Coverage of New Screening Services for Healthy Connections Checkup

Tagged: 

Effective August 1, 2014, The South Carolina Department of Health and Human Services (SCDHHS) will implement changes to the benefit structure for the Family Planning Eligibility Category, now to be known as Healthy Connections Checkup (Checkup).  Checkup is a Medicaid limited benefit program that provides coverage for preventive health care, family planning services and family planning-related services.  Checkup is available to men and women of all ages in South Carolina whose annual family income does not exceed 194 percent of the Federal Poverty Level (FPL) and who are ineligible for full Medicaid coverage under any other eligibility category.  Services currently covered under the Family Planning Eligibility Category will continue to be covered for individuals enrolled in Checkup.  It is estimated that up to 450,000 individuals are eligible for Checkup with enrollment as of July 1, 2014 at 107,000.

Effective with dates of service on or after August 1, 2014, the coverage guidelines for Checkup will be updated to include  biennial adult physical examination and preventive health screenings included in the United States Preventive Services Task Force (USPSTF) recommendations (Grades A & B).  The description and Table 1 below outline the coverage specifications for these new services.  Guidance is also provided regarding appropriate billing procedures, including those for referring Checkup beneficiaries for follow-up care.  For additional information about services currently covered under the Checkup benefit, please refer to the SCDHHS Provider Manual.  For additional guidance on the USPSTF and its recommended list of screenings, please visit http://www.uspreventiveservicestaskforce.org/.

New Covered Service: Biennial Adult Physical Examination

Effective with dates of service on or after August 1, 2014, the Checkup program will sponsor adult physical examinations under the following guidelines:

  • Physical Exams are allowed once every two years per patient.
  • The exams are preventive visits.
  • Procedure code G0438 should be used for new patients and G0439 for established patients
  • The FP modifier must be used when billing these codes for Checkup beneficiaries.
  • Diagnosis code V70.0 must be used when billing these codes for Checkup beneficiaries.
  • The exams can be performed by a Nurse Practitioner, Physician Assistant or Physician.                                 

The adult physical examination for Checkup beneficiaries is a preventive, comprehensive visit and should contain the following components, at minimum:

  • A past family, social and surgical history for a new patient or an interval history for an established patient
  • Height, weight and BMI
  • Blood pressure
  • A generalized physical overview of the following organ systems:

o EENT                       o Lungs                       o Abdomen

o Skin                          o Breasts (Female)     o External Genitalia

o Heart                        o Back                         o Pelvic (Female)

o Prostate (Male)        o Rectal                       o Brief neurological

o Brief Muscular         o Brief Skeletal           o Peripheral Vascular

  • Age, gender and risk appropriate preventive health screenings (see Table 1 below)

 

Family planning counseling must be offered to Checkup patients during the physical exam.

Portions of the physical may be omitted if not medically applicable to the patient’s condition or if the patient is not cooperative and resists specific system examinations (despite encouragement by the physician, NP or office staff). A note should be written in the record explaining why that part of the exam was omitted.

Note: If a medical condition and/or problem is identified during the physical examination that requires medical follow-up and the provider is unable to offer free or affordable care based on the patient’s income, the provider should refer the beneficiary to a provider who can offer services to uninsured or underinsured individuals (examples include FQHCs, RHCs, free clinics, etc.).  Please refer to the section below, titled “Referral Instructions for Healthy Connections Checkup”, for important information about billing for patient referrals.

New Covered Screenings: USPSTF Grade A & B Recommendations

Table 1 below outlines preventive health screenings and associated lab procedures that will be covered for Checkup beneficiaries effective with dates of service on or after August 1, 2014.  Codes for these screenings may be billed in addition to the code for the adult physical examination.  These screenings cover USPSTF Grade A & B recommendations (as of August 1, 2014) and are considered by SCDHHS to be Family Planning or Family Planning-related screenings.  Providers must bill for these screenings according to the guidelines below and must use the FP modifier for all codes billed.

  • STI Screenings will continue to be covered under existing guidelines.  Please refer to the SCDHHS Provider Manual for additional information on currently covered STI screenings.

 

Table 1 – Preventive Health Screenings

Description Appropriate for the following

Checkup Beneficiaries

Allowable Codes Required Modifier Provider Type Requirements Notes
Age and Risk-Appropriate Screenings for the Following:

 

  • Alcohol Misuse
  • BRCA Screening Questions
  •  Depression
  • Intimate Partner Violence
  • Obesity
  • Tobacco Use

Low-Intensity Counseling for the Following:

  • Healthy Diet
  • Skin Cancer Prevention

 

All adults

96150
96151
96152

FP

 

 

NP, PA or Physician Must occur during physical exam

 

 

Cholesterol Abnormalities Screening
  • Men ages 35+
  • Men ages 20-35 if at increased risk for coronary heart disease
  • Women ages 20+ if at increased risk for coronary heart disease
80061
82465
83718
FP

 

 

NP, PA or Physician Must occur during physical exam
Diabetes Screening Asymptomatic adults with sustained blood pressure (either treated or untreated) greater than 135/80 mm Hg 82947
82950
82951
83036
FP

 

 

NP, PA or Physician Must occur during physical exam
Hepatitis C Virus Infection Screening
  • All adults at high risk for virus infection
  • One-time screening for all adults born between 1945-1965
86803
86804
FP

 

 

NP, PA or Physician Must occur during physical exam
Breast Cancer Screening (Mammography) Women ages 50-74 77057
77052
77056
G0202
FP

 

 

Physician Only Can occur outside physical exam
Abdominal Aortic Aneurysm Screening Men ages 65-75 who have ever smoked G0389 FP Physician Only Can occur outside physical exam
Colorectal Cancer Screening Men and Women ages 50-75

45331
82270
82274
G0105

FP

 

 

Physician Only Can occur outside physical exam
Lung Cancer Screening for Smokers Adults ages 55 - 80 who have a 30 pack-year smoking history and currently smoke or have quit within the past 15 years 71260 FP

 

 

Physician Only Can occur outside physical exam
 

 

Billing Instructions for Federally Qualified Health Centers / Rural Health Centers

Federally Qualified Health Centers (FQHCs) and Rural Health Centers (RHCs) should follow the same billing procedures for the physical examination for Checkup beneficiaries that are used for billing the biennial adult physical examination for beneficiaries with full Medicaid coverage.  If any of the preventive health screenings or lab procedures listed above are currently billed in addition to the T1015 code when performed for a patient who has full Medicaid benefits, the same procedures should be followed for Checkup beneficiaries.  Please see the section titled “Referral Instructions for Healthy Connections Checkup” for important information regarding referral codes that should be included on Encounter claim forms for Checkup patients only.  Referral codes should always be included as a separate line on the encounter claim form.

Referral Instructions for Healthy Connections Checkup

Healthy Connections Checkup beneficiares have Medicaid coverage for a limited set of medical services.  Beneficiaries enrolled in Checkup are covered for preventive physical examinations and preventive health screenings, but do not have full Medicaid coverage for follow-up visits, treatment, or medication (apart from those specifically outlined in the benefit structure).

If a health condition or problem is identified during the physical examination or after the provider receives lab results from a preventive screening that was performed, the provider is required to refer the patient to a source of free or subsidized care.  SCDHHS strongly encourages providers to connect uninsured Checkup beneficiaries to sources of care such as FQHCs, RHCs, free clinics, subsidized hospital clinics, etc. 

For more information about where to refer Checkup patients for follow-up care, please visit the South Carolina Health Data website, www.schealthdata.org , for a listing of all FQHCs in the state or contact the SCDHHS Provider Service Center at (888) 289-0709.

Instructions

Effective with dates of service on or after August 1, 2014, providers that refer uninsured Checkup beneficiaries for follow-up care or treatment for a problem or condition identified during the physical examination or annual family planning visit can bill for this referral activity.  Providers must use the procedural coding and modifiers listed below.  These referral codes may only be used in instances when the follow-up care is not covered as a component of the Healthy Connections Checkup program. 

Note: At least one of the modifiers listed below is required when billing for referral codes.

Note: Providers should NOT use the FP modifier when billing for referral codes.

Providers that refer uninsured Checkup patients for follow-up care or treatment for any health issue identified during or after (lab results) the physical examination or annual family planning visit may bill for this referral activity using one of the following referral codes:

S0320 – Same Day Referral or Telephone Referral:Utilized when a patient is referred to follow-up care immediately after the physical exam or family planning visit OR if lab results are received after the physical exam or family planning visit and a) results can be explained to the patient by phone and b) referral to follow-up care can occur by phone.

S0316 – Different Day Referral (In-Person):Utilized when a patient is required to receive lab results in-person, on a different day than the physical exam or family planning visit occurs.

Billing Instructions

  1. Providers may include the S0320 – Same Day Referral or Telephone Referral on the same claim form as the physical examination or annual family planning visit.
  2. Providers may also bill for the S0320 – Same Day Referral or Telephone Referral on a separate claim form.  If submitting a separate claim form, diagnosis code V70.0 must be used.
  3. Providers must bill for the S0316 – In-person, Face-to-Face Referral on a separate claim form. Diagnosis code V70.0 must be used.
  4. Providers must include at least one modifier and up to four modifiers from the list below when billing for both the S0320 and S0316 referral codes.

Modifier Instructions

  1. Providers must use the appropriate modifier from the list below.  Up to 4 modifiers can be used for each referral code (so if a patient is referred to follow-up care for more than one positive screening, include modifiers for all positive screenings)
  1. If referring a patient for a positive diabetes screen, use modifier P1
  2. If referring a patient for a positive cardiovascular screen, use modifier P2
  3. If referring a patient for any positive cancer screen, use modifier P3
  4. If referring a patient for any mental or behavioral health screens, use modifier P4
  5. If referring a patient for any other condition or problem, use modifier P5

 

Referral Instructions for Checkup Providers who DO offer free or subsidized care to uninsured individuals (examples: FQHCs, hybrid clinics, RHCs, subsidized hospital clinics, etc.)

Providers that offer free or subsidized care to uninsured individuals should schedule follow-up visits with Checkup beneficiaries when a problem or condition is identified during or after the physical examination or family planning visit.  This activity is captured in the Encounter rate for the physical examination or family planning visit.  However, for data collection and monitoring purposes, providers who fall into this category should include the referral code and appropriate modifiers listed above as a separate line on the Encounter claim form (these codes will bill to $0.00).  The referral codes and accompanying modifiers will provide important data to SCDHHS regarding the utilization of follow-up care among the Checkup population.

Note: Uninsured Checkup patients will be responsible for any fees associated with follow-up visits.  All visits should follow the provider’s established policies and procedures for treating uninsured patients.

Referral Instructions for Healthy Connections Checkup Providers who refer patients for additional, preventive screenings

  1. If you are a provider that performs a physical examination for a Checkup beneficiary and are unable to perform certain preventive health screenings (examples include mammography, colonoscopy, AAA screening, and lung cancer screening using computerized tomography), you should refer the patient to a provider who is able to perform these screenings.  As a part of the Checkup benefit package, the patients will not be responsible for the cost of the screening.
  2. Providers are not allowed to submit a referral claim for this type of referral.

New Healthy Connections Checkup Cards

Beneficiaries who enroll in Checkup on or after September 1, 2014 will be issued a new Checkup card.  Current Family Planning beneficiaries will also be issued a new Checkup card to replace their current Healthy Connections Medicaid card. The new Checkup card, pictured below, is intended to differentiate Checkup beneficiaries from beneficiaries who receive full Medicaid benefits. 

       

For questions related to this Bulletin or the updated coverage guidelines for Healthy Connections Checkup, please email Checkup@scdhhs.gov or call the SCDHHS Provider Service Center at (888) 289-0709.

Thank you for your continued support of the South Carolina Healthy Connections Medicaid Program.

Report Fraud