ModifiedNeighborhood Health Plan of Rhode IslandPolicy N/A

Children's Care Services / Pediatric Preventive Care — Coverage Criteria

Governs coverage, limitations, coding, and documentation requirements for pediatric preventive and related children's care services for Neighborhood Health Plan of Rhode Island members (Medicaid and Commercial). Affects providers delivering well-child, sick, screening, early intervention, and related services for ages birth through 21.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyChildren's Care Services / Pediatric Preventive Care — Coverage Criteria

Policy CodePolicy N/A

Change TypeUpdated coverage limitations to add Pediatric COVID Vaccine Counseling language

Effective Date

Next Review Date

Key ActionVerify eligibility and obtain required authorizations or bill COVID counseling only on same day as a scheduled preventive or sick visit with CPT 99401-99404 and modifiers CR and 25.

SourceLink

POLICY UPDATE CHANGES

Updated Coverage Limitations and Exclusions to include Pediatric COVID Vaccine Counseling language.

Added Temporary Pediatric COVID Vaccine Counseling language effective 9/1/21.

Updated claims submission to include information about newborn billing.

4maximum fluoride varnish units per year

5developmental screening services allowed up to age 3 without authorization

1CR/25 modifier required for pediatric COVID vaccine counseling billing

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Coverage Criteria

Covered Services with Criteria

Covered when services are medically necessary and meet applicable age/setting limits:

General coverage: Services must be medically necessary per Neighborhood and may be evaluated against NCD, LCD, Interqual, EOHHS recommendations, and CMPs

Provider must verify eligibility and authorization prior to rendering services

Preventive and routine care

Fluoride varnish: Topical fluoride varnish administered by the member's PCP or covering practitionerAge 6 months to 18.99 years; maximum 4 units per calendar year
Provider must confirm member eligibility and render per preventive visit protocols
Ocular photoscreening: Instrument-based ocular photoscreening for vision screeningCovered without authorization for ages 6 months up to 5 years; authorization required for age 5 years and older
Follow age-specific authorization rules
Pediatric development and autism screening (age <3): Developmental and autism screening services rendered by the member's PCP or covering practitionerUp to 5 services without authorization for children up to age 3 years
May require authorization beyond limits
Pediatric development or autism screening (age 3-21): Development or autism screening rendered by the member's PCP or covering practitionerLimited to 1 per year without authorization for ages 3 to 21 years
Provider to verify limits and seek authorization if exceeding frequency
CRAFFT screening: CRAFFT substance use screening for adolescents1 unit per calendar year for ages 11-21 years
Render per adolescent preventive visit guidelines
Prenatal pediatric office visit: Prenatal pediatric visit for expectant mothers and newborn care planningLimited to no more than 2 visits, up to 30 minutes per visit
Count and duration must be documented
School-based health center services: PCP services provided at school-based health centersProvided to children greater than 11 and up to age 21 per regulatory requirements
Services are subject to school-based program rules

Early Intervention (EI): Early Intervention services for qualified children experiencing developmental delaysBirth up to age 3 years; services must be rendered by state certified EI providers

Must meet state EI eligibility and provider certification requirements

Pediatric COVID vaccine counseling: Covered when provided same day as a scheduled preventive or sick visit and billed with appropriate counseling CPT codesAge up to and including 21 years; may be billed once per member per day

Must be billed with CR and 25 modifiers when applicable; not covered if there is no scheduled office visit that day

Routine dental care is not covered for Medicaid members. For RIte Care eligible children born on or after May 1, 2000, providers should refer to the RIte Smiles program for dental coverage. Vision screening (CPT 99172, 99173) and hearing screening (CPT 92551) are considered part of the routine pediatric visit and are not separately billable.

The policy history was updated to add Pediatric COVID Vaccine Counseling language. Document History shows a material change on 10/01/2022 noting: “Updated Coverage Limitations and Exclusions to include Pediatric COVID Vaccine Counseling language,” and an earlier entry adding temporary Pediatric COVID Vaccine Counseling language effective 9/1/21.

Pediatric COVID vaccine counseling is not covered when provided to a member who does not have a scheduled office visit that same day. The exclusions section specifies this limitation and the Document History records the addition of Pediatric COVID Vaccine Counseling language to coverage limitations.

Coding and Billing

Covered CPT Codes (selected list included in policy)CPTCovered

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
92557	Comprehensive audiometry threshold evaluation and speech recognition (92553 and 92556 combined)
96110	Developmental screening with scoring and documentation, per standardized instrument
96112	Developmental test administration, by physician or qualified professional; first hour
96113	Developmental test administration; each additional 30 minutes
97161	Physical therapy evaluation: low complexity; typically 20 minutes
97162	Physical therapy evaluation: low complexity; typically 20 minutes
97163	Physical therapy evaluation: high complexity; typically 45 minutes
97164	Re-evaluation of physical therapy established plan of care; typically 20 minutes

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Listed procedure and service codesmixed

99382	Initial comprehensive preventive medicine evaluation and management, new patient; early childhood (age 1 through 4 years)
99383	Initial comprehensive preventive medicine evaluation and management, new patient; late childhood (age 5 through 11 years)
99384	Initial comprehensive preventive medicine evaluation and management, new patient; adolescent (age 12 through 17 years)
99385	Initial comprehensive preventive medicine evaluation and management, new patient; 18-39 years
99391	Periodic comprehensive preventive medicine reevaluation and management, established patient; infant (age younger than 1 year)
99392	Periodic comprehensive preventive medicine reevaluation and management, established patient; early childhood (age 1 through 4 years)
99393	Periodic comprehensive preventive medicine reevaluation and management, established patient; late childhood (age 5 through 11 years)
99394	Periodic comprehensive preventive medicine reevaluation and management, established patient; adolescent (age 12 through 17 years)
99395	Periodic comprehensive preventive medicine reevaluation and management, established patient; 18-39 years
D1206	Topical application of fluoride varnish

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COVID vaccine counseling modifier requirementmixedCovered

CR + 25 modifier	COVID vaccine counseling codes covered when billed with a CR and 25 modifier on the same day
99401	Preventive medicine counseling and/or risk factor reduction intervention(s); approximately 15 minutes
99402	Preventive medicine counseling and/or risk factor reduction intervention(s); approximately 30 minutes
99403	Preventive medicine counseling and/or risk factor reduction intervention(s); approximately 45 minutes
99404	Preventive medicine counseling and/or risk factor reduction intervention(s); approximately 60 minutes

inv-08: Age limit for fluoride varnish

Age limit for fluoride varnish6 months to 18.99 years

Applies toRendered by member's PCP or covering practitioner

Related codeD1206 / 99188 (see coding section)

inv-09: Fluoride varnish annual units

Annual maximum units4 units per calendar year

ProviderRendered by member's PCP or covering practitioner

Provider Actions, Authorization & Documentation

Prior Authorization

Authorization requirements and limits

Some services in this policy require prior authorization or are subject to unit/age limits. It is the provider's responsibility to verify eligibility, coverage and authorization criteria prior to rendering services. For questions contact Provider Services at 1-800-963-1001 and refer to Neighborhood's Prior Authorization Reference page and Clinical Medical Policies.

Ocular photoscreening: ages 6 months up to 5 years — no authorization required; age 5 years and older require authorization.
Fluoride varnish: limited to members age 6 months to 18.99 years; annual limit 4 units.
CRAFFT screening (ages 11-21): limit 1 unit per calendar year.
Pediatric development screening (age <3): up to 5 services without authorization.
Pediatric autism screening (age <3): up to 5 services without authorization.
Pediatric development or autism screening (age 3-21): limited to 1 per year without authorization.
Prenatal pediatric visit: limited to no more than 2 visits, up to 30 minutes per visit.
Pediatric COVID counseling: covered only with a scheduled office visit the same day; not covered if no scheduled office visit.

Background

Pediatric preventive care includes routine well-child visits, sick visits, age-appropriate screenings, counseling, immunizations, and developmental and autism screening following AAP guidance and applicable state law. Services within this scope—such as fluoride varnish application, vision and hearing screening (as part of the visit), developmental screening, ocular photoscreening, and Early Intervention services for eligible children up to age 3—are covered when medically necessary and when age and unit limits listed in the policy are met. Certain services have specified limits (for example, fluoride varnish and development screening) and other items—like routine dental care for Medicaid members—are excluded; providers must verify eligibility, coverage, and any authorization requirements prior to providing services.

Definitions

inv-24: Early Intervention (EI)

DefinitionEarly Intervention (EI) services: services rendered by state-certified EI providers for qualified children birth up to age 3 who are experiencing developmental delays

Provider requirementMust be delivered by state certified providers

Coverage scopeIncluded among covered pediatric services when medically necessary

Revision History

2022-10-01Annual ReviewLatest

Updated Coverage Limitations and Exclusions to include Pediatric COVID Vaccine Counseling language and updated claims submission guidance to include newborn billing under the mother’s member ID for the first 30 days of life.

2021-12-03Policy Addition

Added temporary Pediatric COVID Vaccine Counseling language effective 2021-09-01 to allow separate reimbursement when billed with required modifiers during a same-day visit.

2010-09-01Original Effective Date