EPSDT is a valuable component of patient care for children under 21. Routine visits can identify potential medical concerns and also help develop the important relationships between children, their caregivers and the primary care provider (PCP).
DHS requires all Medicaid providers to perform screenings that meet national standards recognized by the American Academy of Pediatrics (AAP). Refer to the recent DHS bulletins for the latest updates. You can also refer to the current EPSDT Periodicity Schedule and Coding Matrix for guidelines.
The Bright Futures/American Academy of Pediatrics (AAP) developed a set of comprehensive health guidelines for well-child care, known as the “periodicity schedule.” It includes:
- Prevention: Scheduled immunizations; dentist visit at the first sign of a tooth and to establish a dental home at no later than 12 months of age; regular oral checkups (two each year), teeth cleanings, fluoride treatments and overall oral health.
- Growth and Development: Tracking how much a child has grown and developed in the time since their last visit; discussing the child’s milestones, social behaviors and learning with parents/guardians.
- Identify Concerns: Well-child visits are an opportunity to speak with parents about a wide variety of issues, including developmental, behavioral, sleeping, eating and relationships with other family members.
- Sick Visits: Determine if the condition, illness or injury that led to the sick visit impedes with the ability to complete a well-child visit and that the child is eligible for a well-child visit.
During a well-child visit, please document the following to assure all components of a well-child exam are met:
- A health history
- A physical development history
- A mental development history
- A physical exam
- Health education and anticipatory guidance
For weight assessment and counseling for nutrition and physical activity, please document the following:
- Weight assessment
- BMI percentile or BMI plotted on a growth chart for children age 3 to 16 years
- BMI percentile or BMI value for adolescents ages 16 to 17 years
- Nutrition counseling
- Discussion of nutritional habits
- Checklist indicating nutrition was discussed
- Referral for nutritional education
- Anticipatory guidance for nutrition
- Weight or obesity counseling
- Activity counseling
- Discussion of physical activity habits
- Checklist indicating physical activity was discussed
- Referral for physical activity
- Anticipatory guidance for physical activity
- Documentation that information on physical activity was provided to patient and/or their family
- Weight or obesity counseling
Medicaid providers may bill for vaccine counseling-only visits when Medicaid beneficiaries under age 21 and/or their parent or caregiver receive counseling about any pediatric vaccines covered under the EPSDT benefit from a qualified health care professional who is authorized to administer pediatric vaccines, but no pediatric vaccine is administered. Click here to read the latest bulletin from DHS.
Vaccine counseling-only visits may be provided in addition to another service (including a SARS-CoV-2 vaccine administration, or a COVD-19 vaccine counseling-only visit) and may be provided via telemedicine. MA Providers may not bill vaccine counseling-only visits in addition to a complete EPSDT screen.