ModifiedNeighborhood Health Plan of Rhode IslandPolicy N/A

Children's Care Services (Pediatric preventive and related services)

Defines coverage, limits, billing, and coding for pediatric preventive, screening, early intervention, and related primary care services for Neighborhood Health Plan members (Medicaid and Commercial). Affects providers delivering pediatric care in Rhode Island.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyChildren's Care Services (Pediatric preventive and related services)

Policy CodePolicy N/A

Change TypeRemoved and added coding/table requirementsauthorization language removed for developmental screenings

Effective DateSep 1, 2010

Next Review DateJul 1, 2024

Key ActionVerify member eligibility and billing conditions prior to services; bill developmental screening 96110 with Z00.121 or Z00.129 and Table 3 code.

SourceLink

POLICY UPDATE CHANGES

Removed Table 4 requirements for Fluoride Varnish.

Added Table 3 and 4 to Coding Grid with specific requirements around Pediatric Developmental/Autism Screenings and Fluoride Varnish.

Removed authorization language around Pediatric Development and Autism Screenings.

4maximum fluoride varnish units per year

5maximum pediatric development screening services up to age 3

30 daysnewborn claim submission window

6 mo–18.99 yrs

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Coverage and Benefit Rules

Covered Services

Covered when provided as medically necessary pediatric services per policy and guideline references

Covered pediatric services: Includes prenatal pediatric office visit; pediatric preventive care visits (well-child, routine, sick); pediatric screenings; fluoride varnish; early intervention services for qualified children birth to age 3; pediatric development and autism screening; ocular photoscreening.

Follow AAP guidelines and Rhode Island law as applicable

Screening and counseling coverage conditions

Covered when the following billing conditions are met

COVID vaccine counseling coverage: Counseling codes 99401-99404 are covered when billed with CR and 25 modifier on the same day as a scheduled preventative or sick visitmodifier CR and 25 present

Table 2

Pediatric Developmental Screening coverage: Developmental screening code 96110 must be billed with diagnosis code Z00.121 or Z00.129 and an appropriate Table 3 codediagnosis Z00.121 or Z00.129 plus Table 3 code

Table 3

Pediatric Autism Screening coverage: Autism screening services must be billed with diagnosis code Z00.121 or Z00.129 and a code from Table 3 with modifier U1diagnosis Z00.121 or Z00.129 plus Table 3 code with modifier U1

Section on Pediatric Autism Screening

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 guidance. Vision screening (CPT 99172, 99173) and hearing screening (CPT 92551) are considered part of the routine pediatric visit and are not separately billable. Pediatric COVID counseling is not covered when there is no scheduled office visit for the member on the same day.

As of 07/01/2024 the policy history notes that the prior Table 4 requirements for Fluoride Varnish were removed. Any billing or Table 4–specific requirements that had applied to Fluoride Varnish are no longer in effect as of that date.

No additional coverage text is present in the inventory for this item beyond what is captured elsewhere in the policy. Refer to the Covered Services and Coding sections for detailed coverage, limits, and billing requirements.

This payment policy is informational only and is not a guarantee of reimbursement. Claim payments are subject to Neighborhood Health Plan of Rhode Island benefit coverage, member eligibility, claims payment edit rules, coding and documentation guidelines, authorization policies, provider contract agreements, and state and federal regulations. Services that do not meet plan coverage, eligibility, coding, documentation, authorization, or regulatory requirements may be denied; Neighborhood reserves the right to audit claims and request medical records.

Billing Codes, Limits, and Coding Rules

Covered CPT/HCPCS 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
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)
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)
97165	Occupational therapy evaluation, low complexity (typically 30 minutes)

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Covered CPT Codes - Preventive E/MCPTCovered

99381	Initial comprehensive preventive medicine evaluation and management of an individual including age and gender appropriate history, exam, counseling/anticipatory guidance/risk factor reduction interventions, new patient; infancy (younger than 1 year).
99382	Initial comprehensive preventive medicine evaluation and management ... early childhood (age 1 through 4 years).
99383	Initial comprehensive preventive medicine evaluation and management ... late childhood (age 5 through 11 years).
99384	Initial comprehensive preventive medicine evaluation and management ... adolescent (age 12 through 17 years).
99385	Initial comprehensive preventive medicine evaluation and management ... 18-39 years.
99391	Periodic comprehensive preventive medicine reevaluation and management ... infant (age younger than 1 year).
99392	Periodic comprehensive preventive medicine reevaluation and management ... early childhood (age 1 through 4 years).
99393	Periodic comprehensive preventive medicine reevaluation and management ... late childhood (age 5 through 11 years).
99394	Periodic comprehensive preventive medicine reevaluation and management ... adolescent (age 12 through 17 years).
99395	Periodic comprehensive preventive medicine reevaluation and management ... 18-39 years.

Covered HCPCS/T codes and miscellaneous servicesmixedCovered

D1206	Topical fluoride varnish; therapeutic application for moderate to high caries risk patients.
H0046	Mental health services, not otherwise specified.
H2000	Comprehensive multidisciplinary evaluation.
S0302	Completed EPSDT service (list in addition to code for appropriate evaluation and management service).
S9446	Patient education, not otherwise classified, nonphysician provider, group, per session.
T1013	Sign language or oral interpretive services, per 15 minutes.
T1016	Case management, each 15 minutes.
T1022	Contracted home health agency services, per day.
T1023	Screening to determine appropriateness for participation in specified program, per encounter.
T1024	Evaluation and treatment by an integrated, specialty team contracted to provide coordinated care to multiple or severely handicapped children, per encounter.

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Pediatric Developmental ScreeningCPTCovered

96110

Developmental screening (eg, developmental milestone survey, speech and language delay screen), with scoring and documentation, per standardized instrument.

COVID vaccine counseling codesCPTCovered

99401	Preventive medicine counseling and/or risk factor reduction intervention(s) provided to an individual; approximately 15 minutes.
99402	Preventive medicine counseling and/or risk factor reduction intervention(s) provided to an individual; approximately 30 minutes.
99403	Preventive medicine counseling and/or risk factor reduction intervention(s) provided to an individual; approximately 45 minutes.
99404	Preventive medicine counseling and/or risk factor reduction intervention(s) provided to an individual; approximately 60 minutes.

Required diagnosis codes for screening servicesICD-10

Z00.121	Encounter for routine child health exam with abnormal findings (used here as required diagnosis for pediatric developmental/autism screening).
Z00.129	Encounter for routine child health exam without abnormal findings (used here as required diagnosis for pediatric developmental/autism screening).

Fluoride varnish annual limit

Limit4 units per calendar year

Applicable age rangeAges 6 months to 18.99 years

ProviderMember's PCP or covering practitioner

CRAFFT screening limit

Limit1 unit per calendar year

Applicable agesAges 11–21 years

Provider Responsibilities, Authorization, and Documentation

Prior Authorization

Prior Authorization Required

Prior Authorization Required: Some services described in this policy require prior authorization. Examples include ocular photoscreening for members age 5 years and older and any other services flagged by plan-specific prior authorization guidance. Providers must consult Neighborhood's Prior Authorization Reference page for the full list of services requiring authorization and follow the plan's authorization process before rendering those services.

Ocular photoscreening age 5+ requires authorization
Refer to Neighborhood's plan-specific Prior Authorization Reference page for details

Note

Verify Eligibility and Authorization Prior to Service

Eligibility, Coverage and Authorization Verification: It is the provider's responsibility to verify member eligibility, benefit coverage, and whether prior authorization is required before providing services. Claim payments are subject to member eligibility, benefit coverage, claims payment edits, coding and documentation guidelines, authorization policies, provider contract terms, and state/federal regulations.

Policy Background and Authority

Pediatric preventive care follows American Academy of Pediatrics guidance and applicable Rhode Island law. Covered services include routine well-child and sick visits, prenatal pediatric visits, age-appropriate screenings (developmental, autism, ocular), application of fluoride varnish, and Early Intervention services for qualified children from birth through age 3. Vision and hearing screening are part of the routine pediatric visit and are not separately billable; routine dental care is excluded for Medicaid members. Providers should follow the policy’s coding and documentation requirements when billing these pediatric services.

Definitions and Service Descriptions

Early Intervention services

DefinitionServices rendered by state-certified providers for qualified children from birth up to age 3 years who are experiencing developmental delays

ScopeEarly Intervention services included among covered pediatric services

Provider noteRendered by an EI (Early Intervention) provider or state-certified provider

Developmental screening (96110)

DefinitionDevelopmental screening (CPT 96110): developmental milestone survey or speech/language delay screen with scoring and documentation per a standardized instrument

Billing requirement96110 requires scoring and documentation per the standardized instrument