Early and Periodic Screening and Diagnostic Treatment (EPSDT)
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).
The Pennsylvania Department of Human Services (DHS) requires all Medical Assistance 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:
Refer to the current EPSDT Periodicity Schedule and Coding Matrix for guidelines.
Bright Futures (CHIP)
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.
Providers are encouraged to download the complete Recommendations for Preventive Pediatric Health Care guidelines (updated April 2023) or go directly to the Bright Futures website. Providers may also access handouts for parents specific to the age of the child by visiting https://www.aap.org/en/practice-management/bright-futures/bright-futures-materials-and-tools/bright-futures-tool-and-resource-kit/
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
Childhood and Adolescent Immunizations
DHS Policy: Vaccine Counseling Only Visits for Beneficiaries Under 21 - September 20, 2022
MA providers may bill for vaccine counseling only visits when MA beneficiaries under age 21 and/or their parent or caregiver receive counseling about any pediatric vaccines covered under the Early and Periodic Screening, Diagnostic and Treatment EPSDT benefit from a qualified health care professional who is authorized to administer pediatric vaccines, but no pediatric vaccine is administered.
The following coverage rules apply to this benefit:
- 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.
DHS Policy: COVID-19 Vaccine Counseling Only Visits for Beneficiaries Under 21 – September 23, 2022
MA will cover, without cost-sharing, COVID-19 vaccine counseling provided to MA beneficiaries under the age of 21 and/or their parent/caregiver when a SARS-CoV-2 vaccine is not administered. Providers in both the FFS and managed care delivery systems may bill for COVID19 vaccine counseling only visits for MA beneficiaries under the age of 21 when provided by a qualified health professional who is authorized under state law to administer the SARS CoV-2 vaccine. Vaccine counseling may be provided to MA beneficiaries and/or their parent or caregiver as appropriate. Providers may bill for vaccine counseling when a SARS-CoV-2 vaccine is not administered using the CPT code and modifier listed in this bulletin along with the Fee Schedule.
Please educate families about the need for immunizations. Providers may refer to our Preventive Care Guidelines or the resources listed below for additional information.