Early and Periodic Screening, Diagnostic and Treatment (EPSDT) Program Services: Child and Teen Checkups (C&TC)
Overview
The Early and Periodic Screening, Diagnostic and Treatment (EPSDT) program is a required service under Title XIX of the Social Security Act and applies to all children and youth under 21 years old who are enrolled in Medicaid. The goal of EPSDT is to assure that individual children and adolescents get the health care they need when they need it.
The EPSDT benefit:
Child and Teen Checkups (C&TC) is the name for this program in Minnesota. The purpose of the program is to reduce the impact of childhood health problems by identifying, diagnosing and treating health problems early, and to encourage the development of good health habits. It is necessary to ensure children and teens get the health care they need when they need it and in the most appropriate setting.
C&TC screening services are based on the recommendations of the American Academy of Pediatrics (AAP), the Centers for Disease Control and Prevention (CDC), and the United States Preventive Services Task Force (USPSTF). MHCP regularly updates the C&TC Schedule of Age-Related Screening Standards (Periodicity Schedule) (DHS-3379) (PDF) according to federal requirements of the EPSDT program, state legislation and the unique needs and epidemiology of Minnesota's eligible population.
States are required to provide an annual report to the Centers for Medicare & Medicaid (CMS) that includes the participation rate based on eligible children receiving a C&TC screening service during the federal fiscal reporting year. Accurate billing and coding are critical in documenting the screenings that have been provided. This report, as well as more detailed C&TC data, can be viewed on the PartnerLink C&TC program webpage.
States are required to follow up on referrals made from results of a screening to assure that children and families receive the necessary services to correct or improve health problems. It is important that providers report all referrals from complete C&TC health visit claims using one of the four HIPAA required referral codes. DHS provides these referral codes through a secure data system which informs local program staff to offer referral assistance to families of children younger than 11 years old. Refer to the C&TC HIPAA Compliant Referral Codes fact sheet (PDF) or information under the HIPAA-Compliant Referral Condition Codes heading in this manual section.
Every county, Red Lake, Fond du Lac, and White Earth Tribal Nations, and some Integrated Health Partnerships have a C&TC Coordinator available to assist those eligible for this benefit. C&TC Coordinators help families understand the benefits of preventive care as well as assist with transportation and scheduling. Email DHS at dhs.childteencheckups@state.mn.us to find your local Coordinator.
Coordination of Preventive Health Care
The C&TC program emphasizes the need to avoid fragmentation of care and the importance of continuity of care in comprehensive health supervision. Providers can help reduce duplication of services by providing a complete comprehensive C&TC visit for other preventive health visits, such as:
Eligible Providers
To be reimbursed for C&TC screening services, fee-for-service providers must be enrolled as either of the following and have a signed C&TC Provider Agreement Addendum (DHD-4646) (PDF) on file with Minnesota Health Care Programs (MHCP):
Individual Treating Providers
Eligible treating providers include the following:
Note: providers may be eligible to deliver some services under School-Based Community Services. Refer to the School-Based Community Services section of the MHCP Provider Manual to review provider eligibility, covered services, billing guidance, and related resources.
Facility Types
Eligible facility types include the following:
Eligible Members
Children and youth under 21 years old and enrolled in Medical Assistance (MA) or MinnesotaCare are eligible for C&TC services. Children enrolled in MA or MinnesotaCare through a managed care organization (MCO) must receive screening services from their Prepaid Minnesota Healthcare Program provider.
Use MN–ITS Interactive Eligibility Request to verify a member’s eligibility for this service.
Covered Services – Medical screenings
The C&TC medical screening components include the following:
Refer to the C&TC Schedule of Age-Related Screening Standards (Periodicity Schedule) (DHS-3379) (PDF) for details.
Foster care
Children or teens in foster care or out-of-home placement should receive C&TC visits more frequently, as recommended by the American Academy of Pediatrics (AAP). Refer to AAP's Healthy Foster Care America Health Information Form (PDF) for health visit recommendations and to the AAP’s Foster Care webpage for a variety of resources.
Health Education and Anticipatory Guidance
Health education is a required component of screening services and includes anticipatory guidance. Health education and counseling to either parents or guardians and children is required.
Reimbursement for health education and anticipatory guidance is included in the payment of the Evaluation and Management (E&M) code for a C&TC screening.
Refer to the Child and Teen Checkups fact sheets (webpage) for anticipatory guidance, birth–10 years and 11–20 years for more information on health education and anticipatory guidance.
Preventive counseling is included in the preventive medicine E&M service; do not bill for preventive counseling separately. Bill with CPT codes 99401–99404 if patient visit is for counseling only.
Health History
Health history needs to include social drivers of health. Refer to the C&TC Health History and Social Determinants of Health fact sheet (PDF) for more information about social drivers of health.
Developmental and Social-Emotional or Mental Health Screenings
Developmental and social-emotional or mental health screenings are C&TC screening components. DHS prefers a Minnesota Developmental Screening Task Force-recommended screening instrument; however, a DHS-accepted screening instrument can be used.
For autism screening, review the Screening for Autism Spectrum Disorder (ASD) information in this manual section.
Refer to the C&TC Developmental and Social-Emotional Screening in Early Childhood (PDF) or C&TC Mental Health Screening (6-20 Years) fact sheet (PDF) developed by MDH and DHS and the DHS Screening webpage for more information on developmental and social-emotional or mental health screening and recommended instruments.
Currently, no recommended standardized instrument adequately covers both developmental and social-emotional domains. Two separate screening instruments are needed to adequately screen for potential developmental and social-emotional concerns.
The Survey of Well-being of Young Children (SWYC) milestones, the Baby Pediatric Symptom Checklist (BPSC) and the Preschool Pediatric Symptom Checklist (PPSC), are parent report developmental and social-emotional screening tools that are acceptable to the AAP. These tools may be used to meet the developmental and social-emotional screening components when performing a complete C&TC exam in a clinic setting for children under 5 years old. Refer to MDH’s C&TC Developmental and Social - Emotional Screening in the Clinic Setting webpage and Instruments at a Glance for C&TC Clinic Setting (PDF).
For settings outside of a medical clinic, refer to the Recommended Screening Instruments webpage from the Minnesota Interagency Developmental Screening Task Force section of the Minnesota Department of Health (MDH) website. The Minnesota Developmental Screening Task Force does not recommend the use of the SWYC in screening programs.
Providers engaging in screening must meet the instrument-specific criteria, as outlined by the screening instrument’s publisher. Providers using the standardized instruments may include physicians, nurse practitioners, physician assistants, nurses, medical assistants or other appropriately trained staff.
Maintain required documentation in the child’s health record. Documentation must include, at a minimum, the name of the screening instruments used, the scores, and the anticipatory guidance provided to the parent or caregiver related to the screening results. If the screening results are abnormal, documentation must include how this is being addressed, such as referral to the local school district (directly or via Help Me Grow - Refer a Child webpage), appropriate medical specialists, follow-up plan of care and, when appropriate, a referral to a local community service agency. Review the Referral section of the C&TC Developmental and Social-Emotional Screening in Early Childhood fact sheet (PDF) or the C&TC Mental Health Screening (6-20 Years) fact sheet (PDF) on the MDH website for more information.
Bill developmental and social-emotional or mental health screenings on the same claim as other C&TC services. When using the SWYC for both developmental and social-emotional screenings, record both codes. Use the following CPT codes:
You may bill for both a developmental and a social-emotional or mental health screening on the same date of service on the same claim. However, you may not bill for more than two developmental screenings and more than two social-emotional and mental health screenings on the same date of service.
When a developmental and social-emotional or mental health screening is provided at other pediatric visits, bill the developmental and social-emotional or mental health screening on the same claim as the other pediatric services.
Suicide Risk Screening
Beginning Oct. 1, 2025, suicide risk screening is a recommended component beginning at age 12 years. Maintain required documentation in the youth’s health record. At a minimum, documentation must include the name of the screening instrument used and the results.
Screening for Autism Spectrum Disorder (ASD) in Toddlers
The American Academy of Pediatrics (AAP) and the C&TC Schedule of Age-Related Screening Standards (Periodicity Schedule) (DHS-3379) (PDF) recommends autism screenings be part of standard 18- and 24-month C&TC exams. Refer to the C&TC Autism Spectrum Disorder Screening fact sheet (PDF) for more information.
When billing for an ASD-specific screening, use a standardized screening instrument according to the guidelines of the developer, such as the Modified Checklist for Autism in Toddlers Revised, with Follow-up (M-CHAT-R/F).
Bill an ASD-specific screening on the same claim as other C&TC services using CPT code 96110 and modifier U1.
When an ASD-specific screening is complete in addition to another developmental screening using two separate standardized screening instruments, bill for the ASD-specific screening and the developmental screening on the C&TC claim using one of the following:
Maintain required documentation in the child’s health record. At a minimum, documentation must include the name of the screening instruments used, the scores and the anticipatory guidance provided to the parent or caregiver related to the results. If the screening results are atypical, documentation must include a follow-up plan of care including to whom you referred the child and family and any other ways that the atypical screening results are being addressed. It is important to make a referral right away, do not wait.
ASD Referrals
Review the Referral and Management section of the C&TC Developmental and Social-Emotional Screening fact sheet (PDF) and the C&TC Autism Spectrum Disorder Screening fact sheet (PDF) for more information about referrals.
The following are examples of providers or resources to refer children to when they need additional evaluation:
You may also offer families screening resources and provide information on expected milestones from either the Help Me Grow or Learn the Signs. Act Early websites. The First Steps: Pathway to learning, playing and growing (PDF) is a Minnesota-specific screening, identification and early intervention referral information resource. It provides a summary of key developmental milestones that infants and toddlers should be achieving. This resource contains tips, tools and guidance to help children develop. It also explains resources available to parents and caregivers who have questions or concerns about their child’s development. The resource is also available in Hmong, Karen, Oromo, Russian, Somali, Spanish and Vietnamese.
Refer to the Next Steps: Pathway to services and supports for a child recently identified with ASD (PDF) for children with ASD and related conditions. This resource helps parents and caregivers understand options for their child in the year after diagnosis. This resource is also available in Hmong, Karen, Oromo, Russian, Somali, Spanish and Vietnamese.
For community-based early intervention services, refer directly for a comprehensive evaluation or early intervention services using the EIDBI referral form (DHS-6751S). Anyone can make a referral, including the family.
Visit the Minnesota Autism Resource Portal for more information about ASD.
Postpartum Depression Screening
Postpartum depression screening is covered as a C&TC service or at other pediatric visits. Suggested screening times are at the 0 to 1-month visit, the 2-month visit, the 4-month visit and the 6-month visit; however, providers may screen any time up to 13 months for any accompanying caregiver.
Use one of the following standardized screening instruments:
Providers that meet the instrument-specific criteria for administering the screening tool as outlined by the publisher may perform postpartum depression screenings. Depending on the tool, this may include physicians, nurse practitioners, physician assistants, nurses, medical assistants or other appropriately trained staff.
MHCP allows up to six postpartum depression screenings for any accompanying caregiver at the C&TC visit for each child who is less than 13 months old. For documenting postpartum depression screening services, record the name of the completed screening instrument and document that it was performed as a “risk assessment” in the child’s medical record.
You are not required to include the screening score results or a copy of the screening instrument in the child’s record. You may give the caregiver a paper copy of the screening instrument to bring to a referral appointment or destroy it if it is not wanted. Refer to MDH’s Perinatal Mental Health – Information for Health Professionals webpage and the C&TC Postpartum Depression Screening fact sheet (PDF) for more information on postpartum depression screening, referral, and documentation. You may find helpful tools located on MDH’s Depression or Anxiety During and After Pregnancy Brochure and Postpartum Wellbeing Plan webpage.
Refer to the Screening webpage for information on the relationship between postpartum depression and children’s developmental, social-emotional and mental health.
Bill for the postpartum depression screening only when using one of the standardized screening instruments. Refer to the following criteria when billing for a postpartum depression screening:
The NCCI procedure-to-procedure (PTP) edit pairs immunization administration codes (90460, 90461, 90471-90474) with postpartum depression screening. You may receive the NCCI edit when submitting claims for postpartum depression screening with CPT code 96161.
These edits have a Correct Coding Modifier Indicator of “1” and will bypass the PTP edit if you correctly add a PTP-associated modifier. Refer to the Minnesota National Correct Coding Initiative (NCCI) webpage for information about modifiers.
Tobacco, Alcohol or Drug Use Risk Assessment
Risk assessment for tobacco, alcohol, and drug use is required for ages 11 through 20 years, followed by appropriate action. Refer to the C&TC Tobacco, Alcohol and Drug Use Risk Assessment fact sheet (PDF) for more information, including recommended risk assessment or screening tools.
Resources for adolescent health include the following:
Reimbursement for this assessment using a standardized tool is included in the payment of the Evaluation and Management (E&M) code used for a C&TC screening visit.
Immunization and Vaccinations
Review the immunization status of a child, teen or young adult compared to the current Recommended Childhood and Adolescent Immunization Schedule from the Advisory Committee on Immunization Practices (ACIP). ACIP is part of the Centers for Disease Control and Prevention (CDC) and provides current recommendations for vaccine administration, schedules of periodicity, and appropriate dosage and contraindications. Refer to the CDC’s Vaccines and Immunizations webpage.
State law requires all MHCP-enrolled providers who administer pediatric vaccines to enroll in the Minnesota Vaccines for Children (MnVFC) program. MDH administers the MnVFC for MHCP members ages 1 through 18 to provide most pediatric vaccines to participating providers at no cost. Providers must obtain vaccines through MnVFC whenever available.
MHCP covers flu and other recommended vaccinations for adults aged 19 or older.
When billing for immunizations or vaccinations administered during a C&TC visit, enter the correct immunization or vaccination codes with the SL modifier when applicable, and add the correct administration codes to the C&TC claim. Refer to the Immunizations and Vaccinations section of the MHCP Provider Manual for details on coding and billing criteria. All immunizations are part of the C&TC bundled payment rate.
Vaccine Counseling
Stand-alone vaccine counseling visits are covered when provided to children and youth under age 21. Providers may counsel for standard pediatric vaccines including COVID-19. Counseling may be provided either in person or via telehealth. Providers billing for counseling services must be able to administer the vaccine for which they are counseling. Billable stand-alone vaccine counseling visits do not replace immunization review and administration as required during a complete C&TC visit. Vaccine counseling visits are only billable when done outside of C&TC visits. Review the Immunizations and Vaccinations section of the MHCP Provider Manual for more information.
Stand-alone vaccine counseling visits codes
Code | Explanation |
G0312 | Immunization counseling by a physician or other qualified health care professional when vaccines are not administered on the same date of service for ages under 21 years, 5 to 15 minutes. (This code is used for Medicaid billing purposes.) |
G0313 | Immunization counseling by a physician or other qualified health care professional when vaccines are not administered on the same date of service for ages under 21 years, 16-30 minutes. (This code is used for Medicaid billing purposes.) |
G0314 | Immunization counseling by a physician or other qualified health care professional for COVID-19, ages under 21 years, 16-30 minutes. (This code is used for the Medicaid Early and Periodic Screening, Diagnostic, and Treatment Benefit [EPSDT].) |
G0315 | Immunization counseling by a physician or other qualified health care professional for COVID-19, ages under 21 years, 5-15 minutes. (This code is used for the Medicaid Early and Periodic Screening, Diagnostic, and Treatment Benefit [EPSDT].) |
Immunization and vaccinations resources
Refer to the following documents and webpages for more information:
Laboratory Tests or Risk Assessment
Refer to the Laboratory/Pathology Services section of the MHCP Provider Manual for information about billing for lab services.
MHCP covers venipuncture and capillary specimen collection and handling.
A Clinical Laboratory Improvement Amendments (CLIA) certified lab must perform and bill for most lab services.
If a provider has a CLIA-certified lab on site and lab services are provided on site, the CPT code for the lab service may be included in the C&TC visit claim. Payment for lab services is in addition to the C&TC bundled rate. If a provider refers patients off site to a CLIA-certified lab for lab tests or screenings that are required or part of a C&TC health visit, the off-site lab bills for the lab tests, not the provider. That lab test will not be included on the C&TC health visit claim.
If a required lab service was not done at a C&TC visit, do not include it on the C&TC visit claim. Include documentation in the medical record with the date and results of any required lab screening or test that the C&TC provider or another provider performed within the required age range.
Document in the medical record if a required lab screening or test was not done during the required age range C&TC visit due to the child, adolescent or parent declining the test or being uncooperative. Attempt the screening or test again in the future.
Blood lead test
All children enrolled in Medicaid are required to receive blood lead tests at ages 12 months and 24 months. Any child between 24 months and 72 months old with no record of a previous blood lead test must receive one blood lead test during that age range. Completion of a risk assessment questionnaire does not meet the Medicaid requirement. The Medicaid requirement is met only when the two blood lead tests (12 and 24 months or a catch-up blood lead test) are conducted. Lead testing can occur at other times within the ranges that are indicated on the C&TC Schedule of Age-Related Screening Standards (Periodicity Schedule) (DHS-3379) (PDF) and when medically necessary. A blood lead test done between ages 9 and 15 months can fulfill the 12-month requirement. A blood lead test completed for a child between ages 18 months and 24 months can fulfill the 24-month requirement.
When billing a blood lead test, use the correct CPT code for the lead test.
Refer to the following documents and websites for more blood lead resources:
Hematocrit or hemoglobin
Hemoglobin (Hb) or hematocrit (Hct) blood test is required as part of a C&TC visit at the following ages for diagnosis and prevention of iron deficiency and iron-deficiency anemia:
Refer to the C&TC Hemoglobin or Hematocrit fact sheet (PDF) for more information, including documentation of results and follow up.
Hepatitis C
Screen for Hepatitis C Virus (HCV) infection using a Food and Drug Administration (FDA)-approved anti-HCV laboratory test. This is recommended once for young adults ages 18 and older. A licensed health care provider (physician, nurse practitioner, physician assistant) must interpret the results of HCV screening and ensure appropriate follow-up testing if needed. Document that the HCV lab test was complete, test results, and any needed treatment or follow up.
Refer to the C&TC Hepatitis C Virus (HCV) Screening fact sheet (PDF) for more information.
Tuberculosis (TB) risk assessment
Complete a risk assessment followed by appropriate action for children ages 1, 6, 12, and 24 months and annually beginning at age 3 for their risk of exposure to TB. High-risk children include those in the following groups:
TB testing is not mandatory but is a covered service if clinical documentation supports the medical need for the test. Bill with the appropriate CPT code on the C&TC screening claim when performing TB testing during a C&TC screening. Review the C&TC Tuberculosis Risk Assessment fact sheet (PDF) and the Pediatric TB Risk Assessment Tool (PDF) for more information and recommendations.
Sexually transmitted infection (STI) risk assessment, human immunodeficiency virus (HIV) lab test, and syphilis screening lab test
Beginning no later than 11 years of age, assess all youth for risk of sexually transmitted infections at each C&TC well visit.
Universal HIV screening (offering HIV blood testing to all youth, regardless of risk factors) is required at least once between 15 and 18 years of age, as recommended by the American Academy of Pediatrics (AAP) and Centers for Disease Control and Prevention (CDC). Refer to the MDH C&TC STI Risk Assessment fact sheet (PDF) and C&TC HIV Screening fact sheet (PDF) for more information, including appropriate documentation of confidential screening test results in medical records. Providers may screen for STIs without parental knowledge or consent. If the youth declines the HIV test, or if HIV status is already known, document the reason that the HIV blood test was not done. Youth who have risk factors for HIV exposure should be tested at least annually. Refer to Minnesota Statutes, 144.343.
Beginning Oct. 1, 2025, syphilis screening lab test is a recommended component at least once for young adults 18 years and older. A licensed health care provider (physician, nurse practitioner, physician assistant) must interpret the results of the screening lab test and ensure appropriate follow-up testing if needed. Document that the syphilis lab test was completed, test results, and any needed treatment or follow up.
Refer to the C&TC Syphilis Screening fact sheet (PDF) for more information.
Resources for adolescent health include the following:
Dyslipidemia risk assessment
A risk assessment is required for children at the ages indicated on C&TC Schedule of Age-Related Screening Standards (Periodicity Schedule) (DHS-3379) (PDF). Refer to the Expert Panel on Integrated Guidelines for Cardiovascular Health and Risk Reduction in Children and Adolescents: Summary Report for risk assessment guidelines. Refer to the C&TC Dyslipidemia Risk Assessment fact sheet (PDF) for more information.
Vision screening
A vision risk assessment is required for children younger than 3 years old followed by appropriate action. Provide distance visual acuity screening beginning at age 3. Add near visual acuity (plus lens) screening beginning at 5 years for children who pass their distance screening and do not already have corrective lenses. Use a wall chart at a 10-foot distance.
Starting at age 11, vision screening must be done once during each of the age ranges as indicated on the C&TC Schedule of Age-Related Screening Standards (Periodicity Schedule) (DHS-3379) (PDF).
Refer to the MDH C&TC Vision Screening webpage for detailed procedures, including when a child wears prescription lenses and is under the care of an eye professional. Refer to equipment for visual acuity screening (PDF) for recommended wall charts and equipment. Instrument-based vision screening may be used as an alternative to wall charts for children 3-5 years old who are unable or unwilling to cooperate with routine vision screening. Refer to the C&TC Vision Screening fact sheet (PDF) for more information.
Bill instrument-based vision screening using CPT codes 99174 or 99177.
An NCCI procedure-to-procedure (PTP) edit pairs preventive visit CPT codes in the range of 99381–99397 with vision screening. You may receive the NCCI edit when submitting claims for vision screening with CPT code 99173. These edits have a Correct Coding Modifier Indicator of “1” and bypass the PTP edit if you correctly add a PTP-associated modifier. Refer to the Minnesota National Correct Coding Initiative (NCCI) webpage for information about modifiers.
Hearing screening
Provide hearing risk assessment at all C&TC visits up to 3 years of age or until pure tone audiometry can be performed. Providers must review newborn hearing screen results at the initial newborn C&TC visit. Pure tone audiometry screening is recommended beginning at age 3 years and required starting at age 4 years.
Beginning at 11 years, the addition of a 6,000 Hz at 20 dB hearing screening is required to screen for noise-induced hearing loss once during each of the age ranges as indicated on the C&TC Schedule of Age-Related Screening Standards (Periodicity Schedule) (DHS-3379) (PDF). Refer to the MDH C&TC Hearing Screening webpage for detailed procedures and instrument recommendations. Refer to the C&TC Hearing Screening fact sheet (PDF) for more information.
Covered Services – Oral Health Screening by a C&TC Medical Provider
The C&TC oral health screening components include the following:
Refer to the C&TC Schedule of Age-Related Dental Standards (Dental Periodicity Schedule) (DHS-5544) (PDF) for Minnesota’s age-related dental standards schedule details. Refer to the American Academy of Pediatric Dentistry Periodicity of Examination, Preventive Dental Services, Anticipatory Guidance/Counseling, and Oral Treatment for Infants, Children, and Adolescents (PDF) for more information.
Primary care provider requirements include the following:
Oral health, including fluoride varnish (FVA) and silver diamine fluoride (SDF)
Fluoride varnish application (FVA):
Obtain informed consent for this procedure, either verbally or in writing. Document that you obtained verbal consent, including discussion of benefits and risks of FVA, with each application. Alternatively, written consent signed by the parent or guardian is valid for up to one year.
For more information on FVA by primary care and other nondental providers, refer to the Fluoride varnish in the Child and Teen Checkups (C&TC) setting webpage and the C&TC Oral Health and Fluoride Varnish fact sheet (PDF), and the National Maternal and Child Oral Health Resource Center.
FVA primary provider billing
Use CPT code 99188: Primary care providers (physicians or other qualified health care professionals) and trained clinical staff.
Silver Diamine Fluoride (SDF)
The American Medical Association (AMA) approved a code for health care professionals to receive reimbursement for the application of SDF to arrest dental caries lesions without the provision of restorative care. The application of SDF in the pediatric medical home is new and training considerations are evolving. The American Academy of Pediatrics (AAP) recommends one-on-one training from dental professionals. Providers may apply this solution to a tooth or teeth where there is a visible need identified during the open-mouth exam at a C&TC visit. Obtain informed consent and provide SDF education. Refer to Silver Diamine Fluoride (SDF) Application in the Pediatric Medical Setting webpage for more information.
SDF primary provider billing
Refer to the Non-Dental Health Provider section of the MHCP Provider Manual for specific billing instructions or for more information.
Other Covered Services
The following services are also covered:
Screening Exceptions
For some situations, it is not possible or appropriate to require C&TC providers to complete certain components of the C&TC screening as outlined in the C&TC Schedule of Age-Related Screening Standards (Periodicity Schedule) (DHS-3379) (PDF). According to the Administrative Uniformity Committee (AUC) recommendations, use the billing guidelines for the situations listed in the claim guideline exceptions table when you cannot perform screening components, or an initial screening is not appropriate.
If a screening component is refused by a parent or young adult, provide education of the risks and benefits of the refused component.
Claims submitted using the guidelines for an exception identified in the following Claim guideline exceptions table will be recognized as completed C&TC claims. When submitting a claim, follow these requirements:
Claim guideline exceptions
Exception Reason | Situation | Claim Reporting and Medical Documentation |
Condition already identified (screening is not medically necessary) | ||
Screening recently provided | ||
Service is not applicable | Child’s teeth have not yet erupted; therefore, fluoride varnish application (FVA) may not be provided. | |
Service recently provided elsewhere | FVA was provided in another setting, such as the dental home or public health setting within the last 30 days | |
Parent or young adult declined | ||
Parent or young adult declined | ||
Unsuccessful attempt (Child uncooperative) | ||
Unsuccessful attempt (Child uncooperative) | ||
Screening instrument not reviewed | A developmental screening instrument was sent to parents but not returned for review at the time of the C&TC screening. |
Noncovered Services
MHCP does not cover the following services under C&TC:
Do not bill comprehensive preventive medicine E&M codes because they already include counseling, anticipatory guidance and risk factor reduction as part of the comprehensive exam.
Authorization
C&TC screening services and screening components do not require authorization. For diagnosis and treatment services that may require authorization, refer to the Authorization Policy section of the MHCP Provider Manual. For clinic or physician services provided to a child not included in the C&TC screening benefit, refer to the Physician and Professional Services section of the MHCP Provider Manual.
Billing
Use the 837P claim to bill for C&TC services. Refer to the MN–ITS User Guide for Child and Teen Checkups when submitting claims via MN–ITS Interactive. If billing X12 Batch, follow HIPAA electronic data interchange as outlined in the X12 implementation guides and follow the standards as outlined in the Minnesota Uniform Companion Guides.
C&TC billing processes include complying with HIPAA, AUC and MHCP system and data requirements. Billing C&TC screening services accurately is necessary to do the following:
Follow the C&TC Schedule of Age-Related Screening Standards (Periodicity Schedule) (DHS-3379) (PDF) to identify required C&TC screening components for the periodic visit, including a referral to a dentist. Enter the appropriate CPT or HCPCS codes for each age-related component provided in MN–ITS 837P claim form. Include the following on claims for C&TC screening services:
Refer to the C&TC Schedule of Age-Related Dental Standards (Dental Periodicity Schedule) (DHS-5544) (PDF) for dental screening components.
Refer to the Dental Services section of the MHCP Provider Manual for policy and billing dental screening components.
Separate E&M Service
If a significant, separately identifiable E&M service is provided at the time of the C&TC screening, bill that E&M code with the modifier 25 on a separate claim from the C&TC. Send in electronic attachment supporting key components of the billed E&M. Also, documentation in the member’s health record must support key components of the billed E&M services and show that it is not an extended C&TC visit. Follow CPT instructions for appropriate coding.
Referrals
A referral for C&TC reporting purposes indicates that the child needs to be seen again for further assessment, diagnosis or treatment of a problem, or a concern that was identified during the C&TC screening. Include the appropriate referral code on the C&TC claim.
The referral can be made to the screening provider or to another provider and can be provided on the same day as the C&TC visit. Bill the referral services visit on a different claim than the C&TC even if the visit occurs on the same day as the C&TC screening.
Two-Character HIPAA-Compliant Referral Condition Codes and Definitions
C&TC HIPAA-compliant referral condition codes (also called referral codes) indicate a referral was made as result of the C&TC screening. C&TC claims must list the most appropriate HIPAA-compliant referral condition code: ST, S2, AV or NU. MHCP C&TC screening payment requires one of the four HIPAA-compliant referral condition codes to be entered at the claim (header) level. When no referral is indicated, use referral code NU.
DHS provides referral codes through a secure data system to C&TC programs throughout Minnesota (local public health and tribal health) under contract with DHS. C&TC program staff provide outreach communications and assistance to families of children younger than age 11 requiring further evaluation, diagnosis and treatment for a condition identified during the C&TC screening visit.
Use the most appropriate referral code from the Two-character referral condition codes table. Refer to the C&TC HIPAA Compliant Referral Condition Codes fact sheet (PDF) for more information.
Two-character referral condition codes
HIPAA-compliant referral condition code | Use this referral condition code for billing when a C&TC screening results in one of the following: |
ST | |
S2 | The patient is currently under treatment for diagnostic or corrective health problems |
AV | One or more referrals were made and the patient or patient’s family declined one or more of the referrals |
NU |
HCPCS Code S0302
MHCP does not require the use of HCPCS code S0302 and considers this code as informational only.
If the HCPCS code S0302 is reported without a HIPAA-compliant referral condition code on that claim, the claim will deny.
DHS will recognize a claim as a C&TC screening only when a HIPAA-compliant referral condition code is entered on the claim.
Resources
Department of Human Services (DHS) C&TC resources
Use the MHCP Provider Manual in conjunction with the following resources:
Minnesota Department of Health (MDH) C&TC resources
Other C&TC resources
Training
Training and e-learning modules
Fluoride varnish online trainings
Recommended online trainings:
Silver Diamine Fluoride online training
Legal References
Minnesota Statutes, 144.343 (minor consent)
Minnesota Statutes, 256B.04, subdivision 1b (Contract for administrative services for American Indian children)
Minnesota Statutes, 256B.0625, subdivision 14 (Diagnostic, screening, and preventative services)
Minnesota Statutes, 256B.0625, subdivision 39 (Childhood immunizations)
Minnesota Statutes, 256B.0625, subdivision 58 (Early and periodic screening, diagnosis, and treatment services)
Code of Federal Regulations, title 42, section 441.50-441.62 (Early and Periodic Screening, Diagnosis, and Treatment of Individuals Under Age 21)
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