09212016_PRA Crosswalk 2016 CMS-416 instructions.pdf

Annual Early and Periodic Screening, Diagnostic and Treatment Services (EPSDT) Participation Report (CMS-416)


OMB: 0938-0354

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Change to Instructions and Form for 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.
(No changes are made to the Form CMS-416)

Type of Change

Rationale for Change

C. Effective

Effective date of revised instructions

Change in instructions with new effective date

D. Detailed
- General

Added helpful notes about reporting

Clarification of how to submit the form and format.

Clarify bullet to explain the data for
Lines 3a – 14 (page 2), which now
reads: 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 continues days
during the reporting period.

Clarified reporting requirements bullet points

Clarify definition/language for
Categorically Needy and Medically
Needy Eligibility Groups (page 2) to:
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.

Page 1 of 5

Clarified the definition of Categorically Needy and
Medically Needy

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D. Dental lines
Notes A and B

Page 2 of 5

Type of Change

Rationale for Change

Added to Note A (page 7): 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).

This additional language is intended to assist the
states in understanding that each dental line contains
specific instructions and appropriate procedures
codes to utilize.

Added under Note B (page 7):
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

Explained that it is necessary to review the provider
type to fulfill reporting.

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D. Line 12c

Type of Change
Removed reference to table 1

Total Eligibles
Receiving Dental
D. Line 14
Total Number of
Screening Blood

Revised instructions:
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 fee-for-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:
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
You may include
data collected from use of
the HEDIS® 1 measure
developed by the National
Committee for Quality
Assurance to report blood

1 Health Effectiveness Data and Information Set
Page 3 of 5

Rationale for Change
The Table 1 reference was a carryover from a
previous version and is not needed.

With this change, will be asking states to identify the
type of methodology used for reporting (count of CPT
code, HEDIS or combination).
Included additional clarifications on how to report
using ICD-10 diagnosis codes.
Removed reference to Z57.8 as this was an
occupational code that would not be applicable.

Crosswalk for Paperwork Reduction Act
lead screenings if your
state had elected to use
this performance measure.
You should identify, when
submitting your Form CMS-416 to
CMS, which of these methods you
used to report this data. If a
combination method was used,
please clarify how the sources
were combined.
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 wellchild 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.

Page 4 of 5

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Header and

Updated with version and date of
change to reflect Version 4, as of
August 19, 2016.
Removed reference in the header
that stated, “Pending
Implementation of ICD-10”.


Form CMS-416

Page 5 of 5

Provide the date for the most recent version of the

ICD-10 has been implemented.

Removed the Crosswalk of ICD-9
and ICD-10 code formatting and
reference in the instructions.

Integrated ICD-10 codes into the instructions for Line
14 and Line 6, which removed the need to include an

Deleted the Appendices.

Removed the Crosswalk because the migration to
ICD-10 should have occurred for most states and we
want to encourage the use of ICD-10 codes when
possible. We can address any questions on an
individual state basis.

Added Line 14b

Added Line 14b for providing more insight on the
methodology used in reporting lead screening

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