure Tone audiometry (threshold); air only |

|96110 |Development screening (eg developmental milestone survey, speech |

| |and language delay screen), with scoring and documentation, per |

| |standardized instrument |

|96150 |Health and behavior assessment (eg, |

| |health-focused clinical interview, behavioral observations, |

| |psychophysiological monitoring, health-oriented questionnaires), |

| |each 15 minutes face-to-face with patient; initial assessment |

|96151 |reassessment |

|CPT Code |Description |

|99381 |Initial comprehensive preventive medicine evaluation and management|

| |of an individual including an age and gender appropriate history, |

| |examination, counseling/anticipatory guidance/risk fact reduction |

| |interventions, and the ordering of laboratory/diagnostic |

| |procedures, new patient; infant (age under 1 year) |

|99382 |early childhood (age 1 through 4 years, |

| |11 months) |

|99383 |late childhood (age 5 through 11 years, |

| |11 months) |

|99384 |adolescent (age 12 through 17 years, |

| |11 months) |

|99385 |18 through 20 years, 11 months |

|99391 |Periodic comprehensive preventive medicine |

| |re-evaluation and management of established patient; infant (age |

| |under 1 year) |

|99392 |early childhood (age 1 through 4 years, |

| |11 months) |

|99393 |late childhood (age 5 through 11 years, |

| |11 months) |

|99394 |adolescent (age 12 through 17 years, |

| |11 months) |

|99395 |18 through 20 years, 11 months |

Laboratory Codes CHDP/EPSDT laboratory codes are listed in the following chart.

Laboratory Periodicity These codes reflect the transition of CHDP laboratory periodicity to the American Academy of Pediatrics Bright Futures periodicity schedule and enhanced Bright Futures services.

Billing Providers submitting claims for laboratory services may refer to the following Medi-Cal provider manual sections for helpful billing information:

• CMS-1500 Completion: This section contains field by field instructions for entering information on the CMS-1500 claim form.

• UB-04 Completion: Outpatient Services. This section contains field by field instructions for entering information on the UB-04 claim form.

• Pathology: An Overview of Enrollment and Proficiency Testing Requirements. This section includes information about

Medi-Cal enrollment and proficiency requirements for laboratories and pathologists.

• Pathology: Billing and Modifiers. This section includes information about the billing and reimbursement of pathology services.

• Pathology Billing Example: CMS-1500. This section illustrates how to bill the same lab procedure more than once on the same day.

• Pathology Billing Examples: UB-04. This section illustrates how to bill the same lab procedure more than once on the same day and shows how an outpatient hospital bills for laboratory tests performed by an unaffiliated laboratory.

• Various other pathology related sections: The Medi-Cal provider manual contains pathology sections tailored to the type of lab services. For example, a provider billing for CPT code 82947 (blood glucose) will find information about that code in the Pathology: Chemistry section.

• Correct Coding Initiative: National. This section provides information about how the National Correct Coding Initiative (NCCI) may impact claims. NCCI edits are designed to control incorrect coding combinations or unlikely excessive services reported on claims with CPT and HCPCS Level II codes.

|CPT Code |Description |

|80061 |Lipid panel (dyslipidemia screening) |

|81000 |Urinalysis by dipstick or tablet reagent for bilirubin, glucose, |

| |hemoglobin, ketones, leukocytes, nitrite, pH, protein, specific |

| |gravity, urobilinogen, any number of these constituents; |

| |non-automated, with microscopy |

|81005 |Urinalysis, qualitative or semiquantitative, except immunoassays |

|82465 |Blood/Serum cholesterol |

|82947 |Glucose; quantitative, blood (except reagent strip) |

|83020 |Hemoglobin, fractionation and quantitation, electrophoresis (eg, |

| |A2, S, C, and/or F) |

|83655 |Lead |

|84030 |Phenylanine (PKU), blood |

|84478 |Triglycerides |

|85014 |Hematocrit (Hct) [red blood cell concentration measurement] |

|85018 |Hemoglobin (Hgb) measurement |

|86480 |Tuberculosis test, cell mediated immunity antigen response |

| |measurement; gamma interferon |

|86481 |enumeration of gamma interferon producing |

| |T-cells in cell suspension |

|86580 |Skin test, tuberculosis, intradermal |

|CPT Code |Description |

|86592 |Syphilis test, non-treponemal antibody; qualitative (eg, VDRL, RPR,|

| |ART) |

|86593 |Syphilis test, non-treponemal antibody; quantitative |

|86689 |HTLV or HIV antibody, confirmatory test (eg, Western Blot) |

|86696 |Herpes simplex, type 2 |

|86701 |HIV-1 antibody analysis |

|86703 |HIV-1 and HIV-2, single result |

|86780 |Treponema pallidum |

|86803 |Hepatitis C antibody |

|87070 |Culture, bacterial; any other source except urine, blood or stool, |

| |aerobic, with isolation and presumptive identification of isolates |

|87081 |Culture, presumptive, pathogenic organisms, screening only |

|87110 |Culture, chlamydia any source |

|87140 |Culture, typing; immuno-fluorescent method, each antiserum |

|87177 |Ova and parasites, direct smears, concentration and identification |

|87210 |Smear, primary source with interpretation; wet mount for infectious|

| |agents (eg, saline, India ink, KOH preps) |

|87255 |Virus isolation; including identification by |

| |non-immunologic method, other than by cytopathic effect (eg., virus|

| |specific enzymatic activity) |

|87389 |HIV-1 antigen(s), with HIV-1 and HIV-2 antibodies, single result |

|CPT Code |Description |

|87491 |Infectious agent detection by nucleic acid (DNA or RNA); Chlamydia |

| |trachomatis, amplified probe technique |

|87520 |hepatitis C, direct probe technique |

|87521 |hepatitis C, amplified probe technique |

|87522 |hepatitis C, quantification, includes reverse transcription when |

| |performed |

|87536 |HIV-1, quantification, includes reverse transcription when |

| |performed |

|87591 |Neisseria gonorrhoeae, amplified probe technique |

|87661 |Trichomonas vaginalis, amplified probe technique |

|87798 |not other specified; amplified probe technique, each organism |

|87801 |multiple organisms; amplified probe(s) technique |

|87808 |Infectious agent antigen detection by immunoassay with direct |

| |optical observation; trichomonas vaginalis |

|87902 |Infectious agent genotype analysis by nucleic acid (DNA or RNA); |

| |hepatitis C virus |

|88150 |Cytopathology, slides, cervical or vaginal; manual screening under |

| |physician supervision |

|HCPCS Code |Description |

|88174 |Cytopathology, cervical or vaginal (any reporting system), |

| |collected in preservative fluid, automated thin layer preparation; |

| |screening by automated system, under physician supervision |

|88175 |with screening by automated system and manual rescreening or |

| |review, under physician supervision |

|99000 |Handling and/or conveyance of specimen for transfer from the |

| |[physician’s] office to a laboratory |

| |Code 99000 includes any of the following: Single or multiple |

| |venipuncture, capillary puncture or arterial puncture with one or |

| |more tubes, centrifugation and serum separation, freezing, |

| |refrigeration, preparation for air transportation or other special |

| |handling procedures, supplies, registration of patient or specimen |

| |and third party billing. |

| |Instructions for billing CPT code 99000 are included in the |

| |Pathology: Blood Collection |

| |and Handling section in the appropriate Part 2, Medi-Cal provider |

| |manual. |

| |Counseling services associated with blood lead testing are included|

| |as part of a preventive medicine health assessment. |

|S3620 |Newborn metabolic screening panel, includes test kit, postage and |

| |the following tests: hemoglobin; electrophoresis; |

| |hydroxyprogesterone; 17-D; phenylamine (PKU); and thyroxine, total |

| |Note: Reimbursable once in a lifetime. |

Vaccine Codes CHDP/EPSDT vaccine codes are listed in the following chart.

Vaccine Periodicity These codes reflect the transition of CHDP vaccine periodicity to the American Academy of Pediatrics Bright Futures periodicity schedule and enhanced Bright Futures services.

Billing Providers submitting claims for vaccine services may refer to the following Medi-Cal provider manual sections for helpful billing information:

• Immunizations: Refer to the “Preventive Medicine Services for Children” entry.

• Vaccines For Children (VFC) Program

• Non-Physician Medical Practitioners (NMP)

• Correct Coding Initiative: National. This section provides information about how the National Correct Coding Initiative (NCCI) may impact claims. NCCI edits are designed to control incorrect coding combinations or unlikely excessive services reported on claims with CPT and HCPCS Level II codes.

|CPT Code |Description |

|90371 |Hepatitis B immune globulin (HBIg), human, intramuscular, non-VFC, |

| |purchased vaccine |

|90620 + SL |Meningococcal recombinant protein and outer membrane vesicle |

| |vaccine, serogroup B (MenB), 2 dose schedule, intramuscular, VFC |

|90620 |Non-VFC, purchased vaccine |

|90621 + SL |Meningococcal recombinant lipoprotein vaccine, serogroup B (MenB), |

| |3 dose schedule, intramuscular, VFC |

|90621 |Non-VFC, purchased vaccine |

|90630 + SL |Influenza virus vaccine, quadrivalent (IIV4), split virus, |

| |preservative free, intradermal, VFC |

|90630 |Non-VFC, purchased vaccine |

|90632 |Hepatitis A vaccine (HepA), adult dosage, intramuscular, non-VFC, |

| |purchased vaccine |

|CPT Code |Description |

|90633 + SL |Hepatitis A vaccine (HepA), pediatric/adolescent dosage, 2 dose |

| |schedule, intramuscular, VFC |

|90633 |Non-VFC, purchased vaccine |

|90636 |Hepatitis A and hepatitis B vaccine (HepA-Hep B), adult dosage, |

| |intramuscular, non-VFC, purchased vaccine |

|90644 + SL |Meningococcal conjugate vaccine, serogroups |

| |C & Y and Hemophilus influenza type b vaccine (Hib-MenCY), 4 dose |

| |schedule, intramuscular, VFC |

|90644 |Non-VFC, purchased vaccine |

|90647 + SL |Haemophilus influenza type b vaccine (Hib), |

| |PRP-OMP conjugate, 3 dose schedule, intramuscular, VFC |

|90647 |Non-VFC, purchased vaccine |

|90648 + SL |Hemophilus influenza type b vaccine (Hib), PRP-T conjugate, 4 dose |

| |schedule, intramuscular, VFC |

|90648 |Non-VFC, purchased vaccine |

|90649 + SL |Human Papillomavirus (HPV) vaccine, types 6, 11, 16, 18, |

| |quadrivalent (4vHPV), 3 dose schedule, intramuscular, VFC |

|90649 |Non-VFC, purchased vaccine |

|90650 + SL |Human Papillomavirus (HPV) vaccine, types 16, 18, bivalent (2vHPV),|

| |3 dose schedule, intramuscular, VFC |

|90650 |Non-VFC, purchased vaccine |

|90651 + SL |Human Papillomavirus vaccine types 6, 11, 16, 18, 31, 33, 45, 52, |

| |58, nonvalent (9vHPV), 3 dose schedule, intramuscular, VFC |

|90651 |Non-VFC, purchased vaccine |

|90655 + SL |Influenza virus vaccine, trivalent (IIV3), split virus, |

| |preservative free, intramuscular, VFC |

|90655 |Non-VFC, purchased vaccine |

|90656 + SL |Influenza virus vaccine, trivalent (IIV3), split virus, |

| |preservative free, intramuscular, VFC |

|90656 |Non-VFC, purchased vaccine |

|CPT Code |Description |

|90658 + SL |Influenza virus vaccine, trivalent (IIV3), split virus, |

| |intramuscular, VFC |

|90658 |Non-VFC, purchased vaccine |

|90660 + SL |Influenza virus vaccine, trivalent, live (LAIV3), intranasal, VFC |

|90660 |Non-VFC, purchased vaccine |

|90670 + SL |Pneumococcal conjugate vaccine, 13 valent (PCV13), intramuscular, |

| |VFC |

|90670 |Non-VFC, purchased vaccine |

|90673 |Influenza virus vaccine, trivalent (RIV3), derived from recombinant|

| |DNA, hemagglutinin (HA) protein only, preservative and antibiotic |

| |free, intramuscular, non-VFC, purchased vaccine |

|90674 + SL |Influenza virus vaccine, quadrivalent (ccIIV4), derived from cell |

| |cultures, subunit, preservative and antibiotic free, 0.5 ml dosage,|

| |intramuscular, VFC |

|90674 |Non-VFC, purchased vaccine |

|90675 |Rabies vaccine, intramuscular |

| |Note: For postexposure prophylaxis bites. |

|90680 + SL |Rotavirus vaccine, pentavalent (RV5), 3 dose schedule, live, oral, |

| |VFC |

|90680 |Non-VFC, purchased vaccine |

|90681 + SL |Rotavirus vaccine, human, attenuated (RV1), |

| |2 dose schedule, live, oral, VFC |

|90681 |Non-VFC, purchased vaccine |

|CPT Code |Description |

|90685 + SL |Influenza virus vaccine, quadrivalent (IIV4), split virus, |

| |preservative free, intramuscular, VFC |

|90685 |Non-VFC, purchased vaccine |

|90686 + SL |Influenza virus vaccine, quadrivalent (IIV4), split virus |

| |preservative free, intramuscular, VFC |

|90686 |Non-VFC, purchased vaccine |

|90688 + SL |Influenza virus vaccine, quadrivalent (IIV4), split virus, |

| |intramuscular, VFC |

|90688 |Non-VFC, purchased vaccine |

|90696 + SL |Diphtheria, tetanus toxoids, acellular pertussis vaccine and |

| |inactivated poliovirus vaccine |

| |(DTaP-IPV), intramuscular, VFC |

|90696 |Non-VFC, purchased vaccine |

|90698 + SL |Diphtheria, tetanus toxoids, acellular pertussis vaccine, |

| |Haemophilus influenza type B, and inactivated poliovirus vaccine |

| |(DTaP-IPV/Hib), intramuscular, VFC |

|90698 |Non-VFC, purchased vaccine |

|90700 + SL |Diphtheria, tetanus toxoids, and acellular pertussis vaccine |

| |(DTaP), intramuscular, VFC |

|90700 |Non-VFC, purchased vaccine |

|90702 |Diphtheria and tetanus toxoids adsorbed (DT), intramuscular, |

| |non-VFC, purchased vaccine |

|90707 +SL |Measles, mumps and rubella virus vaccine (MMR), live, subcutaneous,|

| |VFC |

|90707 |Non-VFC, purchased vaccine |

|90710 + SL |Measles, mumps, rubella, and varicella vaccine (MMRV), live, |

| |subcutaneous, VFC |

|90710 |Non-VFC, purchased vaccine |

|CPT Code |Description |

|90713 + SL |Poliovirus vaccine, inactivated, (IPV), subcutaneous or |

| |intramuscular, VFC |

|90713 |Non-VFC, purchased vaccine |

|90714 + SL |Tetanus and diphtheria toxoids adsorbed (Td), preservative free, |

| |intramuscular, VFC |

|90714 |Non-VFC, purchased vaccine |

|90715 + SL |Tetanus, diphtheria toxoids and acellular pertussis vaccine (Tdap),|

| |intramuscular, VFC |

|90715 + SE |State-supplied |

|90715 |Non-VFC, purchased vaccine |

|90716 + SL |Varicella virus vaccine (VAR), live, subcutaneous, VFC |

|90716 |Non-VFC, purchased vaccine |

|90723 + SL |Diphtheria, tetanus toxoids, acellular pertussis vaccine, hepatitis|

| |B, and inactivated poliovirus vaccine (DTaP-HepB-IPV), |

| |intramuscular, VFC |

|90723 |Non-VFC, purchased vaccine |

|90732 + SL |Pneumococcal polysaccharide vaccine, 23-valent (PPSV23), adult or |

| |immunosuppressed patient dosage, subcutaneous or intramuscular, VFC|

|90732 |Non-VFC, purchased vaccine |

|90734 + SL |Meningococcal conjugate vaccine, serogroups |

| |A, C, Y and W-135, quadrivalent (MenACWY) intramuscular, VFC |

|90734 |Non-VFC, purchased vaccine |

|90740 |Hepatitis B vaccine (HepB), dialysis or immunosuppressed patient |

| |dosage, 3 dose schedule, intramuscular, non-VFC, purchased vaccine |

|90743 + SL |Hepatitis B vaccine, (HepB), adolescent, 2 dose schedule, |

| |intramuscular, VFC |

|90743 |Non-VFC, purchased vaccine |

|90744 + SL |Hepatitis B vaccine, (HepB), pediatric/adolescent dosage, 3 dose |

| |schedule, intramuscular, VFC |

|90744 |Non-VFC, purchased vaccine |

|90746 |Hepatitis B vaccine (HepB), adult dosage, 3 dose schedule, |

| |intramuscular, non-VFC, purchased vaccine |

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