CurrentBlue Cross Blue Shield - New MexicoPolicy N/A

EPSDT (Early and Periodic Screening, Diagnostic, and Treatment) services for members under 21

Defines EPSDT-covered services and requirements for pediatric members under age 21, describing screening, diagnostic, treatment, and related support services that providers may deliver and bill. Applies to providers serving Blue Cross Blue Shield - New Mexico members eligible for EPSDT.

Policy Summary

PayerBlue Cross Blue Shield - New Mexico

PolicyEPSDT services for members under 21

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionDocument comprehensive screening components and use appropriate preventive or E/M CPT codes with supporting Z diagnosis code(s) for well-child visits.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

age <21eligible population

comprehensiveservice scope

multipleCPT codes referenced

EPSDT Coverage Criteria

Covered Services

Covered EPSDT services include the following categories:

EPSDT service categories: Screening; Diagnosis and treatment; Personal Care Services; Rehabilitation Services; Case Management; Comprehensive unclothed physical exam; Therapies; Mental Health Services; Medical Health Services; Vision; Hearing; Dental; Appropriate immunizations; Lead toxicity screening; Laboratory tests; Health education (anticipatory guidance including child development; healthy lifestyles and accident and disease prevention); Developmental screenings that are part of the well-child visit; Transportation and scheduling assistance.

These services are covered as part of EPSDT when medically indicated for members under 21.

Coverage Principles

Clinical coverage principles:

Principles: A qualified provider operating within the scope of his or her practice can provide screening; diagnoses can generally be made on an outpatient basis; services that maintain or improve the child's current health condition are covered under EPSDT even if they do not cure the condition.

Policy Summary

PayerBlue Cross Blue Shield - New Mexico

PolicyEPSDT services for members under 21

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionDocument comprehensive screening components and use appropriate preventive or E/M CPT codes with supporting Z diagnosis code(s) for well-child visits.

SourceLink

On This Page

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Relevant Billing Codes

Preventive CPT codesCPTCovered

99381	New patient under one year
99382	New patient (ages 1-4 years)
99383	New patient (ages 5-11 years)
99384	New patient (ages 12-17 years)
99385	New patient (ages 18-20 years)
99391	Established patient under one year
99392	Established patient (ages 1-4 years)
99393	Established patient (ages 5-11 years)
99394	Established patient (ages 12-17 years)
99395	Established patient (ages 18-20 years)

1–10 of 11

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Evaluation and Management CPT CodesCPTCovered

99202-99205	New patient E/M codes
99213-99215	Established patient E/M codes

Referenced diagnosis (Z) codesICD-10

Z00.00-Z00.129	Z codes for well-child examination (as referenced broadly)
Z76.1	Persons encountering health services in other specified circumstances
200.8	Referenced in document (note: appears nonstandard or typographic)
202.89	Referenced in document (note: appears nonstandard or typographic)

Provider Requirements and Billing Guidance

Prior Authorization

Code listing — check PA policy

Check payer-specific prior authorization requirements before scheduling non-routine or specialty EPSDT services. Some diagnostic, imaging, therapy, or inpatient services may require prior authorization under Blue Cross Blue Shield - New Mexico; confirm via the plan's PA portal or provider manual.

Verify PA requirements for specialty therapies, imaging, and inpatient services with BCBSNM prior authorization guidance
Do not assume EPSDT coverage removes PA; confirm per-service

Documentation Required

Documentation for EPSDT services

Providers should document all EPSDT-related care thoroughly in the medical record. For well-child visits and EPSDT encounters include: documented screening components, developmental screening results, immunization records (dates and vaccine codes), lead screening results, anticipatory guidance provided, any referrals or care coordination, and any private nursing or personal care services delivered.

Document screening components and findings (growth, vision, hearing, developmental screens)
Record immunizations with vaccine name, date, and CVX/NDC as applicable
Include lead screening test date and result, and any follow-up actions
Detail anticipatory guidance topics discussed and any referrals or care plans
Retain supporting labs, diagnostic reports, and signed consent/plan of care for therapies or personal care services

Billing Rule

Billing code requirements

Use the appropriate E/M CPT code for the visit and include the required Z-code diagnosis to indicate a well-child/wellness encounter. Omitting the required Z diagnosis or using incorrect code combinations may cause denials or incorrect payment.

Use appropriate CPT E/M codes for new and established patients (e.g., 99202–99205 for new patient; 99213–99215 for established patient) when clinically indicated
Include at least one applicable Z-code for well-child services (e.g., Z00.00–Z00.129, Z00.8, Z02.89, Z76.1) as required by the payer
Report developmental screening and immunization CPT codes in addition to the E/M when those services were performed
Ensure diagnosis and procedure code combinations meet BCBSNM billing requirements to avoid denials

Note

Provider action / alert: follow payer guidance for submission, bundling, and use of modifiers when billing multiple EPSDT services on the same date of service. When in doubt, contact BCBSNM provider services or reference the provider manual.

Key Definitions

EPSDT definition — Early and Periodic Screening, Diagnostic and Treatment

TermEarly and Periodic Screening, Diagnostic and Treatment (EPSDT)

PopulationMedicaid-eligible individuals under 21 years of age

PurposeProvides comprehensive and preventive health care services to ensure individual children get the health care they need

ScopeServices are tailored to the unique needs of the child and include screening, diagnosis, and treatment

Preventive/Well-child services definition — screenings, developmental assessments, immunizations, anticipatory guidance

Core componentsScreenings (including developmental and lead toxicity screening) and laboratory tests

AssessmentsDevelopmental screenings that are part of the well-child visit and comprehensive unclothed physical exam

Preventive interventionsAppropriate immunizations and anticipatory guidance (health education on child development, healthy lifestyles, accident and disease prevention)

Support servicesPersonal care services, rehabilitation, case management, transportation and scheduling assistance

Additional clinical areasVision, hearing, dental, therapies, mental health and medical health services

OpenPayer

EPSDT (Early and Periodic Screening, Diagnostic, and Treatment) services for members under 21

EPSDT Coverage Criteria

Relevant Billing Codes

Provider Requirements and Billing Guidance

Policy Background

Key Definitions