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Periodic Visit vs. Catch-Up Visit vs. Interperiodic Screening of EPSDT

Senior Staff from Medicaid asked the Georgia Academy to share this information to our membership:

On Time EPSDT Periodic Visit Procedure Codes

Georgia Medicaid Early Periodic Screening Diagnostic and Treatment (EPSDT) program follows the AAP/Bright Futures Periodicity schedule.  To provide a well-child exam per the schedule, the child need only be the age of the visit to receive the service.   Please add the 25 modifier to the EPSDT periodic visit code billed when a vaccine is administered during the periodic visit.

For example: the one month visit must occur before the child turns one month old.  However, all children aged 3 years of age and under are allowed to have catch-up visits to get caught up with the schedule.

The EPSDT Periodic visit allows for one well-child exam per age bracket based on the Bright Futures Periodicity schedule.

For example: if the child has a well exam on 9/29/14 and has a birthday on 2/15/15, the child may receive the appropriate well child exam for their age.  They do not need to wait until 9/29/15 to be seen again.

Catch-Up EPSDT Visit Procedure Codes

These catch up visits must include the HA modifier appended to the visit code along with the EP modifier to identify the visit as a catch-up visit.  Please add the 25 modifier to the EPSDT periodic visit code billed when a vaccine is administered during the periodic visit.

For example: In a case where the child was seen for their 4 month visit, is now 7 months but missed their 6 month visit, you would report the preventive health code for the 6 month visit and append the HA modifier to identify this as the catch-up visit.  All components of the catch-up visit that is being performed must be documented in the child’s chart.

The EPSDT Catch-up visit allows for one well-child catch-up exam per age bracket based on the Bright Futures Periodicity schedule for members 3years and younger.

Interperiodic EPSDT Visit Procedure Codes

Interperiodic screening, vision, hearing, and dental services can be performed when it is medically necessary to determine the existence of suspected physical or mental illnesses or conditions. Interperiodic EPSDT visits are used for Medicaideligible and PeachCare for Kids®eligible children who are up to date on their periodic exams, but have been referred because of a suspected problem to a qualified health provider by a health, developmental, or educational professional who comes into contact with the child outside of the formal health care system or a need identified by the provider or parent. These screens are billed with an E&M code and must have the EP modifier with the appropriate diagnosis code.

For example: A 6 year old child receives a well-child exam on schedule on their birthday.  Several months later the child’s teacher suspects a problem with the child’s hearing, however the child is not yet due for a periodic well-child screen.  The child can be referred by the teacher for an interperiodic hearing screen.

Children in state custody (foster care) may require more frequent EPSDT services. Effective March 3, 2014, all children in state custody were transitioned to Medicaid managed care.

Additional information regarding EPSDT visits is available on the DCH web portal (www.mmis.georgia.gov/portal/) under the Provider Information TAB – Provider Manuals – Health Check Services.