MICHIGAN DEPARTMENT OF COMMUNITY HEALTH

NOTICE OF PROPOSED POLICY

Public Act 280 of 1939, as amended, and consultation guidelines for Medicaid policy provide an opportunity to review proposed changes in Medicaid policies and procedures. Please review the policy summary and the attached materials that describe the specific changes being proposed. Let us know why you support the change or oppose the change. Submit your comments to the analyst by the due date specified. Your comments must be received by the due date to be considered for the final policy bulletin. Thank you for participating in the consultation process.

Director, Program Policy Division Bureau of Medicaid Policy and Health System Innovation

Project Number:

1328-EPSDT

Comments Due:

August 23, 2013

Proposed Effective Date:

October 1, 2013

Mail Comments to:

Matthew Hambleton Bureau of Medicaid Policy and Health System Innovation Medical Services Administration PO Box 30479 Lansing, MI 48909 (517) 335-5130 Fax Number: (517) 335-5136 E-mail Address: HambletonM@michigan.gov

Telephone Number:

Policy Subject: Addition of Early and Periodic Screening, Diagnosis and Treatment Chapter to the Medicaid Provider Manual

Affected Programs: Medicaid

Distribution: All Providers

Policy Summary: EPSDT policy currently exists as a section within the Practitioner chapter and will attain its own chapter with several updates. The layout of the EPSDT chapter will follow the order of the American Academy of Pediatrics Bright Futures "Recommendations for Preventive Pediatric Health Care" schedule guidelines. The development of the EPSDT chapter offers providers a consolidated location for subject matter and enables the provider to locate information more efficiently.

Purpose: This bulletin serves as notification regarding the implementation of a new Early and Periodic Screening, Diagnosis and Treatment (EPSDT) Chapter to the Medicaid Provider Manual. Federal regulations require state Medicaid programs to offer EPSDT to eligible Medicaid beneficiaries under 21 years of age. The intent of EPSDT is to find and treat health concerns early so they do not become more serious and costly. EPSDT visits and follow-up services are covered by Medicaid.
Public Comment Cover (07/11)

Michigan Department of Community Health Medical Services A dministration

Distribution: Issued: Subject:

All Providers September 1, 2013 (Proposed) Addition of Early and Periodic Screening, Diagnosis and Treatment Chapter to the Medicaid Provider Manual October 1, 2013 (Proposed) Medicaid

Effective: Programs Affected:

The purpose of this bulletin is to announce the addition of an Early and Periodic Screening, Diagnosis and Treatment (EPSDT) Chapter to the Medicaid Provider Manual. Federal regulations require state Medicaid programs to offer EPSDT to eligible Medicaid beneficiaries under 21 years of age. The intent of EPSDT is to find and treat health concerns early so they do not become more serious and costly. EPSDT visits and follow-up services are covered by Medicaid. EPSDT policy currently exists as a section within the Practitioner chapter and will attain its own chapter with several updates. The layout of the EPSDT chapter will follow the order of the American Academy of Pediatrics Bright Futures "Recommendations for Preventive Pediatric Health Care" schedule guidelines. The development of the EPSDT chapter offers providers a consolidated location for subject matter and enables the provider to locate information more efficiently.

Medicaid Provider Manual Draft

EARLY AND PERIODIC SCREENING, DIAGNOSIS AND TREATMENT
TABLE OF CONTENTS
Section 1 General Information ..........................................................................................................1 Section 2 AAP Periodicity Schedule and Components ..........................................................................1 Section 3 History and Well Child Visits ...............................................................................................1 Section 4 Measurements ...................................................................................................................2 4.1 Length/Height and Weight ..........................................................................................................2 4.2 Head Circumference ...................................................................................................................2 4.3 Weight for Length ......................................................................................................................2 4.4 Body Mass Index........................................................................................................................2 4.5 Blood Pressure ...........................................................................................................................2 Section 5 Sensory Screening .............................................................................................................3 5.1 Vision ........................................................................................................................................3 5.1.A. Preschool ...........................................................................................................................3 5.1.B. School Age .........................................................................................................................3 5.2 Hearing .....................................................................................................................................3 5.2.A. Newborn ............................................................................................................................3 5.2.B. Preschool ...........................................................................................................................4 5.2.C. School Age .........................................................................................................................4 5.2.D. All Ages .............................................................................................................................4 Section 6 Developmental/Behavioral Assessment ...............................................................................4 6.1 Developmental Screening ...........................................................................................................5 6.2 Autism Screening .......................................................................................................................5 6.3 Developmental Surveillance ........................................................................................................5 6.4 Psychological/Behavioral Assessment (Behavioral Health Screening) .............................................5 6.5 Alcohol and Drug Use Assessment (Substance Abuse Risk Assessment) .........................................5 Section 7 Physical Examination .........................................................................................................6 Section 8 Procedures ........................................................................................................................6 8.1 Newborn Metabolic/Hemoglobin Screening ..................................................................................6 8.2 Immunizations ...........................................................................................................................6 8.3 Hematocrit or Hemoglobin ..........................................................................................................6 8.4 Lead Screening ..........................................................................................................................7 8.5 Tuberculin Test ..........................................................................................................................9 8.6 Dyslipidemia Screening ............................................................................................................. 10 8.7 Sexually Transmitted Infections (STI) Screening ........................................................................ 10 8.8 Cervical Dysplasia Screening, Breast Exams, Counseling and Risk Factor Interventions................. 10 8.9 Diabetes (Type 2) .................................................................................................................... 10 Section 9 Oral Health ..................................................................................................................... 11 9.1 Oral Health Screen And Fluoride Varnish ................................................................................... 11 9.2 Periodicity Schedule for Dentists ............................................................................................... 11 Section 10 Anticipatory Guidance .................................................................................................... 11 10.1 Sleep Position Counseling ....................................................................................................... 12 10.2 Nutritional Assessments .......................................................................................................... 12 10.3 Injury Prevention ................................................................................................................... 12 10.4 Violence Prevention ................................................................................................................ 12 10.5 Interpretive Conference .......................................................................................................... 12 Section 11 Children In Foster Care .................................................................................................. 12 11.1 Psychotropic Medication Treatment ......................................................................................... 13 11.2 Enrollment and Billing ............................................................................................................. 13 Early and Periodic Screening, Diagnosis and Treatment Page i

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Section 12 Referrals ....................................................................................................................... 14 12.1 Psychiatric Services ................................................................................................................ 14 12.2 Women, Infants and Children (WIC) ........................................................................................ 14 12.3 Blood Lead Poisoning Follow-Up Services ................................................................................. 14 12.3.A. Environmental Investigations ........................................................................................... 14 12.3.B. Nursing Assessment/Investigation Visits ........................................................................... 15 12.3.C. Blood Lead Resource Documents ..................................................................................... 15 12.4 Other Programs ..................................................................................................................... 16 Section 13 Outreach ....................................................................................................................... 16 13.1 Fee-For-Service (FFS) ............................................................................................................. 16 13.2 Medicaid Health Plans (MHP) .................................................................................................. 16 Section 14 Transportation ............................................................................................................... 16

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SECTION 1 GENERAL INFORMATION
Federal regulations require state Medicaid programs to offer early and periodic screening, diagnosis, and treatment (EPSDT) to eligible Medicaid beneficiaries under 21 years of age; however, beneficiary participation is voluntary. The intent of EPSDT is to correct or ameliorate defects and physical and mental illnesses and conditions discovered by the screening services. Accordingly, EPSDT visits and any needed follow-up services are covered by Medicaid. The main parts of the EPSDT program that providers are responsible for are: Well child visits, including immunizations and objective developmental screening, using a standardized screening tool at specified intervals as defined in the current American Academy of Pediatrics (AAP) Periodicity Schedule. A copy of the AAP Periodicity Schedule is available on the AAP website. (Refer to the Directory Appendix for website information.) NOTE: The AAP requires a risk assessment to be performed for vision, hearing, and blood lead screening at the specified intervals. Michigan Department of Community Health (MDCH) requires vision, hearing, and blood lead testing to be performed at the specific ages indicated on the AAP Periodicity Schedule. Refer to the appropriate section within this chapter for MDCH requirements. Referrals for: Other preventive health care; Medically necessary follow-up services to treat detected conditions; and Transportation and reporting.

Michigan Department of Community Health

SECTION 2 AAP PERIODICITY SCHEDULE AND COMPONENTS

The AAP Periodicity Schedule and components of the current AAP Recommendations for Preventive Pediatric Health Care, available on the AAP website, are to be followed for well child visits. (Refer to the Directory Appendix for AAP website information.) Head Start agencies are directed by federal regulation to meet state EPSDT standards for health screening. MDCH urges providers to cooperate with these agencies. Results of well child visits may be shared, if requested, since Head Start agencies are bound by confidentiality standards. Providers must complete all testing components at the specific ages indicated on the AAP Periodicity Schedule. Well child visits may be performed more frequently than the AAP Periodicity Schedule indicates if required by court order, foster care standards, or if considered medically necessary. The childs medical record must reflect documentation of the circumstances. The following sections follow the AAPs Bright Futures Recommendations for Preventive Pediatric Health Care schedule guidelines and are meant to provide further guidance to providers. The following sections include additional policies and procedures to be performed that are beyond the AAPs schedule guidelines.

SECTION 3 HISTORY AND WELL CHILD VISITS

An initial history must be obtained for each new patient at the first well child visit, with an update (interval history) at each subsequent well child visit. Early and Periodic Screening, Diagnosis and Treatment Page 1

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MDCH supports the concept of a medical home for each Medicaid beneficiary. A medical home is a Primary Care Provider (PCP) who assumes responsibility for assuring the overall care of a beneficiary, and for the maintenance and updating of a beneficiarys medical record. When a PCP accepts a child in a primary care relationship, the provider takes responsibility for arranging or providing well child/EPSDT visits. Well child visits are the health checkups, newborn, well baby, and well child exams represented by appropriate Current Procedural Terminology (CPT) preventive medicine services procedure codes and are used in conjunction with International Classification of Diseases (ICD) diagnosis codes V20.0 - V20.2, V70.0, and/or V70.3 - V70.9 The AAP Recommendations for Preventive Pediatric Health Care indicate all components and age-specific indicators for performing the various components. Developmental screening, using an objective standardized screening tool as recommended by the AAP, should be performed at the specified intervals.

Michigan Department of Community Health

SECTION 4 MEASUREMENTS
4.1 LENGTH/HEIGHT AND WEIGHT Length, height, and weight must be measured each time the provider conducts a well child visit, with good practice requiring graphing of the measurements. A suitable graphing document may be found on the Centers for Disease Control (CDC) and Prevention website. (Refer to the Directory Appendix for website information.) 4.2 HEAD CIRCUMFERENCE A head circumference measurement is required at each well child visit through 24 months of age. 4.3 WEIGHT FOR LENGTH Weight for length must be measured each time the provider conducts a well child visit through 18 months of age, with good practice requiring graphing of the measurements. A suitable graphing document may be found on the CDC website. (Refer to the Directory Appendix for website information.) 4.4 BODY MASS INDEX Body mass index must be measured each time the provider conducts a well child visit for children 24 months of age and older, with good practice requiring graphing of the measurements. A suitable graphing document may be found on the CDC website. (Refer to the Directory Appendix for website information.) 4.5 BLOOD PRESSURE Providers must obtain a blood pressure reading at each well child visit beginning at three years of age. Blood pressure measurement in infants and children with specific risk conditions should be performed at visits before three years of age.

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SECTION 5 SENSORY SCREENING
5.1 VISION Providers must perform a subjective vision screening (i.e., by history) at each well child visit. For asymptomatic children three years of age and older, an objective screening must occur as indicated on the AAP Periodicity Schedule. For children of any age, referral to an optometrist or ophthalmologist must be made if there are symptoms or other medical justification. The AAP requires a vision risk assessment at each visit. MDCH requires vision testing at specific well child visits for children three years of age and older. 5.1.A. PRESCHOOL Since most children cannot cooperate prior to three years of age, the standard screening is subjective. An objective screening should begin at three years of age. An objective vision screening may be performed on eligible Medicaid preschool-aged children from age three through six years of age by qualified Local Health Department (LHD) staff. LHDs may provide objective vision screening services and accept referrals for screening from the PCP and from Head Start agencies. In an effort to promote communication with the childs medical home, the objective vision screening results must be reported to the childs PCP. In the event the LHD is unable to report the objective vision screening results to the childs PCP, the LHD must clearly document why this could not be accomplished. The results must also be shared with the Head Start agency if that agency was the referral source. 5.1.B. SCHOOL AGE A subjective vision screening must be performed at each visit; an objective screening shall be performed as indicated on the AAP Periodicity Schedule. 5.2 HEARING The AAP requires a hearing risk assessment at each visit. MDCH requires a subjective hearing screening at each visit. 5.2.A. NEWBORN All newborns must be screened using evoked otoacoustic emissions (EOAE) and/or auditory brainstem response (ABR) methods. This screening must be accomplished in one of the following ways: If the hospital delivered 15 or more Medicaid-covered newborns between October 1, 1997 and September 30, 1998, the hospital must provide newborn hearing screenings for Medicaid-covered newborns using the policies and procedures recommended by the AAP. If the newborn fails the first screening, another screening shall be conducted prior to the newborns discharge. Coverage for the EOAE and ABR newborn hearing screenings is included within the applicable diagnosis related group (DRG) payment for the newborns inpatient stay. If the hospital delivered fewer than 15 Medicaid-covered babies between October 1, 1997 and September 30, 1998, the following options are available:

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The hospital may obtain the appropriate equipment and train staff to perform newborn hearing screenings using policies and procedures recommended by the AAP. If the newborn fails the first screening, another screening shall be conducted prior to the newborns discharge. Coverage for the EOAE and ABR newborn hearing screenings is included within the applicable DRG payment for the newborns inpatient stay. Fee-for-Service (FFS) Beneficiaries: If the hospital is not equipped for EOAE and/or ABR, the childs PCP (physician, CNM, or NP) shall be made aware of this fact by the hospital so the newborn can be referred to a Medicaid-enrolled hearing center for screening prior to one month of age. Beneficiaries Enrolled in a Medicaid Health Plan (MHP): If the hospital is not equipped for EOAE and/or ABR, the childs PCP (physician, CNM, or NP) shall be made aware of this fact by the hospital so the child can receive an appropriate referral for screening prior to one month of age.

Michigan Department of Community Health

5.2.B. PRESCHOOL A subjective hearing screening (i.e., by history) must be performed at each well child visit. An objective hearing screening may be performed on eligible Medicaid preschool-aged children from three through six years of age by qualified LHD staff. LHDs may provide objective hearing screening services and accept referrals for screening from the PCP and from Head Start agencies. In an effort to promote communication with the childs medical home, the objective hearing screening results must be reported to the childs PCP. In the event the LHD is unable to report the objective hearing screening results to the childs PCP, the LHD must clearly document why this could not be accomplished. The results must also be shared with the Head Start agency if that agency was the referral source. 5.2.C. SCHOOL AGE A subjective hearing screening (i.e., by history) must be performed at each well child visit. Children with symptoms or risk factors should be referred to a hearing center, an otologist, or CSHCS-sponsored otology clinic at a LHD for further objective testing or diagnosis. 5.2.D. ALL AGES For children of any age, a subjective hearing screening (i.e., by history) must be performed at each well child visit. A referral to a hearing center, an otologist, or CSHCSsponsored otology clinic at a LHD should be made if there are symptoms (e.g., parent or guardian has suspicions about poor hearing in the child), risk factors (e.g., exposure to ototoxic medications, family history of hearing deficits), or other medical justification.

SECTION 6 DEVELOPMENTAL/BEHAVIORAL ASSESSMENT

A psychosocial/behavioral assessment and developmental surveillance is required at each scheduled EPSDT well child visit from birth through adolescence as recommended by the AAP. The PCP should screen all children for behavioral and developmental concerns using a validated and standardized screening instrument as indicated by the AAP Periodicity Schedule. A maximum of three objective standardized screenings may be performed in one day for the same beneficiary by a single provider. (Refer to the Billing & Reimbursement for Professionals chapter for Early and Periodic Screening, Diagnosis and Treatment Page 4

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information regarding billing instructions.) If the screening is positive or suspected problems are observed, further evaluation must be completed by the PCP or the child should be referred for a prompt follow-up assessment to identify any further health needs. The provider may administer additional screenings, surveillance, or assessments as described in the following subsections. 6.1 DEVELOPMENTAL SCREENING A developmental screening using an objective, validated, and standardized screening instrument must be performed following the AAP Periodicity Schedule at 9, 18 and 30 (or 24) months of age, and during any other preventive pediatric health care visits when there are parent and/or provider concerns. Standardized developmental instruments that may be administered include the Parents Evaluation of Developmental Status (PEDS), Parents Evaluation of Developmental Status Developmental Milestones (PEDS-DM), and Ages and Stages Questionnaire (ASQ). 6.2 AUTISM SCREENING An autism screening is accomplished by administering a validated and standardized screening instrument at 18 and 24 months of age as indicated by the AAP Periodicity Schedule. The Modified Checklist for Autism in Toddlers (M-CHAT) is validated for toddlers 16 through 30 months of age. For children older than 4 years of age (mental age greater than 2 years of age), the Social Communication Questionnaire (SCQ) may be utilized. Surveillance for Autism Spectrum Disorders (ASD) is accomplished at other visits beginning at 12 months of age when there are parent and/or provider concerns and by observing for developmental lag and "red flags", such as no babbling by 12 months of age. 6.3 DEVELOPMENTAL SURVEILLANCE A developmental surveillance is accomplished by listening to caregiver concerns, asking questions about the childs history, performing an appropriate physical exam, and by observation of the child. A developmental surveillance must be performed at every preventive visit throughout childhood, and must ensure that such surveillance includes eliciting and attending to parents concerns, obtaining a developmental history, making accurate and informed observations of the child, identifying the presence of risk and protective factors, and documenting the process and findings. An early return visit should be scheduled for children whose surveillance raises concerns that are not confirmed by a developmental screening tool. 6.4 PSYCHOLOGICAL/BEHAVIORAL ASSESSMENT (BEHAVIORAL HEALTH SCREENING) Behavioral Health screening is accomplished using standardized screening tools, such as Ages and Stages Questionnaire Social-Emotional (ASQ-SE), PEDS-DM, and Pediatric Symptom Checklist (PSC), with appropriate action to follow if the screening is positive. Social-emotional screening for children from birth to 5 years of age should be performed: whenever a general development or autism specific instrument is abnormal; at any time the clinician observes poor growth, attachment or symptoms such as excessive crying, clinginess, or fearfulness for developmental stage, or regression to earlier behavior; and/or at any time the family identifies psychosocial concerns. 6.5 ALCOHOL AND DRUG USE ASSESSMENT (SUBSTANCE ABUSE RISK ASSESSMENT) A substance abuse risk assessment must be performed at each preventive pediatric health care visit beginning at 11 years of age or when there are circumstances suggesting the possibility of substance abuse beginning at an earlier age. If the risk assessment is positive, appropriate action must follow as indicated by the AAP Periodicity Schedule. A validated and standardized screening instrument, such as the CRAFFT (Car, Relax, Alone, Forget, Friends, Trouble), should be utilized. Early and Periodic Screening, Diagnosis and Treatment

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SECTION 7 PHYSICAL EXAMINATION
A complete physical examination must be performed at each well child visit. Infants are to be totally unclothed; all other children must be undressed and suitably draped. The purpose of the well child examination in children and adolescents is to promote health, detect medical problems, and to counsel in order to prevent injury and future health problems. The physical examination also provides opportunities to educate children and their parents about the body and the growth and development process. The physical examination must be comprehensive and appropriate for the childs age, gender, and developmental status, and should build on the history gathered during previous medical visits.

Michigan Department of Community Health

SECTION 8 PROCEDURES
8.1 NEWBORN METABOLIC/HEMOGLOBIN SCREENING As required by law, hospitals must test newborns for biotinadase, congenital adrenal hyperplasia, galactosemia, hemoglobinopathies, hypothyroidism, maple syrup urine disease, phenylketonuria (PKU), medium chain Acyl-CoA dehydrogenase deficiency (MCADD), arginosuicinic aciduria (ASA), citrallinemia, homocystinuria, and sickle cell. If sickle cell testing is appropriate (as explained on the AAP Periodicity Schedule), a capillary blood sample may be mailed to the Sickle Cell Detection and Information Center. Tubes, forms, and envelopes may be obtained from the Center. (Refer to the Directory Appendix for contact information.) 8.2 IMMUNIZATIONS A review shall be performed at each well child visit, with immunizations administered according to current recommendations and standards of practice recognized by the AAP and the Advisory Committee Immunization Practices (ACIP). Providers are reminded that all immunizations should be reported to the Michigan Care Improvement Registry (MCIR). Immunizations are covered when administered according to ACIP recommendations. MDCH encourages providers to immunize all Medicaid beneficiaries according to the accepted immunization schedule. For Medicaid eligible children 18 years of age and younger, the Vaccine for Children (VFC) Program provides covered immunizations at no cost to the provider. Medicaid covers immunizations for beneficiaries 19 years of age or older. Any LHD in the state can be contacted for specifics about the VFC program.

For immunizations available free of charge under the VFC program, the amount a provider may charge for vaccine administration may be limited. Providers cannot charge more for services provided to Medicaid beneficiaries than for services provided to their general patient population. For example, if the charge for administering a vaccine to a private-pay patient is $5.00, then the charge for immunization administration to the Medicaid beneficiary cannot exceed $5.00. MHP providers enrolled in the VFC program are encouraged to immunize and are discouraged from referring beneficiaries to a LHD for these services. (Refer to the Practitioner Chapter for additional information.) 8.3 HEMATOCRIT OR HEMOGLOBIN The childs hematocrit or hemoglobin must be tested according to the AAP Periodicity Schedule.

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8.4 LEAD SCREENING All Medicaid-covered children are considered at high risk for blood lead poisoning. The Centers for Medicare & Medicaid Services (CMS) has mandated that these children be tested at 12 and 24 months of age. In addition, CMS mandates that if a Medicaid-covered child is between the ages of 36 and 72 months of age and has not been tested for blood lead, he must be tested. Although the AAP requires a blood lead risk assessment at specific visits, CMS and MDCH require blood lead testing at specific well child visits. If the parent or guardian is unsure if the child was previously tested, he must be tested. For children who have been tested, the following questions are intended to assist PCPs in determining if further testing is necessary in addition to that completed at the mandated ages: Does the child live in (or often visit) a house built before 1950 with peeling or chipping paint? This could include day care, preschool, or home of a relative. Does the child live in (or often visit) a house built before 1978 that has been remodeled within the last year? Does the child have a brother or sister (or playmate) with lead poisoning? Does the child live with an adult whose job or hobby involves lead? (The chart following these questions presents examples.) Does the childs family use any home remedies that may contain lead? (The chart following these questions presents examples.)

Michigan Department of Community Health

Possible means of exposure to:

Occupational Battery manufacturing or repair Bridge reconstruction worker Chemical manufacturing Construction worker Glass manufacturing Industrial machine operator Migrant farm worker Painting Plastics manufacturing Plumber, pipe fitter Police officer Printing Radiator repair Rubber products manufacturing Hobbies Brass/copper/aluminum processing Casting lead figures (e.g., toy soldiers) Furniture refinishing Jewelry and pottery making Lead soldering (e.g., electronics) Making lead shot, fishing sinkers, bullets Painting Stained glass making Target shooting at firing ranges Vehicle repair Environmental Burning lead-painted wood Ceramic ware/pottery Lead crystal Lead-soldered cans (imported) Lead paint Lead-painted homes Living near leadrelated industries Renovating/remodeling older homes Soil/dust near industries and roadways Use of water from lead pipes Other Asian cosmetics Folk remedies and/or food additives (e.g., Greta, Azarcon, payloo-ah, ghasard, Hai ge fen, Bali Goli, Kandu, Kohl, X-yooFa, Mai ge fen, poying tan, lozeena)

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Occupational Hobbies Environmental Other

Michigan Department of Community Health

Steel welding and cutting Vehicle repair

Publications and other materials concerning blood lead may be obtained from the MDCH Childhood Lead Poisoning Prevention Program. The MDCH Blood Lead Laboratory can also be contacted. (Refer to the Directory Appendix for contact information.) There are pediatricians in all areas of the state who have expertise in the treatment of blood lead and are available to discuss blood lead issues with other providers. Providers with questions concerning blood lead testing or treatment should contact the Childhood Lead Poisoning Prevention Program to obtain the contact information for these pediatricians. (Refer to the Directory Appendix for contact information.) For blood lead analysis, the blood sample may be obtained via the capillary method (i.e., heel prick or finger stick) or venipuncture. The sample may be sent to the MDCH Blood Lead Laboratory or to any Michigan Medicaid-enrolled laboratory qualified to perform blood lead testing. If the MDCH Blood Lead Laboratory is used, blood lead testing supplies may be obtained from the laboratory. (Refer to the Directory Appendix for contact information.) Michigan has an established statewide blood lead registry. This requires that certain information accompany each blood lead specimen (or request, if the specimen is drawn elsewhere) to the blood lead laboratory. Prior to providers sending blood lead samples to the MDCH Blood Lead Laboratory, they must obtain a Submitter Clinic Code. If providers send blood lead samples to the MDCH Blood Lead Laboratory, the Blood Lead Sampling Request form (DCH-0696) must be used. Providers may obtain a Submitter Clinic Code and a supply of DCH-0696 forms by contacting the MDCH Blood Lead Laboratory. (Refer to the Directory Appendix for contact information.) If blood lead samples are sent to a private laboratory or if the private laboratory draws and tests the sample, the provider must submit the MDCH Blood Lead Analysis Report (DCH-0395) obtained from the MDCH Blood Lead Laboratory or develop a form that includes all of the information from the DCH-0395 form. When testing is completed, the laboratory completes the required information and submits it to the blood lead registry.

PCPs must draw blood in their offices for all children needing blood lead testing. There may be instances when a blood draw is not accomplished. If this occurs and the child resides in a jurisdiction where the LHD agrees to obtain a blood sample for blood lead testing, the PCP may refer a child to the LHD for the service. The MDCH Blood Lead Laboratory reports all results to the childs ordering provider if the information about the ordering provider is included. When ordering provider information is not included, results are sent to the appropriate LHD. All blood lead results should be reported to the MCIR.

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If the results of a capillary blood lead sample indicate an elevated value, a confirmatory venous sample must be obtained. The capillary and venous blood lead value/action chart follows.
Blood Lead (Pb) Interpretation Capillary (Microblood) Samples
(micrograms per deciliter of blood)

Michigan Department of Community Health

Venous (Macroblood) Samples

(micrograms per deciliter of blood)

Pb Result

Action No action needed. Obtain venous sample within one month. Emphasize the importance of the venous confirmation. Obtain venous sample within two weeks. Emphasize the importance of the venous confirmation. Obtain venous sample within one week. Emphasize the importance of the venous confirmation.

Pb Result

Action No action needed. Refer within one month for medical evaluation and retesting. The provider shall contact the LHD to determine if resources are available to provide follow-up services for this Pb range. Refer within five working days for a complete medical evaluation. Refer to the LHD within ten working days for blood lead poisoning follow-up services. Refer within 48 hours for medical intervention. Refer to the LHD within five working days for blood lead poisoning follow-up services. Refer immediately for a complete medical evaluation. Refer to the LHD within 24-48 hours for blood lead poisoning follow-up services. Repeat venous sample.

10 14

15 -19

10 19

20 - 44

20 44

45 69

Obtain venous sample within 48 hours. Emphasize the importance of the venous confirmation. Obtain venous sample immediately. Emphasize the importance of the venous confirmation. Repeat capillary sample one time or obtain venous sample.

45 69

70

70

N.R. (no resultsinsufficient or clotted blood)

N.R. (no resultsinsufficient or clotted blood)

For values above 9, the provider shall always provide general health education to the parents regarding nutrition, house-cleaning techniques, and lead poisoning prevention. (This is considered part of the interpretive conference and is not separately reimbursable.)

For values above 9, the provider shall always: Emphasize the importance of following through with any retesting, evaluation, or intervention. Provide general health education to the parents regarding nutrition, house-cleaning techniques, and lead poisoning prevention. This is considered part of the interpretive conference and is not separately reimbursable.

KEY:

= Less than or equal to = Greater than or equal to

8.5 TUBERCULIN TEST Medicaid covers TB testing according to the guidelines of the AAP, which is based on risk. Coverage for the TB test includes any return visit to read the results of the TB test. A risk assessment must be completed at each visit. For assistance in determining high risk and testing, providers may refer to the current edition of the AAP Red Book: Report of the Committee on Infectious Diseases, or contact the MDCH Communicable Disease and Immunization Division. (Refer to the Directory Appendix for contact information.) Early and Periodic Screening, Diagnosis and Treatment Page 9

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Based on current standards of good practice, Mantoux testing is the preferred testing method. For assistance in determining high risk, providers may contact the MDCH Communicable Disease and Immunization Division or the AAP. (Refer to the Directory Appendix for contact information.) 8.6 DYSLIPIDEMIA SCREENING High-risk children should be tested according to current AAP schedule guidelines. Beginning at two years of age, children must be screened if: Parents or grandparents, at <55 years of age, underwent diagnostic coronary arteriography and were found to have coronary atherosclerosis. This includes those who have undergone balloon angioplasty or coronary artery bypass surgery. Perform a fasting lipoprotein analysis. Parents or grandparents, at <55 years of age, had a documented myocardial infarction, angina pectoris, peripheral vascular disease, cerebrovascular disease, or sudden cardiac death. Perform a fasting lipoprotein analysis. A birth parent has an elevated blood cholesterol level. Perform a random serum cholesterol.

Michigan Department of Community Health

If a family history cannot be ascertained and other risk factors exist, testing is at the providers discretion. 8.7 SEXUALLY TRANSMITTED INFECTIONS (STI) SCREENING All sexually active patients must be screened for sexually transmitted infections (STIs) according to the AAP Recommendations for Preventive Pediatric Health Care. 8.8 CERVICAL DYSPLASIA SCREENING, BREAST EXAMS, COUNSELING AND RISK FACTOR INTERVENTIONS All sexually active females must have a breast exam and screening for cervical dysplasia as part of a pelvic examination and Pap smear beginning within 3 years of onset of sexual activity or age 21 (whichever comes first) as indicated on the AAP Periodicity Schedule. Pelvic exams and Pap smears must be offered to all females 18 years of age and older. Beginning at puberty, all females must receive clinical breast exams and be taught self-breast examination. Whenever a pelvic exam is provided, a breast exam, counseling, and risk factor interventions must be provided. 8.9 DIABETES (TYPE 2) High-risk children must be tested according to current AAP schedule guidelines. Beginning at 10 years of age (or at the onset of puberty, if it occurs at a younger age), a risk assessment must be performed at each well child visit. Children at risk should be tested in accordance with AAP current guidelines. A child is considered high risk if he is overweight (i.e., body mass index >85th percentile for age and sex, weight for height >85th percentile, or weight >120 percent of ideal for height) and has any two of the following factors: A family history of Type 2 diabetes in first- and second-degree relatives; Belongs to a certain race/ethnic group (American Indian, African-American, Hispanic, Asian/Pacific Islander); or Signs of insulin resistance or conditions associated with insulin resistance (acanthosis nigricans, hypertension, dyslipidemia, polycystic ovarian syndrome). Early and Periodic Screening, Diagnosis and Treatment Page 10

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SECTION 9 ORAL HEALTH
The dental health of the beneficiary begins with an oral health risk assessment by the childs PCP. Therefore, MDCH requires providers to stress the importance of preventive and restorative dental care and adhere to the following: The oral cavity must be inspected at each well child visit regardless of whether teeth have erupted. It is recommended that at one year of age a child is seen by a dentist for an examination. Beginning at three years of age (younger if the individual child exhibits needs), a child should visit a dentist every six months for prophylaxis and other preventive care. If the child does not have his next preventive dental appointment scheduled, the provider must make a referral. When restorative dental care is needed, the child must be referred for treatment. A separate periodicity schedule for dentists is established.

Michigan Department of Community Health

9.1 ORAL HEALTH SCREEN AND FLUORIDE VARNISH Providers should follow the AAP schedule guidelines in the oral health screen and development of caries risk assessment for beneficiaries beginning at one year of age. (Refer to the Directory Appendix for AAP website information.) As an oral health intervention, medical providers can apply fluoride varnish to children from birth to 35 months of age up to four times in a 12-month time period. Providers must complete an online oral health training program and obtain certification prior to providing fluoride varnish applications. Providers who complete the specified certification requirements are allowed to bill Medicaid for these services. The Certificate of Completion and the Contact Information Form (available on the MDCH Oral Health website) must be submitted to the MDCH Oral Health Program upon completion of the training program. Upon receipt and verification of the required information, the MDCH Oral Health Program will issue a certificate to the provider. (Refer to the Directory Appendix for website and contact information.) 9.2 PERIODICITY SCHEDULE FOR DENTISTS The periodicity schedule for dentists is as follows: An examination is recommended by one year of age. An examination by a dentist is required by three years of age. It is recommended that dental visits be repeated every six months.

(Refer to the Dental Chapter for additional information.)

SECTION 10 ANTICIPATORY GUIDANCE

Anticipatory guidance provided by the AAP explains any and all changes that will most likely occur before the next recommended well child visit, and offers strategies for dealing with the anticipated changes. This applies to all aspects of the childs life. Anticipatory guidance gives the PCP, parents, and the child or adolescent an opportunity to ask questions and to discuss issues of concern. Anticipatory guidance focuses on 5 priority areas including Physical Growth and Development, Social and Academic Competence, Emotional Well-being, Risk Reduction, and Violence and Injury Prevention. The PCP is encouraged to inquire about these priority areas, and to adapt questions and discussion points to meet the specific needs of their families and communities. Early and Periodic Screening, Diagnosis and Treatment Page 11

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10.1 SLEEP POSITION COUNSELING Positioning of infants through six months of age for sleep must be discussed at each well child visit. Healthy infants should be placed on their backs. (Refer to the Maternal-Child Educational Resources portion of the Directory Appendix for sources of additional information regarding infant sleep positioning.) 10.2 NUTRITIONAL ASSESSMENTS Age-appropriate nutrition counseling must be provided at each well child visit. Nutritional assessments must be based on: Height, weight, and their relatedness; The most recent hematocrit/hemoglobin value; Physical examination; and Health history.

Michigan Department of Community Health

10.3 INJURY PREVENTION Injury prevention must be discussed at each well child visit. 10.4 VIOLENCE PREVENTION Violence prevention must be discussed at each well child visit. 10.5 INTERPRETIVE CONFERENCE The interpretive conference explains the results of the well child visit. Depending on the age and/or family status of the beneficiary, the conference may be held directly with the beneficiary, the beneficiary and parent/guardian, or only with the parent/guardian. If a beneficiary has a potential or apparent abnormality, the PCP is responsible for providing or referring for follow-up diagnostic services and treatment.

SECTION 11 CHILDREN IN FOSTER CARE

Medical interventions, screenings, and various preventive health care services are to be up-to-date for all children in foster care under 21 years of age. The care of children and youth should be comprehensive, well-coordinated, and fully documented throughout their stay in foster care. All children in foster care under 21 years of age must receive a full medical examination by a physician within the first 30 days after entering foster care. The physician must complete the health maintenance visit regardless of whether or not the child in foster care recently received a health maintenance visit prior to entry into the foster care system. The physicians office staff should obtain from the foster care parent the completed Department of Human Services (DHS) form "Consent to Routine, Non-surgical Medical Care and Emergency Medical or Surgical Treatment" before the child in foster care is seen by the physician. The Physician will assess the child in foster care for medical, dental, developmental, and mental health needs. The full medical evaluation will include an immunization review, health history, and physical examination as indicated by the Bright Futures Recommendations for Preventive Health Care Periodicity Schedule. The medical examination should be documented for the initial and for all subsequent visits on the age appropriate DHS Well Child Exam form located on the DHS website. (Refer to the Directory Early and Periodic Screening, Diagnosis and Treatment Page 12

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Appendix for website information.) Physicians may use their own Well Child Exam form if the form contains all of the elements of the DHS form. All children in foster care who are 3 years of age or older at the time of entry into foster care will receive a dental examination within 90 days of entry into foster care unless the child had a dental exam in the six months prior to foster care placement. It is the responsibility of the foster care parent to take the child to the dentist. A behavioral health assessment must be completed at each scheduled well child visit. The physician will recommend to the DHS foster care worker, the birth parents, and the foster care parents (when applicable) when the child in foster care may benefit by visiting with a mental health professional. Recommended screening instruments include the ASQ-SE, or the PSC. The screening instrument (i.e. questionnaire) will be completed by a person who knows the child best (preferably for at least 30 days), before the child in foster care is to be seen by the physician. This may be the childs/youths biological parent, foster care parent, caregiver, or other adult who knows the child. The child in foster care will be referred for a prompt follow-up assessment by an appropriate medical, dental, developmental, or mental health professional for any further identified health needs. 11.1 PSYCHOTROPIC MEDICATION TREATMENT A psychiatric diagnosis using the current Diagnostic and Statistical Manual (DSM) of Mental Disorders (published by the American Psychiatric Association) must be made before prescribing psychotropic medications to any child in foster care. When the physician determines that the child in foster care requires psychotropic medication treatment, the prescribing physician must obtain a written and signed informed consent from the childs birth parent (when the child is a temporary court ward) or other legal guardian (for state or permanent court wards) before treatment with any psychotropic medication begins. Other legal guardians for state or permanent court wards may be the DHS foster care worker for child/youth in guardianship of Michigan Childrens Institute (MCI) or the court of jurisdiction for child/youth in guardianship of the county. Foster care parents cannot consent to administration of psychotropic medication. For questions regarding who may provide consent for treatment with psychotropic medications, the physician should contact the childs DHS foster care worker. If consent is denied by the childs birth parent or other legal guardian, or the consent cannot be obtained and all parties involved agree the medication is needed, a court order shall be obtained by the DHS foster care worker to authorize the administration of the psychotropic medication to the child in foster care held in legal custody. If a child is prescribed psychotropic medication(s) prior to enrollment in the foster care system, the DHS-1643 form must be completed within 45 days of a childs entry into the foster care system to assure uninterrupted psychotropic medication treatment. The child in foster care who has reached the age of 18 is able to consent to, and/or refuse, medical treatment. A new informed consent form will be required if there is a change in provider, a change in medication, or if the child has reached the age of 18. Informed consent forms must be renewed annually. 11.2 ENROLLMENT AND BILLING Phsyicians may complete and bill for an EPSDT/Preventive care visit for any child who must be seen within 30 days of entering the foster care system, and for any additional follow-up visits the physician believes are necessary. The physician will be reimbursed even if the child in foster care has received a recent preventive health service prior to entry into the foster care system. The physician may bill for up to three screenings provided during a well child visit using the appropriate developmental screening codes for scoring and interpreting developmental, autism, and behavioral health screens under 21 years of age.

Michigan Department of Community Health

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SECTION 12 REFERRALS
If a medical issue is determined or suspected during a well child visit, the (suspected) issue must be diagnosed and treated as appropriate. This determination may result in a referral to another provider or a self-referral for further diagnosis and treatment. Referrals must be made based on standards of good practice and the AAPs Recommendations for Preventive Pediatric Health Care or presenting need, if outside the normal schedule. When a FFS provider performs medically necessary treatment involving diagnostic or therapeutic procedures beyond examination of the child (e.g., wart removal) for a medical condition found during a well child visit, these procedures are covered in addition to the well child visit. For information regarding billing a well child E/M visit and other E/M visits occurring on the same date of service, refer to the Evaluation and Management Services Section of the Practitioner chapter. If the provider cannot perform the needed treatment, a referral must be made to an appropriate provider. If providers are not familiar with other providers in the area, the LHD can be of assistance with referrals. MHP providers must follow the referral procedures for the specific plan in which the beneficiary is enrolled. 12.1 PSYCHIATRIC SERVICES Limited psychiatric services are available for Medicaid FFS beneficiaries under 21 years of age with mild/moderate mental health conditions or suspected behavioral disorders through the FFS program. (Refer to the Psychiatric and Substance Abuse Services Section of the Practitioner chapter for specific coverages.) The MHP contracts include a limited mental health benefit coverage for beneficiaries with mild/moderate mental health conditions. Pre-paid Inpatient Health Plans / Community Mental Health Services Programs (PIHPs/CMHSPs) are responsible for the provision of covered specialty mental health services necessary for the treatment of Medicaid beneficiaries with more significant, persistent, complex, and/or serious psychiatric conditions. The PCP who screened the child for ASD and determined a referral for further evaluation was necessary will contact the PIHP directly to arrange for a follow-up evaluation. (Refer to the Mental Health/Substance Abuse chapter for information/policy regarding the treatment of children with autism.) 12.2 WOMEN, INFANTS AND CHILDREN (WIC) The Women, Infants and Children (WIC) program, located at LHDs, Tribal Health Centers, and federally funded clinics, is a special health and nutrition program that has demonstrated a positive effect on pregnancy outcomes, child growth and development. WIC provides supplemental healthy foods, nutrition counseling and education, breast feeding support, immunizations, and referrals to many other helpful services to pregnant women and eligible children under 5 years of age. The PCP is expected to make referrals to a WIC site for eligibility determination if appropriate. 12.3 BLOOD LEAD POISONING FOLLOW-UP SERVICES Many LHDs provide blood lead poisoning follow-up services which consist of environmental investigations and nursing assessment/investigation visits. The PCP must contact the LHD to determine if blood lead services are available in the area and the blood lead levels at which referrals are accepted. Refer to the Additional Information on Blood Lead Testing subsection of the Local Health Departments Chapter for additional information. 12.3.A. ENVIRONMENTAL INVESTIGATIONS Environmental investigations are covered for the LHD if the health officer from the LHD completes the Blood Lead Poisoning Follow-Up Services Assurance of Provision form. Early and Periodic Screening, Diagnosis and Treatment

Michigan Department of Community Health

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(Refer to the Blood Lead Poisoning Follow-Up Services subsection of the Local Health Department Chapter for additional information.) 12.3.B. NURSING ASSESSMENT/INVESTIGATION VISITS MDCH covers up to two nursing assessment/investigation visits per episode of blood lead poisoning. If more than one child in the home has blood lead poisoning, the nursing assessment/investigation visits are covered for each child. Blood lead nursing visits must be provided in the childs home. For FFS beneficiaries, a Medicaid-enrolled home health agency, a LHD or other medical clinic, or a physician may conduct the visits. This procedure is not covered for Maternal Infant Health Program (MIHP) providers. Blood lead nursing visits provided through a MHP are covered by the individual MHP. The first nursing assessment/investigation visit focuses on: Assessment of the growth and developmental status of the child, including any symptomatology that may be present in the child. Behavioral assessment of the child, including any aggressiveness and/or hyperactivity. Nutritional assessment of the child. Assessment of typical family practices that may produce lead risk (e.g., hobbies, occupation, cultural practices). Limited physical identification of lead hazards within the dwelling. Identification and planning for testing of any other family member at risk for sequelae of lead hazard exposure. Education and information regarding lead hazards and ways to minimize those risks in the future. Development of a family plan of care to increase the safety of the child from lead hazards.

Michigan Department of Community Health

The second blood lead nursing visit focuses on: Reinforcement of the educational information presented to the family during the first visit. Validation of the familys ability to carry out activities to minimize risks of continued lead exposure. Modifications of the plan to minimize lead risks, as needed.

12.3.C. BLOOD LEAD RESOURCE DOCUMENTS Providers are encouraged to review Guidelines for Environmental and Nursing Investigations for Children with Elevated Venous Blood Lead Levels and apply these standards. This publication, plus other materials concerning blood lead poisoning, may be obtained from the MDCH Childhood Lead Poisoning Prevention Program. (Refer to the Directory Appendix for contact information.)

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12.4 OTHER PROGRAMS There are other programs that could benefit Medicaid beneficiaries, such as Head Start, intermediate school district services, genetics counseling, nutrition programs, and public health nursing. Providers are encouraged to become familiar with available programs and make full use of the programs whenever referrals are appropriate.

Michigan Department of Community Health

SECTION 13 OUTREACH
MDCH provides outreach to beneficiaries through various means, including informational publications and other beneficiary contacts. When the beneficiarys mihealth card is issued, it is mailed with the MDCH publication "Michigan Free Health Check-Ups." The publication explains the benefits of a well child visit, indicates the recommended AAP Periodicity Schedule, describes procedures included in the free health checkup, and presents information about medical transportation options available to beneficiaries for travel to and from wellchild visits. Soon after the mihealth card is issued, the beneficiary will receive a monthly outreach list and will receive a letter that stresses the importance of well child visits and will be provided with medical transportation information. 13.1 FEE-FOR-SERVICE (FFS) For beneficiaries under two years of age, the letter stressing the importance of well child visits is sent to the beneficiary every six months as a reminder to schedule a well child visit with the PCP. The beneficiary is encouraged to schedule the well child visits recommended during those six months with the childs PCP. For beneficiaries two years of age and older, if a claim for a well child visit has not processed by Medicaid by the time the child is halfway to his next well child visit due date (according to the AAP Periodicity Schedule), the beneficiary will receive the letter again. A list of FFS beneficiaries will be generated and delivered to the LHD of the county nearest to the beneficiarys home address. LHDs may assist Medicaid in informing beneficiaries of the EPSDT program, scheduling appointments, and arranging medical transportation options. 13.2 MEDICAID HEALTH PLANS (MHP) Each MHP is able to download an electronic monthly outreach list of enrollees due or overdue. The MHP must either notify the beneficiary directly or may have the LHD assist in notifications, scheduling appointments, and arranging medical transportation options. Once each year, "Michigan Free Health Check-ups" is mailed to the Medicaid beneficiary.

SECTION 14 TRANSPORTATION
Medical Transportation is available (free of charge) to the beneficiary for travel to and from well-child visits if requested by the family. For beneficiaries enrolled in an MHP, the family needs to make arrangements directly through the MHP or with the assistance of the LHD. Beneficiaries not enrolled in an MHP need to contact their local DHS directly, or with the assistance of the LHD, to make transportation arrangements for the EPSDT well child visit. DHS should be contacted as soon as the date and time of the appointment are known.

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