CMS-416 Instructions 8-23-10 tracked

2700.4 Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) Report

(Form CMS-416)

A. Purpose -- The annual EPSDT report (form CMS-416) provides basic information on participation in the Medicaid child health program. The information is used to assess the effectiveness of State EPSDT programs in terms of the number of children (by age group and basis of Medicaid eligibility) who are provided child health screening services, referred for corrective treatment, and receiving dental services. Child health screening services are defined for purposes of reporting on this form as initial or periodic screens required to be provided according to a state’s screening periodicity schedule.

The completed report demonstrates the sState’s attainment of its participation and screening goals. Participant and screening goals are two different standards against which EPSDT participation is measured on the form CMS-416. From the completed reports, trend patterns and projections are developed for the nation and for individual states or geographic areas, from which decision and recommendations can be made to ensure that eligible children are given the best possible health care. The information is also used to respond to congressional and public inquiries.

B. Reporting Requirement -- Each sState that supervises or administers a medical assistance program under Title XIX of the Social Security Act must report annually on form HCFACMS-416. This data must include services provided under both fee-for-service and capitated managed care arrangements. Each State is required to collect encounter data (or other data as necessary) from managed care entities in sufficient detail to provide the information required by this report. You may contact your HCFACMS regional office EPSDT specialist if you need technical assistance in completing this form.

C. Effective Date -- The form CMS-416 effective date was April 1, 1990. The first full fiscal year for which the form was effective began October 1, 1990. This version of the form must be used effective fiscal year 2010 for data due on or after April 1, 2011.

D. Submittal Procedure – States should submit the annual form CMS–416 and your sState periodicity schedule electronically to the CMS central office via the EPSDT mailbox at [email protected] not later than April 1 of the year following the end of the Federal fiscal year being reported. The electronic form and instructions are available on the CMS website at http://www.cms.hhs.gov/MedicaidEarlyPeriodicScrn/03_StateAgencyResponsibilities.asp#TopOfPage. States may not modify the electronic form. It must be submitted as downloaded. A “hard copy” submittal to CMS is no longer required.

E. Detailed Instructions -- For each of the following line items, report total counts by the age groups indicated and by whether categorically and medically needy. In cases where calculations are necessary, perform separate calculations for the total column and each age group. Report age based upon the child’s age as of September 30.

State. Enter the name of your sState using two character State code in upper case format.

Fiscal Year. Enter the Federal fiscal year (FY) being reported in YYYY format. .

Line 1a – Total Individuals Eligible for EPSDT – Enter the total unduplicated number of individuals under the age of 21 enrolled in Medicaid or a Children’s Health Insurance Program (CHIP) Medicaid expansion program determined to be eligible for EPSDT services, distributed by age (based on age as of September 30) and by basis of eligibility. “Unduplicated” means that an eligible person is reported only once although he/she may have had more than one period of eligibility during the year. Include all individuals regardless of whether the services are provided under fee-for-service arrangements or managed care arrangements. States should determine the basis of eligibility consistent with the instructions for form CMS-2082. Medicaid-eligible individuals under age 21 are considered eligible for EPSDT services regardless of whether they have been informed about the availability of EPSDT services or whether they accept EPSDT services at the time of informing. Individuals for whom third-party liability is available should also be counted in the number.

Do not include in this count the following groups of individuals: 1) medically needy individuals under the age of 21 if you do not provide EPSDT services for the medically needy population;

2) individuals eligible for Medicaid only under a §1115 waiver as part of an expanded population for which the full complement of EPSDT services is not available; 3) undocumented aliens who are eligible only for emergency Medicaid services; 4) children in separate State CHIP programs; or 5) other groups of individuals under age

21 who are eligible only for limited services as part of their Medicaid eligibility (i.e., pregnancy-related services).

Line 1b -- Total Individuals Eligible for EPSDT for 90 Continuous Days -- Enter the total unduplicated number of all individuals under the age of 21 determined to be from line 1a who have been continuously enrolled in Medicaid or a CHIP Medicaid expansion program for at least 90 days and determined to be eligible for EPSDT services, distributed by age and by basis of Medicaid eligibility. “Unduplicated” means that an eligible person is reported only once although he/she may have had more than one period of eligibility during the year. Include all individuals regardless of whether the services are provided under the fee-for-service arrangements or under managed care arrangements. States should determine basis of eligibility consistent with the instructions for form CMS-2082. Medicaid-eligible individuals under age 21 are considered eligible for EPSDT services regardless of whether they have been informed about the availability of EPSDT services or whether they accept EPSDT services at the time of informing. Individuals for whom third-party liability is available should also be counted in the number.

Do not include in this count the following groups of individuals: 1) medically needy individuals under the age of 21 if you do not provide EPSDT services for the medically needy population;

2) individuals eligible for Medicaid only under a §1115 waiver as part of an expanded population for which the full complement of EPSDT services is not available; 3) undocumented aliens who are eligible only for emergency Medicaid services; or 4) other groups of individuals under age

21 who are eligible only for limited services as part of their Medicaid eligibility (i.e., pregnancy-related services).

Line 1c – Total Individuals Eligible for EPSDT under a CHIP Medicaid Expansion Program – Enter the number of individuals included in line 1b who are under the age of 21 and eligible for EPSDT services as part of a CHIP Medicaid expansion program. For children who have been eligible for EPSDT under both Medicaid and a CHIP Medicaid expansion program during the report year, include the child on this line of they are enrolled in CHIP as of September 30.

Line 2a - State Periodicity Schedule -- Enter the number of initial or periodic general health screenings required to be provided to individuals within the age group specified according to the State’s periodicity schedule. (Example: If your State periodicity schedule requires screening at 12, 18 and 24 months, the number 3 should be entered in the 1-2 age group column.) Make no entry in the total column.

Note: Use the sState’s most recent periodicity schedule and attach a copy to the completed report for submittal to CMS.

Line 2b - Number of Years in Age Group -- Make no entries on this line. This is a fixed number reflecting the number of years included in each age group.

Line 2c - Annualized State Periodicity Schedule -- Divide line 2a by the number in line 2b. Enter the quotient. This is the number of screenings expected to be received by an individual in each age group in one year. Make no entry in the total column.

Line 3a - Total Months of Eligibility -- Enter the total months of eligibility for the individuals in each age group in line 1b during the reporting year. A child should only be counted once in the age group the child is in as of September 30. However, a child may have months of eligibility in two different age groups. Months of eligibility should be counted in the age group the child belonged to during the majority of that month. For example, if a child was eligible from June through October but turned 3 on August 25th, the child would be counted on line 1b one time in the 3-5 age group (age as of September 30^th). Three months of eligibility (June through August) are counted in the 1-2 age group and two months (September and October) are counted in the 3-5 age group.

Line 3b - Average Period of Eligibility -- Divide line 3a by the number in line 1b. Divide that number by 12 and enter the quotient. This number represents the portion of the year that individuals remain Medicaid eligible during the reporting year. , regardless of whether eligibility was maintained continuously.

Line 4 - Expected Number of Screenings per Eligible -- Multiply line 2c by line 3b. Enter the product. This number reflects the expected number of initial or periodic screenings per child per year based on the number required by the State-specific periodicity schedule and the average period of eligibility. Make no entries in the total column.

Line 5 - Expected Number of Screenings -- Multiply line 4 by line 1b. Enter the product. This reflects the total number of initial or periodic screenings expected to be provided to the eligible individuals in Line 1b.

Line 6 - Total Screens Received - Enter the total number of initial or periodic screens furnished to eligible individuals on line 1b under either fee-for-service or managed care arrangements based on date of service. .

Note: States may use the CPT codes listed below as a proxy for reporting these screens. Use of these proxy codes is for reporting purposes only. States must continue to ensure that all five age-appropriate elements of an EPSDT screen, as defined by law, are provided to EPSDT recipients.

This number should not reflect sick visits or episodic visits provided to children unless an initial or periodic screen was also performed during the visit. However, it may reflect a screen outside of the normal State periodicity schedule that is used as a "catch-up" EPSDT screening. (A catch-up EPSDT screening is defined as a complete screening that is provided to bring a child up-to-date with the State's screening periodicity schedule. For example, a child who did not receive a periodic screen at age five visits a provider at age 5 years and 4 months. The provider may use that visit to provide a complete age appropriate screening and the screening may be counted on the CMS-416.) Use Report data reflecting date of service within the fiscal year for such screening services or other documentation of such services furnished under capitated arrangements. The codes to be used to document the receipt of an initial or periodic screen are as follows:

CPT-4 codes: Preventive Medicine Services *

99381 New Patient under one year
99382 New Patient (ages 1-4 years)
99383 New Patient (ages 5-11 years)
99384 New Patient (ages 12-17 years)
99385 New Patient (ages 18-39 years)
99391 Established patient under one year
99392 Established patient (ages 1-4 years)
99393 Established patient (ages 5-11years)
99394 Established patient (ages 12-17 years)
99395 Established patient (ages 18-39 years)
99460 Initial hospital or birthing center care for normal newborn infant

99461 Initial care in other than a hospital or birthing center for normal newborn infant

99463 Initial hospital or birthing center care of normal newborn infant (admitted/

discharged same date)

*These CPT codes do not require use of a “V” code.

or

CPT-4 codes: Evaluation and Management Codes **

99202-99205 New Patient
99213-99215 Established Patient

NOTE:** These CPT-4 codes must be used in conjunction with codes V20-V20.2, V20.31 and V20.32 and/or V70.0 and/or V70.3-70.9.

Line 7 - Screening Ratio - Divide the actual number of initial and periodic screening services received (line 6) by the expected number of initial and periodic screening services (line 5). This ratio indicates the extent to which EPSDT eligibles receive the number of initial and periodic screening services required by the sState's periodicity schedule, adjusted prorated by the proportion of the year for which they are Medicaid eligible.

Note: In calculating Line 7, if the number exceeds 100 percent, enter 1.0 in this field. note that Line 6 should not exceed Line 5. The ratio cannot be over 100%.

Line 8 - Total Eligibles Who Should Receive at Least One Initial or Periodic Screen - The number of persons who should receive at least one initial or periodic screen is dependent on each sState's periodicity schedule. Use the following calculations:

1. Look at the number entered in line 4 of this form. I, if that number is greater than 1, use the number 1. If the number ion line 4 is less than or equal to 1, use the number in line 4. (This procedure will eliminate situations where more than one visit is expected in any age group in a year.).

2. Multiply the number from calculation 1 above by the number in line 1b of the form. Enter the product on line 8. Line 9 - Total Eligibles Receiving at Least One Initial or Periodic Screen - Enter the unduplicated count of individuals, including those enrolled in managed care arrangements, who received at least one documented initial or periodic screen during the year. Refer to codes in line 6.

Line 9 - Total Eligibles Receiving at Least One Initial or Periodic Screen - Enter the unduplicated count of individuals from line 1b, including those enrolled in managed care arrangements, who received at least one documented initial or periodic screen during the year. Refer to codes in line 6.

Line 10 - Participant Ratio - Divide line 9 by line 8. Enter the quotient. This ratio indicates the extent to which eligibles are receiving any initial and periodic screening services during the year.

Note: In calculating Line 10, if this number exceeds 100 percent, enter 1.0 in this field. note that Line 9 should not exceed Line 8. The ratio cannot be over 100%.

Line 11 - Total Eligibles Referred for Corrective Treatment - Enter the unduplicated number of individuals on line 1.b, including those in managed care arrangements, who, as the result of at least one health problem identified during an initial or periodic screening service, including vision and hearing screenings, were scheduled referred for another appointment with the screening provider or referred to another provider for further needed diagnostic or treatment services. This element does not include correction of health problems during the course of a screening examination.

Line 12a - Total Eligibles Receiving Any Dental Services - Enter the unduplicated number of children receiving any at least one dental service by or under the supervision of a dentist as defined by HCPCS codes D0100 - D9999 (ADACDT codes D0100 - D9999). "Unduplicated" means that each child is counted only once for purposes of this line even if multiple services were received.

Line 12b - Total Eligibles Receiving Preventive Dental Services - Enter the unduplicated number of children receiving at least one a preventive dental service by or under the supervision of a dentist as defined by HCPCS codes D1000 - D1999 -+

(ADACDT codes D1000 - D1999). "Unduplicated" means that each child is counted only once even if more than one preventive service was provided.

Line 12c - Total Eligibles Receiving Dental Treatment Services - Enter the unduplicated number of children receiving at least one treatment services by or under the supervision of a dentist, as defined by HCPCS codes D2000 - D9999 (ADACDT codes D2000 - 09999). Unduplicated means that each child is counted only once even if more than one treatment service was provided.

Line 12d – Total Eligibles Receiving a Sealant on a Permanent Molar Tooth -- Enter the unduplicated number of children in the age categories of 6-9 and 10-14 who received a sealant on a permanent molar tooth regardless of whether the sealant was provided by a dentist or a non-dentist, as defined by HCPCS code D1351 (CDT code D1351).

Line 12e – Total Eligibles Receiving Diagnostic Dental Services – Enter the unduplicated number of children receiving at least one diagnostic dental service by or under the supervision of a dentist, as defined by HCPCS codes D0120 – D0180 (CDT codes D0120 – D0180).

12f – Total Eligibles Receiving Oral Health Services Provided by a Non-Dentist Provider -- Enter the unduplicated number of children receiving at least one oral health service as defined a HCPCS or CDT code furnished by a licensed provider that is not a dentist. For example, a pediatrician that applies a fluoride varnish or an independently practicing dental hygienist not under the supervision of a dentist furnishing a prophylaxis. These are only examples and are not intended to limit your reporting. NOTE: Due to the variance in State Practice Acts some States may not have data to report on this line.

12g – Total Eligibles Receiving any Dental or Oral Health Service -- Enter the unduplicated number of children who received a dental service by or under the supervision of a dentist or an oral health service by a non-dentist. A child should only be counted once on this line even if the child received a dental service and an oral health service.

NOTES FOR LINE 12 DATA: For purposes of reporting the information on dental services in Lines 12a – 12g, use the total eligible individuals from line 1b. “Unduplicated” means that a child may only be counted once for each line of data. A child may be counted on two or more lines. For example, a child is counted once on line 12a for receiving any dental service, counted again on line 12c for receiving a dental treatment service and, if applicable, counted again on line 12f for receiving an oral health service by a non-dentist. These numbers should reflect services provided under both fee-for-service and managed care arrangements and through any other private health plans that contract with the State. We refer to “dental services” when referring to services provided by or under the supervision of a dentist. We refer to “oral health services” when the service is not provided by or under the supervision of a dentist.

Lines 12b and 12c do not equal to total services reflected on line 12a.

NOTE: For purposes of reporting the information on dental services, "unduplicated" means that each child is counted once for each line of data requested. For example, a child is counted once on line 12a for receiving any dental service and counted again for line 12b and/or 12c if the child received a preventive and/or treatment dental service. These numbers reflect services received in fee-for-service and managed care arrangements.

Line 13 - Total Eligibles Enrolled in Managed Care - This number is reported for informational purposes only. This number represents all individuals eligible for EPSDT services in your State who are enrolled in any type of managed care arrangement at any time during the reporting year. It includes any capitated arrangements such as health maintenance organizations or individuals assigned to a primary care provider or primary care case manager regardless of whether reimbursement is fee-for-service or capitated. Include these individuals in the total number of eligibles on line 1a and b, as appropriate; include the number of initial or periodic screenings provided to these individuals in lines 6 and 8 for purposes of determining the State's screening and participation rates. The number of individuals referred for corrective treatment and receiving dental services are reflected in lines 11 and 12, respectively.

Line 14 - Total Number of Screening Blood Lead Tests - Enter the total number of screening blood lead tests furnished to eligible individuals under the fee-for-service or managed care arrangements. Do not count blood lead tests done on persons who have been diagnosed or treated for lead poisoning. Do not make entries in the shaded columns. Follow-up blood tests performed on individuals who have been diagnosed with or are being treated for lead poisoning should not be counted. You may use one of two methods, or a combination of these methods, to calculate the number of blood lead screenings provided:

1. Count the number of times CPT code 83655 (“lead”) for a blood lead test is reported within certain ICD-9-CM codes (see Note below); or

2. You may include data collected from use of the HEDIS®¹ measure developed by the National Committee for Quality Assurance to report blood lead screenings if your State had elected to use this performance measure.

To report number of screening blood lead tests do the following: Count the number of times CPT code 83655 ("lead") or any State-specific (local) codes used for a blood lead tests reported with any ICD-9-CM except with diagnosis codes 984 (.0-.9)("Toxic Effects of Lead and Its Compounds"), E861.5 ("Accidental Poisoning by Petroleum Products, Other Solvents and Their Vapors NEC: Lead Paints"), and E866.0 ("Accidental Poisoning by Other Unspecified Solid and Liquid Substances: Lead and Its Compounds and Fumes"). These specific ICD-9-CM diagnosis codes are used to identify people who are lead poisoned. Blood lead tests done in these individuals do not count as a screening blood lead test.

NOTE: On a claim, CPT code 83655 is the procedure code used to identify that a blood lead test was performed. CPT code 83655, when accompanied on the claim by a diagnosis code of V15.86 (exposure to lead) or V82.5) (special screening for other conditions such as a screening for heavy metal poisoning) may be used to identify a person receiving a screening blood lead test. However, a claim in which the procedure code 83655 is accompanied by a diagnosis code of 984(.0-.9) (toxic effect of lead and its compounds) or e861.6 (accidental poisoning by lead paints) would generally indicate that the person receiving the blood lead test had already been diagnosed or was being treated for lead poisoning and should not be counted.

F. Disclosure Statement - According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-0354. The time required to complete this information collection is estimated to average 28 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop: C4-26-05, Baltimore, Maryland 21244-1850. 

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