CurrentNeighborhood Health Plan of Rhode IslandPolicy N/A

Children’s Care Services Payment Policy

Payment policy governing coverage, billing, limits, and documentation for pediatric services (preventive visits, screenings, fluoride varnish, early intervention, ocular photoscreening, school-based health center services, and pediatric COVID vaccine counseling) for Neighborhood Health Plan of Rhode Island members (Medicaid excluding EFP/RHP/RHE and Commercial).

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyChildren’s Care Services Payment Policy

Policy CodePolicy N/A

Change TypeMultiple annual and coding updates (revised/added)

Effective DateSep 1, 2010

Next Review Date

Key ActionObtain authorization prior to ocular photoscreening for members age 5 years and older.

SourceLink

POLICY UPDATE CHANGES

07/01/2024 annual review; removed Table 4 requirements for Fluoride Varnish.

05/09/2023 added Table 3 and 4 with specific requirements around Pediatric Developmental/Autism Screenings and Fluoride Varnish.

01/01/2023 removed authorization language around Pediatric Development and Autism Screenings.

10/01/2022 updated Coverage Limitations and Exclusions to include Pediatric COVID Vaccine Counseling language and newborn billing guidance.

12/03/2021 added Temporary Pediatric COVID Vaccine Counseling language effective 9/1/21.

MultipleCovered Service Categories

4Fluoride varnish annual unit limit

Developmental/Autism screenings (age ≤3)

1CRAFFT annual unit limit (ages 11-21)

Policy summary & scope

This payment policy governs reimbursement and billing rules for pediatric services for Neighborhood Health Plan of Rhode Island members, including preventive visits, screenings (developmental, autism, CRAFFT), fluoride varnish, early intervention services, ocular photoscreening, school-based health center services, and temporary pediatric COVID vaccine counseling. It applies to Medicaid (excluding EFP, RHP, RHE) and Commercial plans.

This policy is informational only and is not a guarantee of payment; claims are subject to member eligibility, applicable benefit coverage, provider contract terms, authorization requirements, coding and documentation guidelines, and may be audited. Providers must verify eligibility, coverage, and authorization criteria prior to rendering services and retain documentation supporting billed services in accordance with CMS standards.

Effective date: 2010-09-01. Last review: 2024-07-01.

PayerNeighborhood Health Plan of Rhode Island

Policy titleChildren's Care Services Payment Policy

Policy numberN/A

Effective date2010-09-01

Last review2024-07-01

Next review

StatusCURRENT

Scope summaryPayment policy governing coverage, billing, limits, and documentation for pediatric services (preventive visits, screenings, fluoride varnish, early intervention, ocular photoscreening, school-based health center services, and pediatric COVID vaccine counseling) for Neighborhood Health Plan of Rhode Island members (Medicaid excluding EFP/RHP/RHE and Commercial).

Coverage criteria and limits

General Coverage / Medical Necessity

Covered when ALL of the following are met:

ALL of the following

Service is medically necessary
Provider verifies member eligibility, coverage and authorization criteria prior to rendering services
Coverage aligns with applicable NCD, LCD, InterQual, RI EOHHS recommendations, and Neighborhood Clinical Medical Policies

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Code lists and billing categories

Covered CPT / HCPCS (Table 1 major codes listed)mixedCovered

92522	Evaluation of speech sound production (eg, articulation, phonological process, apraxia, dysarthria)
92523	Evaluation of speech sound production with evaluation of language comprehension and expression (eg, receptive and expressive language)
92557	Comprehensive audiometry threshold evaluation and speech recognition (92553 and 92556 combined)
96112	Developmental test administration; first hour
96113	Developmental test administration; each additional 30 minutes
97161	Physical therapy evaluation: low complexity; typically 20 minutes face-to-face
97162	Physical therapy evaluation: moderate complexity; typically 30 minutes face-to-face
97163	Physical therapy evaluation: high complexity; typically 45 minutes face-to-face
97164	Re-evaluation of physical therapy established plan of care; typically 20 minutes face-to-face
97165	Occupational therapy evaluation, low complexity; typically 30 minutes face-to-face

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COVID Vaccine Counseling Codes (Table 2)CPTCovered

99401	Preventive medicine counseling and/or risk factor reduction intervention; individual, approximately 15 minutes
99402	Approximately 30 minutes
99403	Approximately 45 minutes
99404	Approximately 60 minutes

Pediatric Development/Autism Screening Diagnosis CodesICD-10Covered

Z00.121	Encounter for routine child health examination with abnormal findings
Z00.129	Encounter for routine child health examination without abnormal findings

Developmental Screening Code (Table 3)CPTCovered

96110

Developmental screening, with scoring and documentation, per standardized instrument

Vision/Hearing Screening Not Separately Billable (Exclusions)CPTNot Covered

99172	Vision screening; bundled into routine pediatric visit
99173	Vision screening automated; bundled into routine pediatric visit
92551	Screening test, pure tone, air only; bundled into routine pediatric visit

Billing, authorization & documentation actions

Prior Authorization

Authorization requirement for ocular photoscreening >= age 5

Ocular photoscreening for members age 5 years and older requires authorization prior to service.

Authorization required for members age 5 years and older

Billing Rule

Pediatric COVID counseling billing modifiers and timing

Bill COVID vaccine counseling (99401-99404) only on same day as a scheduled preventive or sick visit; report with modifiers CR and 25; bill once (1 unit) per member per day; member cost sharing waived for counseling.

Affected codes: 99401, 99402, 99403, 99404
Required modifiers: CR and 25

Key definitions and POS codes

School-based Health Center POS codesEpisodes of care can occur across settings including School (POS 03), Office (POS 11), Home (POS 12), Urgent Care (POS 20), Outpatient (POS 22), FQHC (POS 50).

Document changes & timeline

2021-12-03added

Added Temporary Pediatric COVID Vaccine Counseling language effective 9/1/21; temporary coverage reimbursed when billed with CPT 99401-99404 with modifiers CR and 25, once per member per day, waived member cost sharing when on same day as scheduled preventive or sick visit.

2022-10-01revised

Updated Coverage Limitations and Exclusions to include Pediatric COVID Vaccine Counseling language and newborn billing guidance (claims may be submitted under mother's member ID for first 30 days).

2023-01-01revised

Removed authorization language around Pediatric Development and Autism Screenings.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyChildren’s Care Services Payment Policy

Policy CodePolicy N/A

Change TypeMultiple annual and coding updates (revised/added)

Effective DateSep 1, 2010

Next Review Date

Key ActionObtain authorization prior to ocular photoscreening for members age 5 years and older.

SourceLink

On This Page

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Pediatric COVID Vaccine Counseling

Temporarily covered when ALL of the following are met:

ALL of the following

Counseling is provided on the same day as a scheduled preventive or sick visit
May be billed once (1 unit) per individual member per day
Must be billed with CPT code 99401, 99402, 99403, or 99404 and modifier CR and modifier 25
Member cost sharing is waived for this counseling service (cost sharing may apply to the office visit code if applicable)
Not covered if there is no scheduled office visit for that day
Age limit: children up to and including age 21 years

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Early Intervention Services

Covered when ALL of the following are met:

ALL of the following

Rendered by a state certified Early Intervention (EI) provider
Member is qualified and age is birth up to 3 years

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Fluoride Varnish

Covered when ALL of the following are met:

ALL of the following

Rendered by the member's PCP or covering practitioner
Member age between 6 months and 18.99 years
Annual limit of 4 units per calendar year4 units per calendar year

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CRAFFT Screening (Substance Use) (Ages 11-21)

Covered when ALL of the following are met:

ALL of the following

Member age between 11 and 21 years
Limit: 1 unit per calendar year1 unit per calendar year

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Pediatric Developmental Screening

Covered when ALL of the following are met:

ALL of the following

Rendered by the member's PCP or covering practitioner
ANY of the following
- Age <= 3: If member age up to 3 years: limit 5 services5 services up to age 3
- Age 3-21: If member age 3 to 21 years: limit 1 per year1 per year for ages 3-21
Must be billed with one of the diagnosis codes Z00.121 or Z00.129 and with a code from Table 3 (96110)

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Pediatric Autism Screening

Covered when ALL of the following are met:

ALL of the following

Rendered by the member's PCP or covering practitioner
ANY of the following
- Age <= 3: If member age up to 3 years: limit 5 services5 services up to age 3
- Age 3-21: If member age 3 to 21 years: limit 1 per year1 per year for ages 3-21
Must be billed with one of the diagnosis codes Z00.121 or Z00.129 and with a code from Table 3 (96110) with modifier U1

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Ocular Photoscreening

Coverage by age/authorization:

ANY of the following

Without authorization
- Member ages 6 months up to 5 years
With authorization
- Member age 5 years and older

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School-based Health Center Services

Covered when ALL of the following are met:

ALL of the following

Services provided at school-based health centers per regulatory requirements
Services are provided to children greater than 11 and up to age 21
Covers well and sick visits, immunizations, chronic care visits (e.g., asthma, diabetes), and physicals as appropriate

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Prenatal Pediatric Visit

Coverage limitation:

ALL of the following

Limit to no more than 2 visitsMaximum 2 visits
Each visit up to 30 minutesUp to 30 minutes per visit

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Fluoride varnish annual limit4 units per calendar year

CRAFFT screening limit1 unit per calendar year (ages 11-21)

Pediatric Developmental screening limitsIf age ≤3: up to 5 services; Age 3-21: 1 per year (must bill with Z00.121 or Z00.129 and code 96110)

Pediatric Autism screening limitsIf age ≤3: up to 5 services; Age 3-21: 1 per year (must bill with Z00.121 or Z00.129 and code 96110 with modifier U1)

Prenatal pediatric visit limitMaximum 2 visits, up to 30 minutes each

May be billed once (1 unit) per member per day

Member cost sharing for counseling is waived

Billing Rule

Pediatric Development/Autism Screening billing requirements

Pediatric Developmental Screening and Pediatric Autism Screening must be billed with diagnosis code Z00.121 or Z00.129 and a code from Table 3 (96110); Autism screening additionally requires modifier U1.

Required diagnosis codes: Z00.121, Z00.129
Required screening code: 96110
Autism screening additionally requires modifier U1

Billing Rule

Vision and hearing screening bundling rule

Vision (99172, 99173) and hearing (92551) screenings are considered part of the routine pediatric visit and are not separately billable.

Codes not separately billable: 99172, 99173, 92551

Billing Rule

Newborn claim submission

Claims for newborns may be submitted under the mother's member ID for the first 30 days of life; after 30 days submit under the newborn's member ID.

Documentation Required

Medical record retention and support

Neighborhood may request medical records for any billed service; documentation must support services billed and medical necessity and follows CMS documentation standards.

Neighborhood may request medical records for any billed service
Documentation must support billed services and medical necessity
Documentation follows CMS standards

2023-05-09added

Added Table 3 and Table 4 to the coding grid with specific requirements for Pediatric Developmental/Autism Screenings (Table 3: CPT 96110) and Fluoride Varnish (Table 4).

2024-07-01revisedLatest

Annual review: removed Table 4 requirements for Fluoride Varnish; operational coding/requirement change to Fluoride Varnish rules — material change indicated.