New Billing Requirements for EPSDT Screening Services

In an effort to simplify administrative procedures for our network providers Gateway Health Plan^® (Gateway) will align its EPSDT billing requirements with those issued in The Pennsylvania Department of Public Welfare's Medical Assistance Bulletin (99-08-13). To facilitate this change the following EPSDT billing requirements will go into effect March 1, 2010:

• Use of the national standard code (S0302) for EPSDT screening will end February 28, 2010. (Note: In order to receive reimbursement for EPSDT screens rendered through February 28, 2010 continue to bill the S0302 in conjunction with the age-appropriate evaluation and management code.)
• Beginning March 1, 2010 EPSDT screening services must be reported with the age-appropriate evaluation and mangement code (99381-99385, 99391-99395, 99431 and 99435) along with the EP modifier. (Discontinue billing S0302.)
• The EP modifier must follow the evaluation and management code in the first position on the claim form. Claims will be paid at th eprovider's EPSDT rate only if the appropriate evaluation and managementcode and EP modifier are submitted.
• Diagnosis code V20.0, V20.1 or V20.2 must be notated as the primary diagnosis in Box 21. When applicable, you may enter up to three additional diagnosis codes.
• A screen is complete when codes from each service area required for that age including the appropriate evaluation and management codes are documented on the claim.

Enclosed with this notice are complete billing guidelines for submission of EPSDT screens either on a CMS-1500, UB-92 or the corresponding 837P or 837I format for EDI claims; along with the current Periodicity Schedule. This notice and the enclosed documents are available here: EPSDT Screening Billing Guide If you would like to speak to someone regarding the new billing requirements please contact your Provider Relations Representatives directly or Gateway's Provider Services Department at 1-800-392-1145.