Annual Early and Periodic Screening, Diagnostic and Treatment Services (EPSDT) Participation Report

2700.4 Instructions for Completing Form CMS-416: Annual Early and Periodic
Screening, Diagnostic, and Treatment (EPSDT) Participation Report
Effective for reporting period federal fiscal year 2016 (October 1, 2015 through September 30,
2016), with submission of Form CMS-416 by April 1, 2017.
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 individuals under the age of
21 (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 state’s attainment of its participation and screening goals.
Participation and screening goals are two different standards against which EPSDT performance
(or penetration) 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 decisions 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 state that supervises or administers a medical
assistance program under Title XIX of the Social Security Act must report annually on form
CMS-416. These 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. Each state is required to
collect encounter data (or other data as necessary) from managed care and prospective payment
entities in sufficient detail to provide the information required by this report. You may contact
your CMS regional office EPSDT specialist if you need technical assistance in completing this
form.
C. Effective Date -- The form CMS-416’s initial 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 is not changed from the previous version, but these associated revised instructions must be
used for the reporting period federal fiscal year 2016, beginning October 1, 2015 through
September 30, 2016, for data due to CMS on the form CMS-416 on or before April 1, 2017.
D. Submittal Procedure -- States should submit the annual form CMS-416 and your state
medical and dental periodicity schedules 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.medicaid.gov/Medicaid-CHIP-Program-Information/By-Topics/Benefits/Early-andPeriodicScreening-Diagnostic-and-Treatment.html.
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2700.4 Instructions for Completing Form CMS-416: Annual Early and Periodic
Screening, Diagnostic, and Treatment (EPSDT) Participation Report
Effective for reporting period federal fiscal year 2016 (October 1, 2015 through September 30,
2016), with submission of Form CMS-416 by April 1, 2017.
States may not modify the electronic form or submit variations of the form; it must be submitted
as downloaded from Medicaid.gov: https://www.medicaid.gov/medicaid-chip-programinformation/by-topics/benefits/downloads/form-416.zip.
States that have data limitations or that have made program changes during a reporting period
that significantly impact data results, such as a change in the periodicity schedule to follow the
most recent version of the American Academy of Pediatrics’ Bright Futures™ guidelines, may
include a note, not to exceed 50 words, with the cover correspondence accompanying their
CMS-416 submissions. This information will be included in a separate footnotes page on the
Medicaid.gov website, accompanying the national and state data reports.
E. Detailed Instructions -- Enter your state name and the federal fiscal year as
directed below. For each of the following line items, report total counts by the age groups
indicated and by whether categorically or medically needy (described below). In cases where
calculations are necessary, perform separate calculations for the total column and for each age
group. You must enter a number in each line and column of data requested even if the
number is “0.”
Important Reporting Requirements:
x Report age based upon the individual’s age as of September 30 of the reporting year.
x Report all data in the age category reflecting the individual’s age at the end of the federal
fiscal year even if the individual received services in two age categories. For example, if
a child turned age 3 on September 1st, but had a 30-month well-child visit in March, the
30-month visit would be counted in the age 3-5 category.
x The population for which the data is reported on Lines 3a – Line 14 are children from Line
1b, that is unduplicated counts of individuals enrolled for at least 90 continuous days
during the reporting period.
x The objective of CMS-416 reporting is to capture on each line all services that were
provided, regardless of payment status and unduplicated by child. Report data based on
visits during which a service was provided to an eligible individual during the reporting
period, according to the instructions for each line, regardless of whether the unduplicated
claim was paid, unpaid, or denied. States must be able to ensure that once a service is
reported on the CMS-416, it is not reported again in any reporting period if payment
status changes, for example, from unpaid to paid.
State -- Enter the name of your state using the two character state code in upper case format.
Fiscal Year -- Enter the federal fiscal year (FFY) being reported in YYYY format.
Note: The federal fiscal year is from October 1 through September 30. For example, FFY 2016
is October 1, 2015 through September 30, 2016.

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2700.4 Instructions for Completing Form CMS-416: Annual Early and Periodic
Screening, Diagnostic, and Treatment (EPSDT) Participation Report
Effective for reporting period federal fiscal year 2016 (October 1, 2015 through September 30,
2016), with submission of Form CMS-416 by April 1, 2017.
Categorically Needy (CN) and Medically Needy (MN) Eligibility Groups -- For purposes of
reporting data on the CMS-416, children should be reported as medically needy (with or without
spend down) or categorically needy (not medically needy) based on their status as of September
30th of the reporting federal fiscal year. If they weren’t enrolled in Medicaid on September 30th
because their eligibility was terminated prior to that date, their status should be reported as of
the date they were terminated.
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 and by basis of eligibility as of September 30. “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, and that a claim for a service that was provided is only counted once, whether
the claim was unpaid, paid, or denied. Include all individuals regardless of whether the services
are provided under fee-for-service, prospective payment, managed care, or other payment
arrangements. States should determine the basis of eligibility consistent with the instructions
from the Transformed Medicaid Statistical Information System (T-MSIS) Data Dictionary, in
consultation with state Medicaid eligibility officials, if needed. 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:
-

Medically needy individuals under the age of 21 if your state does not provide EPSDT
services for the medically needy group;
Individuals eligible for Medicaid only under a Section 1115 waiver as part of an expanded
population for which the full complement of EPSDT services is not available;

-

Undocumented aliens who are eligible only for emergency Medicaid services;

-

Children in separate state CHIP programs; or

-

Other groups of individuals under age 21 who are eligible only for limited services as part of
their Medicaid eligibility (for example, pregnancy-related services).

Line 1b -- Total Individuals Eligible for EPSDT for 90 Continuous Days -- Enter the total
unduplicated number of individuals under the age of 21 from Line 1a who have been
continuously enrolled in Medicaid or a CHIP Medicaid expansion program for at least 90
continuous days in the federal fiscal year and determined to be eligible for EPSDT services,
distributed by age and by basis of eligibility. For example, if an individual was enrolled from
October 1 to November 30 and again from August 1 to September 30, the individual would not
be considered eligible for 90 continuous days in the federal fiscal year.
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2700.4 Instructions for Completing Form CMS-416: Annual Early and Periodic
Screening, Diagnostic, and Treatment (EPSDT) Participation Report
Effective for reporting period federal fiscal year 2016 (October 1, 2015 through September 30,
2016), with submission of Form CMS-416 by April 1, 2017.
Line 1c -- Total Individuals Eligible for EPSDT under a CHIP Medicaid Expansion
Program -- Enter the total unduplicated 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 if they are
enrolled in a CHIP Medicaid expansion 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 medical periodicity schedule. (Example: If your state’s periodicity schedule requires
screening at 12, 15, 18 and 24 months, the number 4 should be entered in the 1-2 age group
column.) Make no entry in the total column.
Note: As noted above, use the state’s current medical periodicity schedule to complete Line
2a and submit a copy of the state’s current medical and dental periodicity schedules to
CMS with your CMS-416 submission.
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. An individual child should only be
counted once in the age group the individual is in as of September 30. Include the total months
of eligibility in the age category where the individual is reported, even if the individual had
months of eligibility in two age categories during the reporting period. For example, if an
individual was eligible for 12 months, from October 1 st through September 30 th, but turned
age 3 on August 1 st, all 12 months of eligibility would be counted in the age 3-5 category.
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 remained eligible for EPSDT services during the reporting year.
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
individual under age 21 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.

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2700.4 Instructions for Completing Form CMS-416: Annual Early and Periodic
Screening, Diagnostic, and Treatment (EPSDT) Participation Report
Effective for reporting period federal fiscal year 2016 (October 1, 2015 through September 30,
2016), with submission of Form CMS-416 by April 1, 2017.
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 from Line 1b under fee-for-service, prospective payment,
managed care or other payment arrangements, based on an unduplicated paid, unpaid, or denied
claim.
Note: States may use the CPT codes listed below as a proxy for reporting these initial or
periodic 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 the enrolled
individual 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 an individual 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.) Report all
screening data in the age category reflecting the individual’s age at the end of the federal
fiscal year even if the individual received services in two age categories. For example, if a
child turned age 3 on September 1 st, but had a 30-month well-child visit the previous
March, the 30-month visit would be counted in the age 3-5 age category. Use the codes
below or other documentation of such services furnished under capitated or prospective payment
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

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2700.4 Instructions for Completing Form CMS-416: Annual Early and Periodic
Screening, Diagnostic, and Treatment (EPSDT) Participation Report
Effective for reporting period federal fiscal year 2016 (October 1, 2015 through September 30,
2016), with submission of Form CMS-416 by April 1, 2017.
99463 Initial hospital or birthing center care of normal newborn infant (admitted/discharged
same date) *These CPT codes do not require use of a “Z” code.
OR
CPT-4 codes: Evaluation and Management Codes **
99202-99205 New Patient
99213-99215 Established Patient
** These CPT-4 codes must be used in conjunction with the following Z codes:
Z76.2 (Encounter for health supervision and care of other healthy infant and child),
Z00.121 (Encounter for routine child health examination with abnormal findings),
Z00.129 (Encounter for routine child health examination without abnormal findings),
Z00.110 (Health examination for newborn under 8 days old) and
Z00.111 (Health examination for newborn 8 to 28 days old) and/or
Z00.00-01 (Encounter for general adult medical examination without/with abnormal findings),
and/or
Z02.0 (Encounter for examination for admission to educational institution),
Z02.1 (Encounter or pre-employment examination),
Z02.2 (Encounter for examination for admission to residential institution),
Z02.3 (Encounter for examination for recruitment to armed forces),
Z02.4 (Encounter for examination for driving license),
Z02.5 (Encounter for examination for participation in sport),
Z02.6 (Encounter for insurance purposes),
Z02.81 (Encounter for paternity testing),
Z02.82 (Encounter for adoption services),
Z02.83 (Encounter for blood-alcohol and blood-drug test),
Z02.89 (Encounter for other administrative examinations),
Z00.8 (Encounter for other general examination),
Z00.6 (Encounter for examination for normal comparison and control in clinical research
program),
Z00.5 (Encounter for examination of potential donor of organ and tissue),
Z00.70 (Encounter for examination for period of delayed growth in childhood without abnormal
findings),
Z00.71 Encounter for examination for period of delayed growth in childhood with abnormal
findings)
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 received the number of initial and
periodic screening services required by the state's periodicity schedule, prorated by the
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2700.4 Instructions for Completing Form CMS-416: Annual Early and Periodic
Screening, Diagnostic, and Treatment (EPSDT) Participation Report
Effective for reporting period federal fiscal year 2016 (October 1, 2015 through September 30,
2016), with submission of Form CMS-416 by April 1, 2017.
proportion of the year for which they were EPSDT eligible. Note: In calculating Line 7, if the
number exceeds 100 percent, enter 1.0 in this field.
Line 8 -- Total Eligibles Who Should Receive at Least One Initial or Periodic Screen -- The
number of individuals who should receive at least one initial or periodic screen is dependent on
each state's periodicity schedule. Use the following calculations:
1.

Look at the number entered in Line 4 of this form. If that number is greater than 1, use the
number 1. If the number on 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 on 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 number of individuals under age 21 with at least 90 days continuous enrollment
within the federal fiscal year from Line 1b, including those in fee-for-service, prospective
payment, managed care, and other payment arrangements, who received at least one documented
initial or periodic screen during the year, based on an unduplicated paid, unpaid, or denied
claim. 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.
Line 11 -- Total Eligibles Referred for Corrective Treatment -- Enter the unduplicated
number of individuals from Line 1b, including those in fee-for-service, prospective payment,
managed care, and other payment arrangements, who had a paid, unpaid, or denied claim for a
visit/service that occurred within 90 days from the date of an initial or periodic screening within
the reporting period, where none of the following is included as part of the claim: capitation
payments, administrative fees, transportation services, nursing home services, ICF-MR services,
HIPP payments, inpatient services, dental care, home health services, long-term care services, or
pharmacy services. Include only those instances where both the screening and the visit/service
for which the subsequent claim was processed occurred within the reporting period.
Dental Lines 12a – 12g
NOTE A: For purposes of reporting the information on dental and oral health services in Lines
12a – 12g, “unduplicated” means that an individual may be counted only once on each line.
However, an individual may be counted on two or more lines. For example, individuals under
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2700.4 Instructions for Completing Form CMS-416: Annual Early and Periodic
Screening, Diagnostic, and Treatment (EPSDT) Participation Report
Effective for reporting period federal fiscal year 2016 (October 1, 2015 through September 30,
2016), with submission of Form CMS-416 by April 1, 2017.
the age of 21 may be 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 qualified health care practitioner or by a dental
professional who is neither a dentist nor providing services under the supervision of a dentist.
These numbers should be inclusive of services reimbursed directly by the state under fee-forservice, or under managed care, prospective payment, or any other payment arrangements, or
through any other health or dental plans that contract with the state to provide services to
Medicaid or CHIP Medicaid expansion enrollees, based on an unduplicated paid, unpaid, or
denied claim. For each dental line (Lines 12a – 12g), the universe of appropriate procedure
codes to report is provided in the instructions below (HCPCS or equivalent CDT or CPT codes).
NOTE B: “Dental services” refers to services provided by or under the supervision of a dentist.
Supervision is a spectrum and includes, for example, direct, indirect, general, collaborative or
public health supervision as provided in the state’s dental practice act. The most common
examples of this are dentists themselves, and dental hygienists who are working under the
supervision of dentists. “Oral health services” refers to services provided by any qualified
health care practitioner or by a dental professional who is neither a dentist nor providing services
under the supervision of a dentist. The most common examples of this are primary care medical
providers and dental hygienists or dental therapists who are not working under the supervision
of a dentist.
IMPORTANT: Each dental line, Lines 12a-12g, collects information related to a type of dental
service, a type of oral health service, or both. As described in Note B, this distinction relates to
the type of provider who delivered the service. The instructions for each dental line specify the
provider type(s) relevant to that line. It is important to pay close attention to this part of the
instructions, and to report on each line only services delivered (rendered) by the type(s) of
providers specified for that line. Rendering provider type can usually be discerned from the
claim form. For example: a child who received a fluoride varnish treatment (D1208) from a
dentist should be reported on Line 12b, preventive dental service; a child who received a
fluoride varnish treatment from a physician should be reported on Line 12f, oral health service.
Line 12a -- Total Eligibles Receiving Any Dental Services -- Enter the unduplicated number
of individuals under the age of 21 with at least 90 continuous days of enrollment during the
federal fiscal year from Line 1b who received at least one dental service by or under the
supervision of a dentist as defined by HCPCS codes D0100 - D9999 (or equivalent CDT codes
D0100 - D9999 or equivalent CPT codes), based on an unduplicated paid, unpaid, or denied
claim. All individuals reported on Lines 12b through 12e should be reported on this line, though
an individual should be counted only once on this line regardless of how many dental services
he or she received during the reporting period. See Notes A and B, above.
Line 12b -- Total Eligibles Receiving Preventive Dental Services -- Enter the unduplicated
number of individuals under the age of 21 with at least 90 continuous days of enrollment during
the federal fiscal year from Line 1b who received at least one preventive dental service by or
under the supervision of a dentist as defined by HCPCS codes D1000 - D1999 (or equivalent
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2700.4 Instructions for Completing Form CMS-416: Annual Early and Periodic
Screening, Diagnostic, and Treatment (EPSDT) Participation Report
Effective for reporting period federal fiscal year 2016 (October 1, 2015 through September 30,
2016), with submission of Form CMS-416 by April 1, 2017.
CDT codes D1000 - D1999 or equivalent CPT codes, that is, only those CPT codes that are for
preventive dental services and only if provided by or under the supervision of a dentist), based
on an unduplicated paid, unpaid, or denied claim. See Notes A and B, above.
Line 12c -- Total Eligibles Receiving Dental Treatment Services -- Enter the unduplicated
number of individuals under the age of 21 with at least 90 continuous days of enrollment during
the federal fiscal year from Line 1b who received at least one dental treatment service by or
under the supervision of a dentist, as defined by HCPCS codes D2000 - D9999 (or equivalent
CDT codes D2000 – D9999 or equivalent CPT codes (please refer to the CPT-to-CDT
crosswalk available on Medicaid.gov) that include only those CPT codes that involve
periodontics, maxillofacial prosthetics, implants, oral and maxillofacial surgery, orthodontics,
adjunctive general services, and only if provided by or under the supervision of a dentist, based
on an unduplicated paid, unpaid, or denied claim. See Notes A and B, above.
Line 12d -- Total Eligibles Receiving a Sealant on a Permanent Molar Tooth -- Enter the
unduplicated number of individuals with at least 90 continuous days of enrollment during the
federal fiscal year from Line 1b, in the appropriate age categories of 6-9 and 10-14, who
received a sealant on a permanent molar tooth, as defined by HCPCS code D1351 (or equivalent
CDT code D1351), based on an unduplicated paid, unpaid, or denied claim. For this line,
include sealants placed by any dental professional for whom placing a sealant is within his or
her scope of practice. Permanent molars are teeth numbered 2, 3, 14, 15, 18, 19, 30, 31, and
additionally, for those states that cover sealants on third molars, also known as wisdom teeth, the
teeth numbered 1, 16, 17, 32. See Notes A and B, above.
Line 12e -- Total Eligibles Receiving Diagnostic Dental Services -- Enter the unduplicated
number of individuals under the age of 21 with at least 90 continuous days of enrollment during
the federal fiscal year from Line 1b who received at least one diagnostic dental service by or
under the supervision of a dentist, as defined by HCPCS codes D0100-D0999 (or equivalent
CDT codes D0100 –D0999 or equivalent CPT codes, that is, only those CPT codes that are for
diagnostic dental services, and only if provided by or under the supervision of a dentist, based
on an unduplicated paid, unpaid, or denied claim. See Notes A and B, above.
12f -- Total Eligibles Receiving Oral Health Services Provided by a Non-Dentist Provider -Enter the unduplicated number of individuals under the age of 21 with at least 90 continuous
days of enrollment during the federal fiscal year from Line 1b who received at least one oral
health service, as defined by HCPCS or CDT codes, or equivalent CPT codes, that is, only those
CPT codes that are for oral health services, and only if provided by a non-dentist provider, based
on an unduplicated paid, unpaid, or denied claim. A “non-dentist provider” is any qualified
health care practitioner who is neither a dentist nor providing services under the supervision of a
dentist. NOTE: Due to the variance in state practice acts and reimbursement policies, some
states may not have data to report on this line. See Notes A and B, above.

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2700.4 Instructions for Completing Form CMS-416: Annual Early and Periodic
Screening, Diagnostic, and Treatment (EPSDT) Participation Report
Effective for reporting period federal fiscal year 2016 (October 1, 2015 through September 30,
2016), with submission of Form CMS-416 by April 1, 2017.
12g -- Total Eligibles Receiving any Dental or Oral Health Service -- Enter the unduplicated
number of individuals under the age of 21 with at least 90 continuous days of enrollment during
the federal fiscal year from Line 1b who received either a “dental service” by or under the
supervision of a dentist or an “oral health service” by a qualified health care practitioner who is
neither a dentist nor providing services under the supervision of a dentist, based on an
unduplicated paid, unpaid, or denied claim. All individuals reported in Lines 12a through 12f
should also be reported on this line, though an individual should be counted only once on this
line regardless of how many dental services and oral health services he or she received during
the reporting period, that is, no matter how many times they appear in lines 12a through 12f.
See Notes A and B, above.
Line 13 -- Total Eligibles Enrolled in Managed Care -- This number is reported for
informational purposes only. Enter the total unduplicated number of individuals from Line 1b
who are enrolled in any type of managed care arrangement, whether medical or dental or both, at
any time during the reporting year. This includes any capitated arrangements such as managed
care entities or individuals assigned to a primary care provider or primary care case manager,
regardless of whether reimbursement to the provider is fee-for-service or capitated.
Line 14 -- Total Number of Screening Blood Lead Tests -- Enter the total number of
screening blood lead tests furnished to eligible individuals under the age of six from Line 1b
(that is, with at least 90 continuous days of enrollment during the federal fiscal year) under feefor-service, prospective payment, managed care, or any other payment arrangements, based on
an unduplicated paid, unpaid, or denied claim. 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-10 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
has elected to use this performance measure.
When responding to the question on the Form CMS-416, “Which methodology was used for
calculating the total number of screening blood lead tests on Line 14,” you should identify the
methodology used by your state for the calculation:
1. CPT Code 83655 within certain diagnoses codes (Method I)
2. HEDIS (Method II)
3. Combination Methodology (Method III)

1

Health Effectiveness Data and Information Set

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2700.4 Instructions for Completing Form CMS-416: Annual Early and Periodic
Screening, Diagnostic, and Treatment (EPSDT) Participation Report
Effective for reporting period federal fiscal year 2016 (October 1, 2015 through September 30,
2016), with submission of Form CMS-416 by April 1, 2017.
NOTE: On a claim, CPT code 83655 is the procedure code for blood lead level tests. States
should report instances of CPT code 83655 which are accompanied by a diagnosis code that
would indicate a person is receiving a screening blood lead test, such as a well-child check (for
example Z00.121 or Z00.129), exposure to lead (Z77.011), or encounter for screening for
disorder due to exposure to contaminants (Z13.88), with or without secondary codes. CPT
83655, when accompanied by a diagnosis code of T56.0X1A–4A, T56.0X1D-4D, T56.0X1S-4S
or a code in the M1A.1 series would generally indicate that the person receiving the blood lead
test had already been diagnosed with, or was being treated for, lead poisoning. This would not
be considered a screening test. States should not report CPT codes 83655 when accompanied by
a diagnosis code of T56.0X1A–4A, T56.0X1D-4D, T56.0X1S-4S or a code in the M1A.1 series.
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 (Expires: TBD). The
time required to complete this information collection is estimated to average 29 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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