Crosswalk for Instructions

Crosswalk for Paperwork Reduction Act
Change to Instructions Only for Form CMS-416: Annual Early and Periodic Screening, Diagnostic, and Treatment (EPSDT)
Participation Report
Changes are effective on 10/1/2014 for the federal fiscal year 2015 reporting period
(No changes are made to the Form CMS-416)
Section

Type of Change

Rational for Change

B. Reporting
Requirements

Expanded language on data reporting to state
explicitly that data must include services
reimbursed directly by the state under fee-forservice, or through managed care, prospective
payment, or other payment arrangement or
through any other health or dental plans that
contract with the state.

While this requirement was implicit in previous instructions, the
expanded language is intended to clarify and reinforce reporting
requirements to report services to all eligibles, regardless of the
health care setting.

C. Effective Date

Effective date of revised instructions

Change in instructions with new effective date (10/1/2014).

D. Detailed
Instructions - General

Added helpful notes about reporting,
including reporting data on visits based
only on adjudicated, or paid, claims.

Clarification of how to count individuals in the age ranges.

Gave an example of a federal fiscal year.

To help states identify the exact reporting period.

D. Line 1
Total Individuals
Eligible for EPSDT

Page 1 of 8

Added explicit language that data must
include visits reimbursed directly by the state
under fee-for-service, or through managed
care, prospective payment, or other payment
arrangement or through any other health or
dental plans that contract with the state.

While this requirement was implicit in previous instructions, the
expanded language is intended to clarify and reinforce reporting
requirements to report services to all eligibles, regardless of the
health care setting.

Crosswalk for Paperwork Reduction Act
Section
D. Line 6
Total Screens Rec’d
D. Line 11
Total Eligibles
Referred for
Corrective treatment
D. Dental lines
Notes A and B

Type of Change
ICD-9 codes changed to ICD-10 codes,
with each identified V diagnostic code
changed to the corresponding new Z code.

Code change is required by HIPAA, effective 10/1/2014.

Limits the count of individuals referred
for corrective action to those with a visit
90 days after an initial or periodic screen.

There is no code to capture a referral for corrective treatment.
This change attempts to capture referrals by assuming that a visit
occurring within 90 days of an initial or periodic screen is based
on a referral for corrective treatment.

Explanatory notes for the dental lines are
moved from the end of the dental lines
instructions to the beginning of the dental
lines into Note A and Note B:

This additional language is intended to assist the states in
understanding how to count individuals for each of the dental
lines.

Note A.) Explains how to count
individuals across the dental lines;
Note B.) Explains the meaning of the
terms “dental services” and” oral health
services” for reporting purposes.
A new Table 1 is identified Note B. For
each dental line, the universe of
appropriate procedure codes to report is
provided in the instructions (HCPCS and
CDT) or on the attached Table 1
(Crosswalk of CPT to CDT Codes).
CPT = Current Procedural Terminology
CDT = Code on Dental Procedures and
Nomenclature
Page 2 of 8

Rational for Change

We clarify the term, “dental services” to explain supervision
(“under the supervision of a dentist”) as a spectrum that includes,
for example, direct, indirect, general, collaborative or public
health supervision as provided in the dental practice act.
We clarify the term “oral health services” to refer to services
provided by any health care practitioner working within their
scope of practice and who is neither a dentist nor providing
services under the supervision of a dentist, in lines 12f and 12g.
Note B and the referenced Table 1 Crosswalk of CPT to CDT
Codes are intended to assist states in identifying the correct CDT
code for reporting dental and oral health services on the CMS416 report.

Crosswalk for Paperwork Reduction Act
Section
D. Line 12a
Total Eligibles
Receiving Any
Dental Services

Type of Change
Inserts in each dental line, the instruction
that was previously only stated in a global
note, to only count individuals enrolled
for at least 90 continuous days.

Rational for Change

Clarifies how to count a child for line 12a.

Reminds states to only count a child once
on this line, based on line 1b.

D. Line 12b
Total Eligibles
Receiving Preventive
Dental Services

Refers to notes A and B and Table 1.
Inserts in each dental line, the instruction
that was previously only stated in a global
note, to only count individuals enrolled
for at least 90 continuous days.

Clarifies how to count a child for line 12b.

Reminds states to only count a child once
on this line, based on line 1b.

D. Line 12c
Total Eligibles
Receiving Dental
Treatment Services

Refers to notes A and B and Table 1.
Inserts in each dental line, the instruction
that was previously only stated in a global
note, to only count individuals enrolled
for at least 90 continuous days.
Reminds states to only count a child once
on this line, based on line 1b.
Refers to notes A and B and Table 1.

Page 3 of 8

Clarifies how to count a child for line 12c.

Crosswalk for Paperwork Reduction Act

Section
D. Line 12d

Type of Change
Inserts in each dental line, the instruction
that was previously only stated in a global
note, to only count individuals enrolled
for at least 90 continuous days.

Total Eligibles
Receiving a Sealant
on a Permanent Molar
Reminds states to only count a child once
Tooth
on this line, based on line 1b.

Rational for Change

Clarifies how to count a child for line 12d.

Refers to notes A and B.
To assist states in programming data systems to capture data
Added language to include sealants placed
correctly.
by any dental professional for whom
placing a sealant is within his or her scope
of practice.

D. Line 12e
Total Eligibles
Receiving Diagnostic
Dental Services

Added the teeth numbers for permanent
molars, including third molars.
Inserts in each dental line, the instruction
that was previously only stated in a global
note, to only count individuals enrolled
for at least 90 continuous days.
Reminds states to only count a child once
on this line, based on line 1b.
Refers to notes A and B and Table 1.

Page 4 of 8

Clarifies how to count a child for line 12e.

Crosswalk for Paperwork Reduction Act

Section
D. Line 12f
Total Eligibles
Receiving Oral
Health Services
Provided by a NonDentist Provider

Type of Change
Inserts in each dental line, the instruction
that was previously only stated in a global
note, to only count individuals enrolled
for at least 90 continuous days.

Clarifies how to count a child for line 12f.

Reminds states to only count a child once
on this line, based on line 1b.
Expands usable codes to include CPT
(medical) and related CDT (dental) codes.
Defines a “non-dentist provider” as any
health care practitioner working within
their scope of practice who is neither a
dentist nor providing services under the
supervision of a dentist who is neither a
dentist nor providing services under the
supervision of a dentist.
Adds 2 new dental codes for diagnostic
services that do not specify a dentist as the
rendering provider, for which states can
report on this line for services performed
by a non-dental professional or by a dental
professional not under the supervision of a
dentist. These codes are:
D0190 – Screening of a patient
D0191 – Assessment of a patient
Refers to Notes A and B.

Page 5 of 8

Rational for Change

This additional information offers states that collect this data an
opportunity to demonstrate this activity on the CMS-416, and
may offer an opportunity to non-dentist providers to bill the state
for their services.

Crosswalk for Paperwork Reduction Act

Section
D. line 12g
Total Eligibles
Receiving any Dental
or Oral Health
Service

Type of Change
Inserts language in each dental line, the
instruction that was previously only stated
in a global note, to only count individuals
enrolled for at least 90 continuous days.
Reminds states to only count a child once
on this line, based on line 1b.
Explains that an oral health service by a
non-dentist is a health care practitioner
working within their scope of practice
who is neither a dentist nor providing
services under the supervision of a dentist
who is neither a dentist nor providing
services under the supervision of a dentist.

Rational for Change

Clarifies how to count a child for line 12g.
This additional information offers states that collect this data an
opportunity to demonstrate this activity on the CMS-416, and
may offer an opportunity to non-dentist providers to bill the state
for their services.

Refers to notes A and B.
D. Line 13
Total Eligibles
Enrolled in Managed
Care

Changes language to only pull data from
line 1b and removes reference to line 1a,
in order to only count individuals enrolled
for at least 90 continuous days.
Language is edited for clarification.
Some wording on the related lines is
removed because it is unnecessary.

Page 6 of 8

Language is edited for clarification purposes only.

Crosswalk for Paperwork Reduction Act

Section
D. Line 14
Total Number of
Screening Blood Test

Type of Change
Changes language to pull data from line
1b and removes reference to line 1a, to
only count individuals enrolled for at least
90 continuous days.
Added explicit language that data must
include visits reimbursed directly by the state
under fee-for-service, or through managed
care, prospective payment, or other payment
arrangement or through any other health or
dental plans that contract with the state.

Table 1

Crosswalk of CPT
Codes to CDT Codes
for Lines 12a-12g

ICD-9 codes changed to ICD-10 codes,
with each identified V diagnostic code
changed to the corresponding new Z code.
Crosswalk of CPT codes to CDT codes
for Lines 12a – 12g of the Form CMS416.
CPT means Code on Dental Procedures
and Nomenclature. These are the dental
procedure codes to be used in collecting
data for the CMS-416 report on the dental
lines
CPT means Current Procedural
Terminology. These are the medical
procedure codes to be used in collecting
data for the CMS-416 report.

Page 7 of 8

Rational for Change
Clarification purposes only.

This requirement was implicit in previous instructions, but
language was added to clarify and reinforce reporting
requirements to report services to all eligibles, regardless of the
health care setting.

Code change is required by HIPAA.
Table 1 was added to the instructions to assist states in
identifying medical codes related to specific dental codes so that
they can capture all allowable data for the services provided.

Crosswalk for Paperwork Reduction Act
Section

Type of Change

Rational for Change

Corrected introductory language for each
section under CPT codes column to
conform with CMS-416 instructions.

Corrected introductory language for each section under CPT
codes column to conform with CMS-416 instructions.

Changed the clarification of the term “oral
health services” to refer to services
provided by a health care practitioner
working within their scope of practice and
who is neither a dentist nor providing
services under the supervision of a dentist,
in lines 12f and 12g.

This additional information offers states that collect this data an
opportunity to demonstrate this activity on the CMS-416, and
may offer an opportunity to non-dentist providers to bill the state
for their services.

Self-explanatory.
Table 2
Crosswalk of ICD-9
Codes to ICD-10
Codes for Line 14

Corrected misspelling of mandibular
Crosswalk of ICD-9 to ICD-10 Codes for
Line 14 of the Form CMS-416. Line 14
captures the total number of screening
blood lead tests.
Added ICD-9 code 984.0 Toxic effect of
inorganic lead compounds with crosswalk
to ICD-10 code T56.0X1A Toxic effect of
lead and its compounds, accidental
(unintentional), initial encounter

Page 8 of 8

Table 2 was added to the instructions to assist states in
converting from ICD-9 codes to ICD-10 codes. There are many
more ICD-10 codes that relate to the ICD-9 codes, so this will
help states to determine the most appropriate codes for reporting
purposes.
To incorporate all codes that states may use for reporting
purposes on the CMS-416.