NC Medicaid Children's Developmental Service Agencies (CDSAs)
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Defines the roles, covered services, and service descriptions for North Carolina Infant-Toddler Program local lead agencies (CDSAs) and lists the Medicaid-covered early intervention services and responsibilities of CDSAs. Applies to providers and beneficiaries participating in NC Medicaid through CDSAs.
No material clinical or coverage changes in this revision.
Coverage Criteria for CDSA Early Intervention Services
General Coverage (CDSA responsibilities and service types)
Medicaid covers multidisciplinary early intervention services delivered or coordinated by CDSAs when provided for evaluation, diagnosis, habilitation, rehabilitation, prevention, or service planning for eligible infants and toddlers.
From 1.0 Description
Service-Specific Coverage
Medicaid-covered service categories and the circumstances/functions for which each service is provided.
1.1 Audiological Services
1.2 Nutrition Services
1.3 Occupational Therapy
1.4 Physical Therapy
1.5 Psychological Services
1.6 Speech and Language Services
1.7 Medical Services
1.8 Clinical Social Work Services
General Criteria Covered
Covered when ALL of the following are met
From Sec 3.1
IFSP and Outpatient Therapy Criteria
Covered when ALL of the following are met
From Sec 3.2.2
Medicaid Additional Criteria Covered
Covered when ALL of the following are met
Refer to policy 10A for detailed PT/OT/SLP criteria
General and Additional Not Covered
Not covered when ANY of the following apply
From Sections 4.1 and 4.2.2
Sections 4.0 and 4.1 of the Table of Contents indicate that there are both general and specific criteria for services that are not covered under this policy. The full policy text for specific exclusions is not present in this excerpt, but providers should refer to the policy's When Not Covered sections for detailed exclusion language and any referenced subsections before billing or delivering services.
For beneficiaries under age 21, the EPSDT special provision applies: Medicaid must cover services that are medically necessary to correct or ameliorate a defect, illness, or condition identified through screening or evaluation. EPSDT does not, however, require coverage of services that are unsafe, ineffective, experimental or investigational, or that are not medical in nature or not generally accepted medical practice. When requesting exceptions to policy limitations for EPSDT-eligible beneficiaries, documentation must show the service meets EPSDT medical necessity criteria and that equivalently effective, less costly statewide options have been considered where applicable.
No additional or specific "not covered" criteria are listed in Subsection 3.2.1 and Subsection 4.2.1 of this policy; both sections state None Apply. Providers should therefore rely on the general coverage and not-covered criteria elsewhere in the policy when determining eligibility for coverage.
All claims must report diagnoses using ICD-10-CM codes to the highest level of specificity that supports medical necessity, using the current edition in effect at the time of service. If clinicians use DC:0-5 diagnostic terminology for clinical purposes, claims must still be submitted with the corresponding ICD-10 diagnosis code mapped to the chosen DC:0-5 diagnosis.
For services delivered via interactive audio-visual telehealth, providers must append modifier GT to the CPT or HCPCS code. This modifier is explicitly not appropriate for non-interactive virtual patient communications or remote patient monitoring; providers should follow the Telehealth, Virtual Communications, and Remote Patient Monitoring policy (Policy 1-H) for additional guidance on non-interactive modalities.
The Table of Contents references a Not Medically Necessary (NMN) section (4.0), but the specific NMN conditions are not included in the excerpt provided. Providers should review the complete policy text for the full list of NMN conditions before concluding a service is not medically necessary under this policy.
There are no additional specific criteria applicable in the referenced subsection: Subsection 3.2.1 states None Apply. Coverage determinations should therefore be based on the policy's general medical necessity rules and the IFSP-specific criteria where relevant.
High-level reasons a service may be not covered include: the beneficiary does not meet the policy eligibility requirements (Section 2.0); the beneficiary does not meet the policy coverage criteria (Section 3.0); the procedure/product/service duplicates another provider's service; or the procedure/product/service is experimental, investigational, or part of a clinical trial. EPSDT exceptions for beneficiaries under 21 are noted elsewhere and may affect these determinations.
Claims and Coding (Attachment A mappings and modifiers)
| see Attachment A | Claims-related coding information (ICD-10-CM/PCS, CPT/HCPCS codes, modifiers, billing units) provided in Attachment A |
| CPT codes | CPT codes, descriptors, and other data referenced for audiological services (copyright noted) |
| 90785+ | mapped to 92557; add-on |
| 90791 | mapped to 92567 / 96112 / 97750 (see Attachment A mappings) |
| 90792 | mapped to 92568 / 96113 / 97802 (see Attachment A mappings) |
| 90832 | mapped to 92579 / 96121 / 97803 (see Attachment A mappings) |
| 90833 | mapped to 92583 / 96132 / 99202 (add-on as listed) |
| 90834 | mapped to 92585 / 96133 / 99203 (see Attachment A mappings) |
| 90836 | mapped to 92587 / 96136 / 99204 (add-on as listed) |
| 90837 | mapped to 92590 / 96137 / 99205 (see Attachment A mappings) |
| 90838 | mapped to 92591 / 96138 / 99211 (see Attachment A mappings) |
| 90839 | mapped to 92592 / 96139 / 99212 (see Attachment A mappings) |
| 92555 | CPT Code listed |
| 92556 | CPT Code listed |
| 90785 | Interactive Complexity add-on |
| 90791 | Psychiatric diagnostic evaluation |
| 90792 | Psychiatric diagnostic evaluation with medical services |
| 90832 | Psychotherapy 30 minutes |
| 90833 | Psychotherapy add-on |
| 90834 | Psychotherapy 45 minutes |
| 90836 | Psychotherapy add-on |
| 90837 | Psychotherapy 60 minutes |
Provider Actions — Prior Approval, Billing, Documentation, and Denial Risks
Prior approval high-level change
Medicaid prior approval rules for CDSA services were revised effective 2025-01-01: prior approval is not required for Children's Developmental Service Agencies (CDSAs). Note that prior approval remains required for certain other policies (for example, Clinical Coverage Policy 10A, Outpatient Specialized Therapies). Providers must consult the referenced policies for any services that do require prior approval.
- Effective 2025-01-01: Prior approval is not required for services provided by CDSAs under this policy.
- Prior approval IS required for Clinical Coverage Policy 10A (Outpatient Specialized Therapies).
Code reporting requirement
Providers must report the appropriate CPT and HCPCS procedure codes (including add-on codes) and billing modifiers when submitting claims for IFSP-related services. Add-on codes (marked with '+') are never billed alone and must be submitted in conjunction with the related primary procedure code.
- Include the IFSP-specific CPT/HCPCS codes on claims (see Attachment A Code(s)).
- Report add-on codes only as additions to primary service codes; do not bill add-on codes as stand-alone services.
- Follow CPT and HCPCS instructions when billing unlisted procedures and include special reports when required.
CDSA oversight responsibilities
CDSAs are the local lead agencies for the NC Infant-Toddler Program and are responsible for oversight and compliance of program services. CDSAs must ensure salaried and contracted personnel adhere to documentation and service requirements and must maintain required records accessible to NC Medicaid.
- CDSA responsibilities include receiving referrals, contacting families, determining eligibility, providing services, and reviewing IFSPs.
- CDSAs must ensure personnel follow documentation requirements and allow NC Medicaid access to required records.
Eligibility verification and enrollment
Providers must verify Medicaid eligibility at every encounter and ensure the beneficiary is enrolled in NC Medicaid before providing services. Services may be denied if the beneficiary is not enrolled or eligibility is not verified for each visit.
- Verify beneficiary enrollment and Medicaid eligibility at the time of each service.
- Confirm there are no service restrictions tied to the beneficiary's eligibility category that would make them ineligible for the service.
Triggers for denial
Claims or services may be denied for a number of triggers. Common denial triggers include unmet eligibility, failure to meet medical-necessity or policy criteria, duplicate services, services not documented in the IFSP, experimental services, or failure to obtain required prior approval where applicable.
- Beneficiary does not meet Section 2.0 eligibility requirements.
- Service does not meet the medical necessity criteria in Section 3.0 or EPSDT criteria for under-21 beneficiaries.
- Service duplicates another provider's service or is experimental/investigational.
- Services provided that are not outlined in the IFSP or that do not follow policy guidelines.
- Failure to obtain prior approval when required for services covered under other policies (e.g., 10A).
Missing IFSP modifier
When billing IFSP-related services, append the required IFSP modifier (TL) to applicable CPT/HCPCS codes. Failure to include required IFSP modifiers may result in incorrect processing or denial of the claim.
- Append the IFSP modifier (e.g., TL) to applicable procedure codes on the claim.
- Ensure place of service is designated appropriately and matches the IFSP location when required.
EPSDT medical necessity documentation
For beneficiaries under 21, providers must document EPSDT medical necessity when requesting services that exceed standard policy limits. Documentation must demonstrate how the service will correct or ameliorate a defect, illness, or condition, or prevent it from worsening, consistent with EPSDT criteria.
- Under-21 status does NOT waive prior approval requirements where those apply; follow NCTracks and EPSDT guidance for prior approval processes.
- Documentation should show how the requested service meets EPSDT criteria (correct/ameliorate, improve/maintain health, prevent worsening or additional problems).
- See NCTracks Provider Claims and Billing Assistance Guide and the EPSDT provider page for additional prior approval and documentation guidance.
Background and Program Context
Children's Developmental Service Agencies (CDSAs) serve as the local lead agencies for the North Carolina Infant-Toddler Program under IDEA Part C. CDSA responsibilities include receiving referrals, contacting families of potentially eligible children, determining eligibility, providing initial and ongoing early intervention services through staff and contracted providers, and developing and reviewing Individualized Family Service Plans (IFSPs). These oversight functions are integral to ensuring services are provided appropriately and in accordance with Medicaid coverage rules.
Key Definitions
Policy Revision History
Revised Section 5.0 and related subsections to remove prior approval requirements for Clinical Coverage Policies 8C (Outpatient Behavioral Health Services Provided by Direct-Enrolled Providers) and 8A-5 (Diagnostic Assessment), clarified that prior approval remains required for Policy 10A (Outpatient Specialized Therapies), and updated Section 5.1 wording to reflect these changes to comply with MHPAEA and CFR §438.900.
Corrected omission of multiple CPT codes (including 90838, 90849, 90853, 96138, 96139 and telehealth/telephonic eligibility corrections) and posted the policy with amended date 11/01/2023.
Updated policy template language due to North Carolina Health Choice Program's move to Medicaid; policy posted 4/15/2023 with effective date 04/01/2023.
Corrected omission in Attachment A Section C on 02/22/2023.
Corrected a date typo in section 8.0 amended date on 07/06/2023.
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