Pediatric Care Information for Providers

One of our primary goals is to ensure that all our members, and especially our youngest members, receive the preventive care they need from their providers.

Well-Child Visits

We will continually provide materials and resources to help our participating providers complete Child and Adolescent Well-Child Visits for their patients in our Medicaid and CHIP plans.

Well-Child Visit Timeline

Your patients are eligible for a well-child visit once every year, even if 365 days have not yet passed since their last well-child visit in the prior calendar year. Providers will be reimbursed as long as it is a new calendar year.

For Example:
A Well-Child Visit takes place on January 1, 2023, and the next visit takes place on December 30, 2023. This is NOT reimbursable.
A Well-Child Visit takes place on February 1, 2023, and the next visit takes place on January 15, 2024. This is reimbursable.

Combined Sick Visits and Well-Child Visits

Your office can submit claims for both a sick visit and a preventive well-child visit for services provided on the same day, provided that the Modifier 25 is added to the claim if appropriate.

Please note the following coding reminders/clarifications:

•  As necessary, modifier 25 should be billed in the first modifier position with the applicable E&M code for the allowed sick visit. If modifier 25 is not billed in the first position, the sick visit may be denied.

•  Providers can bill the age-appropriate preventive CPT codes (99381-99385, 99391, 99392- 99395), and 99461) and a separate identifiable E&M code with the modifier 25, when appropriate.

•  Well-child visits can be reported with the following diagnosis codes: Z00.00, Z00.01, Z00.5, Z00.8, Z00.110, Z00.111, Z00.121, Z00.129, Z02.0-Z02.6, Z02.71, Z02.82, Z76.1, and Z76.2.

•  Appropriate diagnosis codes must be billed for the respective well-child visit and sick visit.

 

Note: Providers must have proper medical record documentation to support the CPT codes and the E/M codes billed. This documentation should be able to be separated into two distinct notes that will support both E/M services billed for the visit.

Examples of Proper Coding

a. New Patient E&M Visit

Well-child Visit Diagnosis Code (in the primary position): Z00.121
Well-child Visit E&M Code: 99382
Allowable Sick Visits with Modifier 25 (when billing with a well-child visit): 99202-25

b. Established Patient E&M Visit

Well-child Visit Diagnosis Code (in the primary position): Z00.121
Well-child Visit E&M Code: 99392
Allowable Sick Visits with Modifier 25 (when billing with a well-child visit): 99212-25

c. Established Patient E&M Visit

Well-child Visit Diagnosis Code (in the primary position): Z00.129
Well-child Visit E&M Code: 99394
Allowable Sick Visits with Modifier 25 (when billing with a well-child visit): 99213-25

Quality Care
Clinical and Quality Resources

We have created a Comprehensive Pediatric Education Kit that includes the following resources:

Programs and Initiatives

Jefferson Health Plans currently makes monthly automated phone calls for the following:

Pediatric Birthday Calls (monthly) — outreach calls are made 60 days before the member’s birthday to remind them to schedule their appointment and reminds members what screenings they may need based on their age.

Pediatric Overdue PCP Visits (monthly) — outreach calls to remind families/members that they are overdue for a PCP visit.

Pediatric Overdue Lead Screening (quarterly) — call reminder to families/caregivers that members are overdue for lead screening.

Asthma (quarterly for Medicaid, monthly for CHIP) — calls are made to the asthma population regardless of age to remind them about potential symptom triggers, medications as needed, scheduling PCP visits and getting the flu shot.

Quality Outreach

Our members/your patients may receive outreach from one of the following resources to assist them with appointment scheduling, preventive health reminders and/or care coordination:

Internal Quality Campaigns
Jefferson Health Plans has a team of Quality Outreach Representatives who contact members proactively to help close care gaps and help them schedule appointments as needed.

Clark Resources:
A third-party call center that contracts with Jefferson Health Plans to engage members who need preventive dental services and help them schedule a visit.

Carenet
A third-party vendor that contracts with Jefferson Health Plans to do telephonic outreach to members to help schedule visits or remind them to close care gaps.

Healthy Measures
A third-party vendor that contracts with Jefferson Health Plans to do in-home visits and provide services at health events. Healthy Measures can perform lead screenings for our youngest members.

Block Scheduling Events
Jefferson Health Plans can assist with outreach and scheduling for collaborative events at the PCP office. Please contact Khalif Moore (khalif.moore@jeffersonhealthplans.com) if you are interested.

 

Referrals for Case Management

If you have members who you feel may benefit from case management services, please refer them to our Clinical Care Management team.

How to refer a member for case management:

  1. Contact us at 215-845-4797.
  2. Email ClinicalConnections@jeffersonhealthplans.com using the Clinical Programs Referral Form.
  3. Fax the Clinical Programs Referral Form to 215-845-4181.
Depression Screening

Screening for Depression (ages 12-17)

Every member age 12–17 years old should receive an annual depression screening administered by a clinician who can bill a qualifying CMS encounter.

This is monitored by the CDF measure which tracks members ages 12-17 who receive a standardized depression screening during the measurement year at any outpatient visit, and if positive, have a documented follow-up plan on the qualified encounter date or within 2 days after.

Screenings must be completed on the encounter date or up to 14 days prior. 

Follow-Up Plan

An acceptable follow-up plan must be evidence-based and documented the same day or within 2 days. Acceptable examples: 

  • Behavioral Health Referral (psychology, psychiatry, therapy, counseling)
  • Medication initiation/adjustment (when clinically appropriate and after sufficient diagnostic evaluation)
  • Other therapeutic interventions depression interventions
  • Psychiatric Evaluation 
  • Crisis intervention/safety planning
  • TiPS: Telephonic Psychiatric Consultation Service Program

Important: High Risk results (e.g., self-harm) require urgent action based on clinical judgement.

Not acceptable as follow-up:

  • Another depression screen
  • Suicide risk assessment alone (clinically appropriate, but does not count)

Use CMS-acceptible G-codes to close the quality gap:

Scenario

Code

Meaning

Positive screen + follow-up plan

G8431

Positive screen AND follow-up plan documented

Negative screen

G8510

Negative screen, no follow-up required

Bipolar Diagnosis

G9717

Documentation stating the patient has had a diagnosis of bipolar disorder
Measure Exclusions:

Prior diagnosis of bipolar disorder - G9717

What Counts as a Qualifying Encounter?

Any visit billed with approved CMS CPT/HCPCS encounter codes such as: 

  • Office visits (99202–99205, 99212–99215) 
  • Behavioral health visits (90791, 90792, 90832, 90834, 90837) 
  • Telehealth visits (allowed under CMS telehealth policy) 
  • Preventive visits (G0402, G0438, G0439) 
Depression Screening Requirements

Use a standardized, validated, age-appropriate tool

Document tool name, score, result, and interpretation

If positive, document a follow-up the same day or within 2 days.

Positive Screen Examples:
High scores
Suicidal thoughts
Provider discretion

Resources

The following tools may be helpful to use before, during or after a well visit:

Well Child Visits

CDC’s Developmental Milestones – available in English and Spanish

Developmental Milestone Resources for WIC Programs – available in English and Spanish

Penn State Extension: ABCs of Growing Healthy Kids – available in English and Spanish